Chapter 6: Dispensing Medications in the Community Pharmacy

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Learning Objectives

Discuss overall community pharmacy operations, including
Restricted area
Hours of operation
Drive-through options
General responsibilities of the pharmacy technician with regard to dispensing prescription drugs

Learning Objectives

Identify the parts of a patient profile, detail the steps required to select a patient from the database, and discuss the importance of including up-to-date allergy and adverse drug reaction information.

Learning Objectives

Describe the parts of a prescription and identify the most commonly used abbreviations for
Amounts
Dosage forms
Times of administration
Sites of administration

Learning Objectives

Describe controls necessary for reviewing prescriptions of scheduled drugs, including the identification of possible forgeries.
Explain the typical procedures for processing new and refill prescription orders.

Learning Objectives

Identify the parts of a prescription stock label and know the importance of comparing NDC numbers in medication selection and filling.
Describe the parts of a typical medication container label.

Learning Objectives

Contrast the purposes of the patient medication information sheet and leaflet with those of the medication guide.
Discuss the importance of a final check and verification by the pharmacist prior to dispensing to the patient.

Operations of a Community Pharmacy

A community pharmacy is a business designed to serve the needs of its customers, where customer service and convenience is important.

Discussion

Where are the majority of prescriptions filled?
In chain or independent community pharmacies

Operations of a Community Pharmacy

In the community pharmacy, the pharmacy technician performs many near-simultaneous tasks, with
Focused care
Attention to detail

Discussion

Which pharmacy technician duties listed in Table 6.1 (page 153) do you think seem the most challenging? Why?

Operations of a Community Pharmacy

The area of the pharmacy where the prescription medications are stored and prepared is
Secured by code or key
Off-limits to the public

Terms to Remember

prescription
an order written by a qualified, licensed practitioner for a medication to be filled by a pharmacist in order to treat a qualified medical condition

Operations of a Community Pharmacy

The critical path of a new prescription
Starts with receipt of prescription
Ends with dispensing to patient
Takes about 5 to 10 minutes
Has many phases that are completed by the pharmacy technician

Critical Path of a New Prescription

1. The pharmacy technician checks the prescription to make certain it is complete and authentic.

Critical Path of a New Prescription

2. The pharmacy technician verifies that the patient information is contained in the pharmacy database. If not, then the technician obtains necessary demographic, insurance, allergy, and health information from the patient and enters the information into the computer.

Critical Path of a New Prescription

3. The pharmacy technician enters (or scans) the prescription into the computer database, billing the insurance company or calculating the cost to the patient.

Critical Path of a New Prescription

4. The pharmacist verifies the accuracy of the technician's computerized entry against the original prescription (or a photocopied image) and generates the medication container label.

Critical Path of a New Prescription

5. When required, the pharmacy technician asks the pharmacist to check the drug utilization review (DUR) or drug interaction warning screen.

Critical Path of a New Prescription

6. The pharmacy technician selects the appropriate medication and verifies the National Drug Code (NDC) number on the drug stock bottle against the computer-generated medication container label.

Critical Path of a New Prescription

7. The pharmacy technician prepares the medication:
The prescribed number of tablets or capsules are counted or the prescribed amount of liquid is measured.
Controlled drugs are often double-counted and initialed.

Critical Path of a New Prescription

8. The pharmacy technician packages the medication in the appropriate container.

Critical Path of a New Prescription

9. The pharmacy technician labels the prescription container with the computer-generated medication container label. (In some states the law requires the pharmacist to affix the label to the container.)

Critical Path of a New Prescription

10. The pharmacy technician prepares the filled prescription (including original prescription, drug stock bottle, medication container label, and medication container) for the pharmacist to check.

Critical Path of a New Prescription

11. The pharmacist checks the prescription and may initial the label and prescription.

Critical Path of a New Prescription

12. The pharmacist or pharmacy technician bags the approved prescription for patient sale and attaches an information sheet about the prescription, including
Indications
Interactions
Possible side effects

Critical Path of a New Prescription

13. The pharmacy technician returns the drug stock bottle to the shelf. If the bottle is opened, then the bottle is so marked or labeled for inventory ordering.

Critical Path of a New Prescription

14. The pharmacy technician delivers the packaged prescription to the cash register area for patient pickup (or storage) and pharmacist counseling:
Verify that the correct patient is receiving the prescription (ask for address or birth date).
Photo ID may be required.

Critical Path of a New Prescription

15. If payment is due, then the patient pays by cash, credit card, or check. Most insurance providers require the patient to sign a form verifying that the prescription was picked up.

Discussion

Why is customer service and convenience important in a community pharmacy?
What are some of the key duties of the pharmacy technician in a community pharmacy?

The Patient Profile

A patient-specific record of
All prescriptions that have been dispensed in the past at the pharmacy
Relevant demographic information
May be shared nationally among chain pharmacies

The Patient Profile

Identifying information
Insurance and billing information
Medical and allergy history
Medication and prescription history
Prescription preferences
HIPAA confidentiality statement

The Patient Profile

New pharmacy customers require new patient profiles:
created at the time the prescription is submitted to the pharmacy
if phoned in, created prior to dispensing the medication(s) to the patient

The Patient Profile *Safety Note

If a patient profile already exists for a patient, then it is important for the pharmacy technician to verify that the correct profile is selected.

The Patient Profile

Obtaining information from the patient
Customers may complete a hard-copy form.
The pharmacy technician may need to interview the patient to obtain the necessary information. (See Figure 6.2)

The Patient Profile

It is extremely important for the pharmacy technician to ask the patient about
Allergies to medications
Past adverse drug reactions
All allergies must be documented and entered into the patient profile.

Documenting Drug Allergies and Adverse Drug Reactions *Safety Note

Inquire about allergies every time a patient comes to the pharmacy with a prescription for an antibiotic.

Discussion

Why is it important to inquire about allergies every time a patient comes to the pharmacy with a prescription for an antibiotic?
Patients can develop allergies to antibiotics, even if they have taken antibiotics without adverse reactions in the past.

Documenting Drug Allergies and Adverse Drug Reactions

Some food allergies may cross-react with medications:
Eggs
Peanuts
Gluten (wheat)
Dyes
Soy

Documenting Drug Allergies and Adverse Drug Reactions *Safety Note

Once a patient profile contains allergy-related information, the computer software will "warn" the pharmacist that a potential allergy or hypersensitivity reaction may occur if a prescription is filled for that drug.

Terms to Remember

patient profile
a record kept by the pharmacy listing a patient's identifying information, insurance information, medical and prescription history, and prescription preferences

Terms to Remember

allergy
a hypersensitivity to a specific substance, manifested in a physiological disorder

Discussion

How is the patient profile used in a community pharmacy?
How are patient profiles kept up-to-date?

Components of a Prescription

Pharmacy technicians check prescriptions to confirm
The prescription is complete
Medication information is documented accurately

Components of a Prescription

Prescriber information
Date
Patient information
Rx
Inscription
Subscription
Signa
Additional instructions
Signature

Terms to Remember

e-prescribing
transmission of a prescription via electronic means

Discussion

Why is there a trend toward electronic transmission of prescriptions?

Reading the Prescription

Subscription and sig may be written using abbreviations.
Become familiar with common abbreviations.
Misinterpretation of abbreviations can result in serious medication errors.

Abbreviations: Amounts

g = gram
gr = grain
gtt = drop
mg = milligram
mL = milliliter
qs = a sufficient quantity
(See Table 6.5)

Abbreviations: Dosage Forms

cap = capsule
sol = solution
supp = suppository
susp = suspension
tab = tablet
(See Table 6.5)

Abbreviations: Times

ac = after meals
bid = twice daily
pc = after meals
prn = as needed
qid = four times daily
tid = three times daily
(See Table 6.5)

Abbreviations: Sites

po = by mouth
pr = per rectum
sl = sublingual
top = topical
vag = vaginal
(See Table 6.5)

Abbreviations: Dangerous

hs = at bedtime
ad = right ear
as = left ear
au = each ear
od = right eye
os = left eye
ou = each eye
(See Table 6.5)

Discussion

The Institute for Safe Medication Practices (ISMP) has identified several abbreviations as dangerous. Why?
Refer to page 379 and Table 12.13 for more information on problematic abbreviations.

Reading the Prescription

If any part of the prescription is unclear or undecipherable, then the technician must check with the pharmacist prior to beginning the prescription-filling process.

Reading the Prescription

This prescription for azithromycin (Z-PAK) directs the patient to take "as directed for sinus infection."

Components of a Prescription *Safety Note

Amounts on prescriptions should be written out to prevent alterations.

Terms to Remember

DEA number
inscription
subscription
refill
dispense as written (DAW)
brand name medically necessary
signa (or "sig")

Discussion

What are the components of a prescription?
What are some of the potential problems a pharmacy technician might deal with in reading a prescription?

Other Types of Prescriptions

Prescription refill requests
New telephone orders
Transfer prescriptions
Prescriptions not yet due
Controlled-drug prescriptions

Prescription Refill Requests

The pharmacy technician
Verifies that refills exist for the requested medication
Forwards the request for pharmacist review and approval

New Telephone Orders

The pharmacy technician refers the call to the pharmacist.
The pharmacist verifies the accuracy of the prescription and submits it to writing.
Now the pharmacy technician can enter the information into the patient profile, as with a new prescription.

Transfer Prescriptions

In most states, by law only a licensed pharmacist can transfer or copy a prescription from (or to) another pharmacy.
The pharmacy technician can enter the transferred Rx into the computerized patient profile after it is transcribed to an order by the pharmacist.

Prescriptions Not Yet Due

Held prescriptions are commonly stored in an alphabetized file box for easy retrieval at a later date.
In most states, prescriptions for Schedule II drugs cannot be stored or held in the pharmacy.

Controlled-Drug Prescriptions

Controlled drug, Schedule II-V
Potential for intentional or unintentional abuse
Requires special review
Is it authentic or is it a forgery?
Has it be altered?

Controlled-Drug Prescriptions

State laws or regulations may control the time period for initially filling a Schedule II prescription.
A new prescription is required each time it is dispensed.
There may also be limits on the quantity of a controlled drug that may be dispensed.

Controlled-Drug Prescriptions

Emergency dispensing of controlled substances
With a valid medical reason
In most states

Controlled-Drug Prescriptions

Emergency dispensing of controlled substances
A controlled substance administration is to be immediate for proper treatment.
The pharmacist immediately converts an oral order into writing.
The pharmacist documents the need for the emergency dispensing of the Schedule II prescription.

Controlled-Drug Prescriptions

Emergency dispensing of controlled substances
Good faith efforts are made by the pharmacy to verify prescriber authenticity.
Within 7 days (72 hours in some states), the prescriber must deliver a written version of the emergency oral order to the pharmacy, with "authorization for emergency dispensing" written on its face.

Controlled-Drug Prescriptions *Safety Note

The legitimacy of the prescription for all scheduled drugs, especially Schedule II drugs, must be carefully assessed by both the pharmacy technician and the pharmacist.

Controlled-Drug Prescriptions

Forgeries are often difficult to recognize.
Do not rush the review of the prescription because of a busy workload.
The pharmacist must resolve any discrepancies by talking directly to the prescribing physician.

Controlled-Drug Prescriptions

Pharmacy technicians should also take care when a person other than the patient or a family member attempts to call in a refill or to pick up medication.
When in doubt, the pharmacy technician should call the patient to verify the authenticity of the prescription or the validity of the refill request.

Terms to Remember

drug seeker
a patient/customer who tries to obtain more than the normally prescribed amount of a controlled substance medication
gets prescriptions from multiple physicians for controlled substances
may be constantly requesting "early refills"

Terms to Remember

safety paper
a special tamper-proof paper required in many states for C-II prescriptions; used to minimize forgeries

Controlled-Drug Prescriptions *Safety Note

Authentication of Controlled-Substance Prescriptions
Because the role of the pharmacy profession is to safeguard public health, both the technician and the pharmacist have important roles in reviewing and monitoring all new and refill-controlled medications.

Controlled-Drug Prescriptions

The right to refuse a controlled-substance prescription
If a legitimate concern exists that a prescription was not written in good faith, then the pharmacist's duty is to determine the reason for issuing the prescription from the prescriber.

Controlled-Drug Prescriptions

Refilling controlled-substance prescriptions
In some states, for certain Schedule II drugs (e.g., ADHD medications) a prescriber is permitted to write two additional future dated prescriptions, to be held until needed.

Controlled-Drug Prescriptions

Refilling controlled-substance prescriptions
A prescription for a Schedule III or IV drug may be refilled up to five times if allowed by the physician, but these refills must occur within a 6 month period, after which time a new prescription is required.

Controlled-Drug Prescriptions

Refilling controlled-substance prescriptions
Early refill requests by patients for Schedule III-IV drugs must be carefully monitored by the pharmacy technician.
If refills are indicated for a controlled drug, then prescriptions are refilled no sooner than 1 or 2 days before the customer's supply will run out.

Documenting Insurance Information

The pharmacy technician often submits an online claim to an insurance plan.
It is not uncommon for insurance to cover only a 30 day supply of medication even if the prescriber approved a higher quantity.
A prior authorization (PA) requires the pharmacy technician or pharmacist to call or fax the prescriber's office so that the prescriber can be explain the justification for the use of the drug with the patient's insurer.

Terms to Remember

prior authorization (PA)
approval for coverage of high-cost medication or a medication not on the insurer's approved formulary, obtained after a prescriber calls the insurer to justify the use of the drug

Discussion

Besides new prescriptions, what other types of prescriptions are received in a community pharmacy, and what challenges do they pose for the pharmacy technician?
What should a pharmacy technician be aware of when authenticating a controlled-substance prescription?

Pharmacist Verification and DUR Evaluation

Pharmacy software can compare a prescription with others the patient has received to determine whether a drug utilization review is necessary.
A drug utilization review (DUR) requires a closer review of the patient profile and an override by the pharmacist indicating that the prescription is safe to dispense.

Pharmacist Verification and DUR Evaluation

A DUR may be needed if the prescribed drug may
Interact with existing or past medications on the patient's profile
Be contraindicated because of the patient's allergy or medical history
Be a duplicate of a similar drug prescribed in the past
Have been prescribed in doses too low or too high for the patient
Not be indicated in certain patients or must be used with caution

Pharmacist Verification and DUR Evaluation

In most pharmacies, the action taken on severe DURs must be documented.
The pharmacist will use his or her training and experience to review the patient profile and assess the significance of any potential interaction or adverse effect.

Terms to Remember

drug utilization review (DUR)
a procedure built into pharmacy software designed to help pharmacies check for potential medication errors
dosage
drug interactions
allergies

Discussion

What situations might trigger a drug utilization review?

Medication Selection and Preparation

Why must the technician become familiar with the precise location of drug inventory?
In order to efficiently and accurately select medications from the pharmacy stock to fill the prescriptions received

Medication Selection and Preparation

Why must the technician become familiar with the precise location of drug inventory?
In order to efficiently and accurately select medications from the pharmacy stock to fill the prescriptions received

Medication Selection and Preparation

Schedule II drugs
Can be dispersed through stock
Can be stored in locked cabinet
In most pharmacies, access limited to pharmacist

Medication Selection and Preparation *Safety Note

The expiration date should always be checked by the pharmacy technician before filling, especially on infrequently used medications.

Medication Selection and Preparation

The pharmacy technician fills a medication order based on
A printed medication container label
A patient-specific medication information sheet
After computer entry from the original prescription has been reviewed and approved by the pharmacist

Medication Selection and Preparation

NDC number
Use this number to identify the exact drug, dose, and package size for the preparation of the prescription.
Compare the NDC number of the stock bottle with the printout.

Discussion

What is the best way to select the correct drug from stock? Why?

Medication Selection and Preparation *Safety Note

Avoid basing product identification on size, color, package shape, or label design.

Medication Selection and Preparation

A common error is the selection of the
Wrong drug stock bottle
Dose
Package size
Because two products
Look alike (similar labeling)
Have names that sound alike

Medication Selection and Preparation

Check each drug at least three times to confirm that the correct drug is dispensed:
When the product is initially being pulled from the inventory shelf
At the time of preparation
When the product is returned to the shelf

Medication Selection and Preparation

Tablets and capsules must be counted out and placed in the appropriately sized vial or medication container.
Some pharmacies may use barcode scanners and automated counting machines
Minimize the chance of human error in drug selection
Facilitate the counting of tablets and capsules

Medication Selection and Preparation

Top, from left: a label printer, an automatic counting machine, and a bar-code scanner
Bottom, at left: a counting tray and spatula

Medication Selection and Preparation

Equipment should be cleaned after counting
Sulfa
Penicillin
Aspirin products

Medication Selection and Preparation

Liquid products are sometimes dispensed in their original packaging.
Pediatric cough and cold syrups
Suspensions

Medication Selection and Preparation

Counting out the medication may not be necessary.
A drug may be commercially available in a prepackaged, unit-of-use form.

Terms to Remember

unit of use
a fixed number of dose units in a drug stock container, usually consisting of a month's supply or 30 tablets or capsules

Medication Selection and Preparation

Unit-of-use packaging saves time and reduces medication preparation errors.

Medication Selection and Preparation

Many drugs are prescribed as one dose daily, and many insurance companies reimburse for only a 1 month supply of medication:
Birth control pills
Topical ointments or creams
Eye and ear drops

Medication Selection and Preparation

Birth control pills come prepackaged for dispensing.

Medication Selection and Preparation

Sometimes filling a prescription involves
Retrieving a multiple-dose container of a premixed drug
Measuring out the prescribed quantity
Placing the drug into a container with a label

Medication Selection and Preparation *Safety Note

The pharmacist must check all drugs prepared by the pharmacy technician.

Medication Selection and Preparation

Most pharmacies maintain a limited drug inventory to remain profitable.
It is not uncommon to be either out of a prescribed medication or unable to completely fill a prescription order.

Terms to Remember

out of stock (OOS)
a medication not in stock in the pharmacy
a drug that must be specially ordered from a drug wholesaler

Medication Selection and Preparation

Options for OOS medications
Allowing the patient to take the prescription to another pharmacy
Borrowing the medication from another pharmacy
Ordering the medication from the wholesaler

Terms to Remember

partial fill
a supply dispensed to hold the patient until a new supply is received from the wholesaler because insufficient inventory in the pharmacy prevents completely filling the prescription

Medication Selection and Preparation

Inventory may be insufficient to completely fill the prescription
A partial fill may
Provide a 2 day to 5 day supply of medication
Should be sufficient until the new drug inventory is received

Medication Selection and Preparation

Choosing medication containers
A wide variety of plastic vial sizes are available for tablets and capsules in various dram sizes (from 10 to 60 drams).
Selecting the proper vial size is a skill that becomes easy with experience.

Medication Selection and Preparation

All medications should be dispensed in child-resistant containers that are designed to be difficult for children to open.
Poison Prevention Packaging Act of 1970
Most prescription drugs are to be packaged in child-resistant containers.
A non-child-resistant container may be used if the prescriber or the patient makes a request for such a container.

Discussion

What are the sources of potential errors in medication selection? How are they minimized?
What precautions must the pharmacy technician take in preparing medications?

Medication Information for the Patient

It is important to provide each patient with sufficient information to correctly take the prescribed medication.
Written information is delivered through
Medication container labels
Patient information sheets

Terms to Remember

medication container label
a label containing the dosage directions from the physician, affixed to the container of the dispensed medication
the technician may use this hard copy to select the correct stock bottle and to fill the prescription

Medication Information for the Patient

Remember the law:
The pharmacy technician is not allowed to counsel patients.
The pharmacy technician is legally bound to offer patients verbal counseling to be provided by the pharmacist.

Medication Information for the Patient

The information required on a medication container label depends on the laws and regulations of a given state.

Terms to Remember

auxiliary label
a supplementary label added to a medication container at the discretion of the pharmacist to provide additional directions

Medication Information for the Patient

Application of auxiliary labels
Requires a thorough knowledge and understanding of the drug
Is usually restricted to the professional judgment of the pharmacist

Terms to Remember

patient information sheet
a leaflet printed from the prescription software and provided to patients on each medication dispensed
the tech may use this hard copy to select the correct drug stock bottle and fill the prescription

Medication Information for the Patient *Safety Note

Patient information sheets provide package insert information in a format the patient can understand.

Medication Information for the Patient

Patient medication guides
For select, high-risk drugs
Must be provided to patients
A "black box" warning advising consumers of a potential adverse reaction or of the proper use of a medication with a special dosage formulation

Discussion

What types of medication information are available to the patient?
How is the information delivered?

The Final Check of the Prescription

It is extremely important—and required by law—that the pharmacist check every prescription before it is dispensed to the patient to verify its correctness.

The Final Check of the Prescription

The pharmacist
Reviews the original prescription order
Compares it with the patient profile
Confirms that the patient information sheet has been printed
Verifies that the drug selected by the technician (from the stock bottle) is correct
Checks the accuracy of the medication container label

The Final Check of the Prescription

After this review, the pharmacist may initial the medication container label and/or the original prescription.
In doing so, the pharmacist assumes legal responsibility for the correctness of the prescription.

The Final Check of the Prescription

A duplicate of the computer-generated copy of the medication container label is usually affixed to the back of the original new prescription by the pharmacist or pharmacy technician.
The original prescription is filed numerically.

Discussion

What checks does the pharmacist complete before the prescription is delivered to the patient?

Delivering the Filled Prescription to the Patient

After the final verification and filing of the original prescription, the medication is available for immediate or future distribution to the patient.
If the prescription is a "partial fill" or "change of manufacturer," the pharmacy technician should be sure to relay this information to the patient.

Delivering the Filled Prescription to the Patient

Most medications are stored in alphabetical or numeric storage bins.
Some medications, such as all insulins, many injections, and suppositories, should be stored in the refrigerator once the final verification by the pharmacist is completed.
Other medications, such as antibiotic suspensions, must be mixed just before dispensing.

Delivering the Filled Prescription to the Patient

Verify that the correct patient is receiving the dispensed medication, especially if someone else (i.e., a family member or a friend) picks up the prescription.

Delivering the Filled Prescription to the Patient

Pharmacist counseling
Every patient for new prescriptions
Available for patient questions on refill medications

Delivering the Filled Prescription to the Patient *Safety Note

Pharmacist counseling
The technician must offer the patient (or the patient's representative) the opportunity for counseling.
Counseling is required by law.

Terms to Remember

tablet splitter
a device used to manually split or score tablets

Discussion

When delivering the prescription to the patient
What are the pharmacy technician's responsibilities?
What are the pharmacist's responsibilities?

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