1.

Einführung

The major expectation from the in-patient pharmacy is to make appropriate and correct
drugs available at the right time. Any delay in this has a huge impact on the patient care and
hence the smooth functioning of the pharmacy. A standardized formulary forms the basis of
the drugs that are stored and dispensed in the in-patient store. This enhances therapeutic
opportunities for pharmacists and also assists the prescribing doctors to know about the
availability of drugs for better inventory control. Drug Inventory control is an essential
element of Health care management, and its significant activity to achieve efficient patient
care in a health care.

Monitoring medication turnaround time in inpatient pharmacy department allows

organizations to measure the impact of their quality on the increased efficiency of patient
care. Medication turnaround time or medication turn-around time, is considered the
interval from the time a medication order was composed to the time the medication was
delivered. Minimizing the medication turnaround time can promote efficiency, patient
safety and quality of patients care.

A multidisciplinary team of healthcare personnel provides better patient care, individual

possessing a characteristic skills set appropriate to his/her allotted duties. For high-quality
and safe patient care, the team should work cooperatively, remain focused, and
professionally communicate. Health care team rely upon communication across
departmental limits for effective functioning.

Hospital pharmacy is the health care service comprises of choosing, preparing, storing,
compounding, and dispensing medicines and medical devices, advising health care
professionals and patients on their safe and effective use. It forms an integrated part of
patient health care in a health facility.

It was observed that the indent demand to the IP pharmacy of a tertiary care hospital was in
excess than the ideal required amount. The main reason for this was over ordering of
indents from the wards and later all the extra, unused medications were returned back to
the IP pharmacy store. The returned indent was of large quantity and required one person
(pharmacist/helper) to be continuously appointed to receive returned indent drugs from
each ward and ICU’s. This study was conducted to determine the medication TAT and state
causes about the findings. An analysis of indents was also carried out to observe which
department creates medication indenting error in an attempt to reduce number of indents
from various wards.
2. Literature review

Appropriate medicine use in the hospital setting is a multidisciplinary responsibility that

includes:

 Selection and formulary management by a multi-disciplinary committee

 Prescribing by the physician
 Procurement, storage, medication order review, and preparation and dispensing by
the pharmacy department
 Medication administration by nurses or other health care professionals
 Monitoring the effect of medicines on the patient by all members of the health care
team

The drug and therapeutics committee (DTC) is responsible for developing policies and
procedures to promote the rational medicine use. Its functions include:

 Management of the approved medicine list or hospital formulary

 Ongoing drug use review
 Adverse drug event reporting and implementation of safe medication practices

Members of the DTC should include representatives from the medical, pharmacy, and
nursing staffs, hospital administrators, and the quality assurance coordinator.
Subcommittees are often formed for in depth analysis of particular issues. The pharmacy
department, under the direction of a qualified pharmacist, is responsible for the
procurement, storage, and distribution of medications throughout the hospital. In larger
hospitals, satellite pharmacies may bring the pharmacist closer to patient care areas,
facilitating interactions between pharmacists and patients. In some settings the pharmacist
is used as a resource for medicine information and specialized medication therapy
management.

Medications may be distributed in bulk, in courses of therapy or in unit doses. Unit dose
distribution is optimal for patient care but requires initial capital outlay for repackaging
equipment and medication cabinets. Recent technological advances such as computerized
dispensing machines and barcoding are now available to further promote safe medication
practices.

Additional mechanisms for In-patient management include:

 Patient medication profiles, maintained in Pharmacy department

 Medication administration records, maintained by nurses
 Periodic inspection of medicine storage areas
 Procedures for strict control of dangerous drugs and controlled substances
 Responsible disposal of pharmaceutical waste
 Procedures for after-hours pharmacy service
Small-scale pharmaceutical production often is not cost effective and should be evaluated
by the DTC.

The control of narcotics is of particular concern in the hospital setting and requires a
systematic approach for the prevention and detection of abuse.

A hospital exists to provide diagnostic and curative services to patients. Pharmaceuticals are
an integral part of patient care. Appropriate use of medicines in the hospital is a
multidisciplinary responsibility shared by physicians, nurses, pharmacists, administrators,
support personnel and patients. A medical committee sometimes called the drug and
therapeutics committee, pharmacy and therapeutics committee, or the medicine and
therapeutics committee is responsible for approving policies and monitor practices to
promote safe use of drugs.

2.1. Responsibilities of hospital staff

The hospital pharmacist should be an expert on medicines who advises on prescribing,
administering as well as a supply manager who ensures that medicines are available
throughout procurement, storage inventory control and quality assurance. The balance
between these two roles varies, depending individual background and the work setting. A
pharmacist may assume prominent clinical role in settings where his or her knowledge of
clinical pharmacology and capacity to provide expert advice have earned the acceptance of
hospital medical and nursing staff.

2.2. Purchasing and Stock procurement

In some hospitals, a separate department manages all hospital purchasing (pharmaceuticals,
medical supplies, epuipment and so forth) this department may be called medical stores or
material management. In such cases, the chief pharmacist prepares an annual budget
request for pharmaceutical purchases and places orders for medicines through the medical
stores.

In other settings the pharmacy department manages pharmaceutical purchasing directly. No

single individual should have total control of pharmaceutical procurement. A designated
committee should review and approve all the purchases either a special purchasing
committee or the DTC may manage this function.

Procedures for procurement and inventory management should be written in a manual that
has been approved by hospital administration and the appropriate committees. Stock
management procedures are determined by the hospital’s size and whether a warehouse is
attached to the hospital or not.
2.3. Medication use
The medication use process can be divided into four components:

Prescribing: The physician has overall responsibility for the care of patient, prescribing, or
ordering medications as part of the treatment plan. The mechanisms to ensure appropriate
prescribing within the hospital, customarily fall within the preview of the medical staff
committees usually including the DTC. The DTC may establish protocols or procedures that
allow pharmacists and nurses to prescribe within specifics guidelines.

Preparation and dispensing: The pharmacy department under the direction of a registered
pharmacist, is responsible for preparing and dispensing medications. Policies and
procedures for these functions should be approved by the DTC. The chief pharmacist
reports to the hospital administration.

Medication administration: Administering medications is generally the responsibility of the

nursing staff. The chief nursing officer oversees all nursing functions. In some cases,
physicians may administer medicines such as anaesthetic agents. Other healthcare
professionals may administer medicines the scope of their practice.

Monitoring the effect of medications on the patient and ordering appropriate changes in
therapy: Monitoring activities are primarily the responsibility of the physician. However,
observation and reporting are required from the person who administered the medication
(usually the nurse) and from other members of the health care team involved in the
patient's therapy. In some settings, a clinical pharmacist or pharmacologist monitors
medication therapy in the hospital and consults on medication therapies that require special
expertise to ensure safety and efficacy, for example, total parenteral nutrition,
anticoagulation, or treatment with aminoglycoside antibiotics.

Government agencies and licensing boards regulate medications through laws and
professional practice standards. The laws and regulations usually specify that the chief
pharmacist be the person responsible for the control of medications within a hospital,
including procurement, storage, and distribution throughout the facility.

Although the chief pharmacist is responsible for the pharmaceutical budget and the control
of medications, he or she does not supervise those who prescribe or administer the
medications. In addition, in some hospitals, purchasing, receiving, and storing of
medication's are handled by a medical stores department that is not under the supervision
of the pharmacist.

These varying responsibilities illustrate the complexity of pharmaceutical procurement,

storage, and use in the hospital. Efforts to improve the system should respect this
complexity and include multidisciplinary representation and involvement. Coordination is
required at the policy level through the DTC, at the management level (beginning with
hospital administration) and through the different branches of the organizational tree.
2.4. Organization of hospital pharmacy services
In organizing hospital pharmacy services, both the way in which the staff is organized and
the physical layout of the building must be considered.

1. Personnel

Hospital pharmacy personnel can be divided into three major categories:

 Management: Management includes the chief pharmacist and sometimes deputy

chief pharmacists, who are responsible for procurement, distribution, and control of
all pharmaceuticals used within the institution and for management of personnel
within the pharmacy department.
 Professional staff: These professionals are qualified pharmacists who procure,
distribute, and control medications and supervise support staff tor these activities. In
some facilities pharmacists provide clinical consulting services and medicine
information.
 Support staff: The support staff category often includes a combination of trained
pharmacy technicians, clerical personnel and messengers.
 The smallest hospitals may have only two or three pharmacy staff members, with
the chief pharmacist as the only pharmacist. Larger hospitals that provide extensive
pharmaceutical distribution and clinical services may have more than 100 staff
members.
 The cornerstone for a well -functioning medication system is an up-to-date manual
of policies and procedures. Staff members should be familiar with the manual and
adhere to it.

2. Physical organization

The extent of the pharmacy's physical facility is determined by the size of the hospital and
the services provided. A large pharmacy department might have the following sections
within one physical space or in separate locations throughout the hospital

 Administrative offices
 Bulk storage
 Narcotic or dangerous drug locker
 Repackaging
 Intravenous solution compounding
 Inpatient and outpatient dispensing
 Medicine information resource centre
 After-hours pharmacy
 Emergency medicine storage

Inpatient dispensing is sometimes done from satellite pharmacies throughout the hospital.
In larger hospitals, satellite pharmacies are beneficial because they enable a shorter
turnaround lime for individual medication orders, especially in distribution systems that
dispense medications packaged for individual patients. Satellites also increase the
pharmacist's presence in the patient care area, facilitating interactions with medical stall
nursing staff and patients and thus ultimately improving patient care.

With satellite pharmacies, there is reduced need for ward stocks. However, each satellite
requires a certain minimum inventory level of pharmaceuticals. A system with multi
satellites most likely has a higher total inventory level than that of a central pharmacy
system. The higher inventory and additional personnel costs needed to staff satellite
pharmacies may be justified by reductions in pharmaceutical supply costs (because there is
less wastage) and improvements in patient care. Whether or not multiple satellite
pharmacies serve inpatients, separate pharmacies often serve inpatients and outpatients

3. Hospital drug and therapeutics committee

Most commonly, the committee designated to ensure the safe and effective use of
medications in the hospital is the DTC. The American Society of Health-System Pharmacists
guidelines on DTC states that "medication use is an inherently complex and dangerous
process that requires constant evaluation. Organizations need to implement tools and
processes necessary to meet the goals of using medications effectively and safely"

Purpose and functions

The DTC promotes the rational use of medication through the development of relevant
policies and procedures for medication selection, procurement, distribution, and use and
through the education of patients and staff.

In some hospitals, the DTC becomes overwhelmed with the difficulty of obtaining an
adequate supply of medications. Members are caught up in routine decisions about which
medicines to buy, how much, and from whom rather than focusing on long-term planning,
policies, and programs for improving the safe and cost-effective use of medications.

Membership

An effective DTC requires that members participate in the meeting and assist with other
committee activities. Membership should include representation from:

1. Medical Staff (representation from each department)

2. Pharmacy (Chief pharmacist often serves as secretary)
3. Nursing
4. Hospital Administration
5. Quality Assurance staff

A membership of eight to fifteen members often fulfils these criteria. The committee may
occasionally invite a specialist to make a presentation or provide advice on a particular
issue. DTC’s often have subcommittees to address particular issues, such as, antibiotic use
or medication errors.
4. Hospital formulary management

The hospital formulary is the cornerstone of medication management in the hospital and it
should be the principal concern of the DTC. The following list provides general guidelines for
the hospital setting:

 Limit the formulary list to conserve resources: stocking all medicines on the national
formulary is usually not necessary.
 Eliminate generic duplication: only one brand or label of each generic medicine
should be routinely stocked.
 Minimize the number of strengths stocked for the same medication: multiples of
lower strengths can be used for infrequently needed higher strengths.
 Select medications for the formulary based on diseases and conditions treated at the
facility
 Specify formulary medicines of choice for common therapeutic indications.
Medicines of choice should be selected by comparing efficacy, safety, toxicity
pharmacokinetic properties, bioequivalence, and pharmaceutical and therapeutic
equivalence. Cost-effectiveness and availability should be primary considerations,
evaluating alternatives. After medicines of choice are selected, they form the basis
for standard treatment guidelines and for therapeutic substitution program.
 Include second-line alternatives to medicines of choice as needed, but minimize
therapeutic duplication.
 Ensure that the formulary corresponds with the national standard treatment
protocols approved by the health system.

5. Drug use review

Drug use review (DUR) is a tool to identify such common problems as inappropriate product
selection, incorrect dosing, avoidable adverse drug reactions, and errors in medication
dispensing and administration. DUR may then be used to implement action plans for
change. DUR is an ongoing planned, systematic process for monitoring, evaluating, and
improving medicine use and is an integral part of hospital efforts to ensure quality and cost
effectiveness. More appropriate and more effective use of medicines ultimately results in
improved patient care and more efficient use of resources.

2.5. In-Patient Pharmacy Department:

Inpatient pharmacy provides services to the wards, clinics and other units in the hospital
through the unit dose system supply, bulk ward stock replenishment and automated
medication dispensing.

For patients who have been discharged from hospitals, dispensing and counselling services
are provided by the pharmacists. The Inpatient pharmacy also supplies the Psychotropic and
Dangerous Drugs to the wards and units which are under controlled regulation.
Functions of the Pharmacy department:

1. Medication distribution systems

Medication distribution has long been the primary function of hospital pharmacy services.

Four basic types of medication distribution systems exist:

 Bulk ward stock replenishment

 Individual medication order system
 Unit-dose system
 Automated medication dispensing

Variations of each exist, and all four systems may be in use in the same facility, depending
on the strategy developed. For example, a facility may use the bulk ward stock system for
high-volume, low-cost medicines (aspirin, paracetamol, and antacids) that do not require a
high level of control for preventing theft or medication errors. Individual medication order
systems or unit doses can be used for medicines requiring a higher level of control. In
addition, automated dispensing systems are now frequently used in developed countries
and will become more common in the future.

Bulk ward stock

In a ward stock system, the pharmacy functions as a warehouse and dispenses bulk
containers on requisition without reviewing individual patient medication orders for
appropriateness. The main advantage is shorter turnaround time between prescribing and
administering the medication. The use of ward stock medications should be minimized, but
it is appropriate and desirable for certain situations-

 In emergency departments and operating rooms medications are usually required

immediately after the physician prescribes them. Unless a pharmacy satellite is
located in these emergency areas, dispensing medications according to individual
patient orders is not possible. Unfortunately, medicines used in these situations are
often expensive, and control is always a challenge for the pharmacy department.
 In life-threatening emergency situations, medications need to be kept in patient care
areas as a time-saving measure.
 High-volume, low-cost medicines can be dispensed from ward stock if the patient
safety risk is low

Individual medication order system

The individual medication order system closely resembles dispensing to outpatients; a

course of therapy is dispensed according to a written prescription for an individual patient.
Compared with ward stock distribution, the advantages are that the pharmacist can review
the appropriateness of therapy, a patient specific medication profile can be maintained,
pharmacy charges to patients are facilitated, and closer control of inventory is possible. This
system can limit the time intervals for dispensing: for example, an individual supply for
three days of therapy is sent initially; if therapy is continued beyond three days, the empty
container is returned to the pharmacy to be refilled.

Unit-dose medicine distribution

A preferred system from a patient care perspective is the unit-dose system, which has a
lower possibility for error. Medications are dispensed in unit-dose packages (each dose is
separately packaged) in separate bins or drawers for each patient. Commonly, a twenty-
four-hour supply is provided. Medications returned to the pharmacy can be put back in
stock without concern for identity or contamination. This system is efficient but requires a
large initial capital outlay for the purchase of repackaging machines and medication
cabinets with individual patient drawers. The cost per delivered dose is higher than with
bulk packaging, but this increased expense may be offset by reduced wastage and easier
detection of leakage. Hospitals in some countries have found innovative ways of adapting
local technologies to construct their own fixtures and equipment.

Automated medication dispensing

Technology-based interventions have been investigated as a mechanism to improve

medication distribution and reduce medication errors that lead to adverse drug reactions.
The use of automated dispensing machines has become common place in many hospitals,
but cost remains a big deterrent for implementation in resource-limited settings. The
mechanism is founded on a computer interface between the hospital pharmacy computer
terminals and the dispensing machines at the clinical ward. This system electronically
controls and tracks the dispensing of unit doses for each patient based on individual
medication profile. The dispensing machines allow medicines to be stored on the ward and
to be more conveniently accessed by the clinical staff.

2. Maintenance of Patient medication profiles

Patient medication profiles are necessary if hospital pharmacists are to monitor inpatient
medication therapy. Each profile contains data on the patient's current and recent
pharmaceutical therapy, allergies, diagnosis, height, weight, age, and sex. Profiles work best
in conjunction with unit dose medicine distribution or automated dispensing systerns but
can be used with the individual medication order system.

A pharmacy profile allows the pharmacist to review all the medications that a patient is
taking before dispensing the first dose and with each new medication order. Problems with
pharmaceutical therapy, such as allergies duplicate therapy, medicine-medicine
interactions, medicine-disease interactions, inappropriate length of therapy and
inappropriate dosing, can be detected and avoided or corrected.

Computerized pharmacy systems display the patient’s medication profile on the screen, and
the pharmacist edits the screen with each new order. Medication interactions, dosage
ranges, and other monitoring functions can be programmed into the computer. In
developed countries information technology advances now provide linkages to patient-
specific information from laboratory and clinical monitoring.
3. Medication treatment record

Also known as the medication administration record (MAR), the medication treatment
record helps the nurse schedule treatments for each patient and provides a permanent
record of the medications administered. It also allows nurses to review the patient's
pharmaceutical regimen and provides a way to compare quantities of medications
dispensed from, and returned to, the pharmacy with quantities administered to the patient.
Physicians review MARs to verify current therapy and as part of their routine rounds. The
trend is toward computerizing MARs; in the United States, over two-thirds of hospital
computer generated or electronic records.

4. Ward and department inspections

The pharmacy department should undertake periodic inspections of medication storage

areas throughout the hospital to ensure appropriate levels of properly stored medications,
to monitor expiration dates, and to remove unnecessary stock. When problems are
detected in inspections, pharmacy and nursing staff must develop methods to correct the
situation.

5. Dangerous drugs and controlled substances

Controlled substances require greater attention in the hospital setting than other
medications, just as they do outside the hospital. The various definitions and categories of
controlled drugs all relate to abuse and addiction potential.

Procedures specific to the procurement, reception, storage, dispensing, and administration

of controlled drugs should establish a readily retrievable trail of accountability for each
individual drug unit. The records should document ordering, receiving, dispensing,
administration and wastage. Perpetual inventory records should be used at all storage sites,
and controlled drug stocks should be counted and reconciled against the records daily, with
unexplained losses reported to the pharmacy. Controlled substances stored throughout the
hospital should be securely double locked within a well-constructed storage area, with the
pharmacy department in control of the distribution and duplication of keys.
2.6. What is an Indent?
An indent is an official order or requisition for medicine and supplies from the medical
stores or Pharmacy. The quantity to be procured is also mentioned in the indent. The nurse
acquires the drugs, equipment and supplies based on the need estimation, availability and
the budget. As the drugs are received it should be inspected and stored as per the
classification and rate of consumption.

Types of Indent:
To prioritize the indent orders that are issued in the In-Patient Pharmacy department they
are classified depending on their severity. This included:

Stat Indents:

Any order for a medication which meets at least one of the following criteria:

 written as “Stat”
 eg: thrombolytic or antithrombotic, vasopressors.

All orders meeting the above criteria will have an expected pharmacy turnaround time of
20 minutes according to the SOP of the hospital.

Routine Indents:

Any order for drug that are routine in nature.

All orders meeting the above criteria will have an expected pharmacy turnaround time of 60
minutes according to the SOP of the hospital.

Urgent Indents:

Any order which has ‘Urgent’ written on it.

All orders meeting the above criteria will have an expected pharmacy turnaround time of 30
minutes according to the SOP of the hospital.

Discharge Indents:

Any order issued for patients who are scheduled for discharge.

All orders meeting the above criteria will have an expected pharmacy turnaround time of 45
minutes according to the SOP of the hospital.
3. Discussion

Few issues, which come out from the study, the medication turnaround time for all types of
indents was higher than SOP standards. This delayed the delivery of medications to the
respective wards which affects the quality of patient care. Evidence, from others studies,
suggests that decreasing medication turnaround time can improve patient care, particularly
for medications that have a critical impact on patient outcomes.6 For example, timely
administration of antibiotics prescribed for community-acquired pneumonia, sepsis, and
meningitis has decreased mortality rates and length of stay.9–11

The primary objective of the study was to determine turnaround time and the difference
between the TAT mentioned in the SOP with the actually observed time. The average
turnaround time for routine indent was found to be 1hour 55 minutes, for STAT indent it
was 1hr10mins, for discharge indent it was 1hr 6mins and for urgent indent it was 1hr
02mins. These values were seen to be more than the SOP values. Delivery of all the types of
indents was delayed. The total average turnaround time was 1hr 41min.

Few reasons that were observed for delay in delivery of medication are as follows:

1. Delay occurs in delivering of medicines due to stock variability. In other words, availability
of stock of any item shown by the software but actually, when the assistant searches for the
medicine he finds that particular item is physically unavailable in the pharmacy. Errors occur
in reflecting the transferred medications to the OP Pharmacy, Surgical stores in the system
and as a result the system shows availability of such items but those are physically
unavailable.

2. Lot of load on the department as compared to the availability of staff.

3. Sometimes more than one indent is ordered for the same patient.

4. Sometimes the medicines, which have been dispatched from the pharmacy does not
reach the respective wards in time due to expensive crowd in the hospital.

5. Some of the reasons were due to the delay in dispensing of the medication. The main
responsible factors for this were.

i. Negligence of employees.
ii. Staff shortage on some days.( because of illness and other personal reasons of
the staff.
iii. Out of stock medicines.
iv. Software issues. (indents not being received in department)
 v. The employees seem to neglect the indents being received in the department
and do their own work rather than clearing out the indents being received in the
department.
vi. The dispensing of Narcotic substances requires documentation which consumes
a lot of time of the pharmacists.
vii. The medications not used by the patients in the wards are returned to the
pharmacy. Excessive return medicines due to indenting errors by the nursing
staff increase the workload of the pharmacists.

The secondary objective was to identify wards ordering highest number of indents. Highest
number of indents was ordered from Ward N.6, NHHI-ICCU and Critical unit. 3 which
increased the chances of errors. Nurses often issue more than 1 indent for the same patient
on the same day. Proper training should be given to the nursing staff about indenting
practices and use of hospital information system. Department indents are ordered at the
start of the day which should include the commonly indented items. The commonly
indented items included NS, Hospimol and dianora extra stock of which should be
maintained at the nursing stations of respective wards. This can help in reducing the
medicines that are returned to the pharmacy.

It was also seen that after collection of drugs, it is kept in the rack for long time, though it is
ready to be dispatched. Major reasons for the above problem were:

 Lack of Manpower (Pharmacists as well as assistants)

 Assistants who are supposed to deliver medicines to the respective wards are busy in
collecting the drugs for other indent
 Assistants are on leave (less number of relivers)
 Assistants who are supposed to deliver the medications do not arrive on time after
the delivery is done.

Another important issue that was observed was frequent miscommunications between
nursing and pharmacy staff. This results in missing and duplicate medications. In addition,
there was a continual stream of secondary communication between pharmacy and nursing
staff over the ordered indent. This is time consuming and a distraction from other value-
added tasks. The poor communication leads to constant checking from nurses to make sure
that the medications they have requested were not forgotten. The pharmacists and
pharmacy technicians waste time checking and reassuring nurses that medications are on
the way.

A lot of telephone calls are made to the pharmacy department in regards to clarification of
any doubts about the medication, clearance for discharge of patients, from vendors of
different medications, from the nursing staff, from doctors and other departments. A lot of
time is also wasted in answering calls from these different departments. This leads to the
overall increase in the medication turnaround time.
4. Recommendations:

 The drugs can be dispatched in the paper bags with the details (Name, Admission no.
and wards) of respective patients so that at the nursing unit, less time will be
consumed in segregation of medicine and non-drugs.

 Items for STAT and urgent indents should be immediately dispatched after collection
and not be kept in rack as per the department.

 For dispatching immediately, manpower should be checked and priority should be

given for urgent and STAT.

 The nurse ordering drugs for patient should indent the complete order (bulk order)
at once, instead of indenting numerous incomplete orders.

 Training should be given to the nurses about the indenting process. The should be
aware of the difference between STAT, urgent, routine and discharge and colour
coding for the same should be known that is used in the hospital system.

 Regular training should be given for each staff (involve in indenting) and part of
induction program for new employees.

 Regular store audit should be done in order to check any discrepancy between the
stock shown in the system and what is actually present physically.

 The staff should be increased if it is feasible. Leaves should be given only when
reliever is arranged.

 Standard delivery routes can be designed/ allocated so as to reduce time of

transportation by the delivery assistants.
5. Conclusion

Through this study, various points of delays were identified, which were occurring in
delivering indents to the patients. The results of the study revealed that all types of indents
were delayed; especially STAT indents also got delayed, which became the major area of
concern. In addition, if hospital follows indenting practices by the nursing staff, than the
training for nursing staff is essential requirement regularly, to overcome this problem.

Everyone within the circle of care, first has to ensure patient safety in every step of process
from the initial step of selecting the appropriate medication to prescribe, to dispensing the
medication is improved to prevent delays in therapy and medication errors. Eventually, it is
most important that effective communication takes place to ensure accurate prescriptions
and optimal patient care. This study can be used to conduct further studies to improve the
TAT. Interdisciplinary interventions are necessary to reduce the total turnaround time.