Pharmacy Technician Exam (CH 1D

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Factors Affecting Drug Stability

-dosage form
-humidity
-ingredients used in a compound
-light
-material of the container
-order and method of preparation
-temperature

Physical Incompatibilities

-occur from changes in solubility -> change in color or precipitation
-change in pH of solution, use of buffers, type of solvent used create problems

Chemical Incompatibilities

-incompatibility may not be noticeable
-changes in pH/chemical decomposition may occur
-presence of light cause deterioration of ingredients
-IV medications are normally prepared using D5W except ampicillin, ampicillin-sulbactam, erythromycin, lactobionate, imipenem-cilastatin, & oxacillin which must be mixed with normal saline

Therapeutic Incompatibilities

-mixing together of 2 or more ingredients -> change in therapeutic response of the drugs

Procedures to Prepare Intravenous Admixtures

-flow hood on >30 min
-wear protective clothing
-clean laminar flow hood with 70% isopropyl alcohol or other disinfectant, pole to hang IV bags, sides of hood moving from back to front, bottom of hood moving side to side from back to front
-collect supplies. check expiration dates & bags for leaks. use presterilized needles, syringes, & filters
-position supplies in the hood
-sterilize puncture surfaces with alcohol wipe
-prevent coring by placing vial on flat surface, insert needle into rubber closure at 45-60 degree angle. Use downward pressure on needle & move needle to 90 degree angle

Using Vials With Solutions

-draw into syringe volume of air equal to amount of volume being replaced
-penetrate vial without coring
-invert vial upside down & fill syringe
-tap to bring air bubbles to top of syringe
-transfer solution to final container

Vial With Lyophilized Powder

-determine correct volume of diluent & withdraw it
-transfer diluent into vial with powder
-remove more air from vial than amount of diluent injected. Whirl vial until powder dissolves
-use new syringe & needle, proceed as if using a vial with solution

Using Ampules

-score neck of ampule with fine file if not already done so
-hold it upright & tap. wipe neck with alcohol swab
-wrap gauze around neck & gently snap neck
-insert & use filter needle to withdraw
-hold ampule downward at 20-degree angle & withdraw solution with filter syringe
-exchange old filter needle with new one & transfer solution into final container

Procedures To Prepare Chemotherapy Drugs

-same procedures as IV, with a few exceptions
-require vertical laminar airflow hood (smaller)
-special chemotherapy clothing is worn
-hands in vertical flow hood should not be over top of any needle, vial, or IV bag

Preparing Parenteral Antineoplastics

-safety cabinet work surface covered with plastic-backed absorbent paper (disposed of in biohazard container)
-personnel wear surgical gloves & closed-front surgical gown with knit cuffs
-reconstituted vials vented to reduce possibility of spraying/spillage
-sterile alcohol pledget wrapped around needle & vial top during withdrawal of solution
-external surfaces of syringes & IV bags (bottles) wipe clean of contamination
-when use ampules: wrap neck with sterile alcohol pledget to protect fingers
-syringes & IV bottles properly identified & dated (caution labels needed)
-safety cabinet wiped down with 70% alcohol on completion of compounding
-contaminated needles & syringes placed in sharps container. Disposable gowns, gloves, masks, head & shoe covers placed in red biohazard bags
-wash hands
-dispose of remaining antineoplastic agents according to regulations

Procedures To Prepare Total Parenteral Nutrition Solutions

-TPN: 50% dextrose, 10% amino acids, 20% fat
-aseptic technique require: TPN infused into right atrium of heart
-TPN compounders: include multichannel pump for amino acids, dextrose, fats, & other additives that connect to personal computer. Computer assists calculations & drives pump
-micro compounding pump used for electrolytes & other additives
-PPN (peripheral parental nutrition): 25% dextrose, 10% amino acids, 10% fat, short-term therapy
-TPN & PPN premixed from manufacturer but electrolytes, vitamins, & medications added to nutrients at pharmacy

Compounding Techniques

-Method 1: amino acids & dextrose mixed first. Add fat emulsion & then additives
-Method 2: amino acids added to fat emulsion. Add dextrose then additives
-Method 3: dextrose, amino acids, & fat emulsion added simultaneously while swirling & mixing. Add additives last

Procedures To Prepare Reconstituted Injectable and Noninjectable Medications

-reconstitution: mixing liquid & powder to form a suspension/solution
-measure solute & solvent (distilled water) to be used
-add solute to solvent in small portions & mix
-check precipitation for solutions or changes in color
-add new expiration date & affix a "shake well" auxiliary label

Procedures To Prepare Radiopharmaceuticals

-may be diagnostic/therapeutic; oral/IV/inhaled
-individual must wear meter indicating radioactive levels to which individual is exposed
-quality-control tests perform to ensure radiopharmaceutical is sterile, pyrogen-free, & pure
-proper handling of isotopes during preparation & disposal
-radiopharmaceuticals: prepare in vertical flow hood, strict packaging requirements (special shipping containers)
-safety principles of time, distance, & shielding
-special training completed if one is to work in a nuclear pharmacy

Procedures To Prepare Oral Dosage Forms

-Unit dose: provides medication in "final unit of use" form. Contained in small packet (made of thermal paper & foil laminate; other side of poly film material)
-machines are manually, semiautomatically, or automatically loaded
-single-drop machine: 60 packages/min
-double-drop machine: 120 packages/min
-machine drops drug into package, seals, & prints medication info in one operation

Procedures To Compound Sterile Noninjectable Products

Factors considered in preparing ophthalmic products:
-sterilzation: by autoclave, filtration, gas, radiation
-clarity: free from foreign particle (filtration)
-stability: affected by chemical nature of drug, pH, method of preparation, solution additives, & packaging
-Buffer & pH: should be formulated at 7.4 pH but rarely occurs. pH chosen should be optimum for stability
-Tonicity: osmotic pressure exerted by salts. Isotonic solution have tonicity = NaCl 0.9%
-Viscosity: agents used to prolong contact time in eye & enhance drug absorption & activity

Procedures To Compound Nonsterile Products

-blending: combing 2 substances
-comminution: reduce substance to small, fine particles
-geometric dilution: mixing 2 ingredients of unequal quantities (begins with smallest quantity & adds equal quantity of ingredient with larger amount)
-emulsifier: stabilizing agent in emulsions
-flocculating agent: electrolytes used in preparations of suspensions
-levigation: trituration of powder drug with solvent (drug is insoluble)
-mucilage: wet, slimy liquid formed as initial step in wet gum method
-pulverization by intervention: reduce particle size in solid with aid of additional material
-sifting: blend or combine powders
-thickening agent: ingredient used in preparation of a suspension to increase viscosity
-trituration: rubbing, grinding, pulverizing powder to create fine particles
-tumbling: combine powders in bag & shake

Weighing Procedures

-unlock balance, make sure it's level, relock
-place weighing paper on
-unlock scale & ensure it's balanced
-place weights on right-hand pans using forcep
-place material on left-hand pans
-release beam by unlocking balance
-lock balance before adding/removing additional powder
-unlock to check for equilibrium
-close lid & have pharmacist verity weight
-remove ingredient & remove weight with forceps

Measuring Using a Torsion Balance

-leave balance in draft-free area
-make sure bubble is inside bull's-eye & adjust using leveling feet
-place weighing boat/paper on pan
-press tare bar to compensate for weighing boat
-add ingredients

Procedure For Measuring Liquids

-choose proper size graduate (quantity to measure not <20% of total volume of graduate)
-pour liquid into graduate
-measure level of liquid at eye level & observe bottom of meniscus
-pour liquid into container

Procedure For Filling Capsules

-triturate ingredients to same particle size, mix using geometric dilution
-calculate enough for several extra capsules
-place powder on ointment slab where depth of powder is 1/2 length of capsule body
-hold capsule vertically & punch the open end into powder until it's filled
-place cap on capsule & weigh using empty capsule as counterweight
-add/remove ingredients as needed

HINTS:
-remove exact # of capsules from box
-wear finger cots to protect fingers
-roll capsules on clean towel to remove traces of drug
-place completed capsules in glass/plastic vial
-store in dry place

Emulsions

-contains 2 immiscible liquids; 1 dispersed throughout another & aided by stabilizing agent
-may be oil-in-water (O/W) or water-in-oil (W/O)
-Ex: continental, wet gum, & beaker method

Continental Method (Dry Gum Method)

-primary emulsion: 4 parts oil, 2 parts water, 1 part gum (emusifier-acacia)
-with Wedgwood or porcelain mortar, gum & oil levigate
-water added & trituration continues
-additional ingredients added up to initial volume with external phase

Wet Gum Method

-primary emulsion: formed by triturating 1 part gum & 2 parts water to form mucilage
-slowly add 4 parts oil & triturate slowly
-add additional ingredients

Beaker Method

-water-soluble & oil-solute ingredients mixed in separate containers
-both heated to 70 degrees C, removed heat
-internal phase added to external phase
-final product cooled to room temp. but continually sirred

Powders

-prepared through trituration & geometric dilution

Liquid Drug In Liquid Vehicle

-measure quantities of each liquid
-add drug to vehicle slowly
-shake & stir

Solid Drug In Liquid Vehicle

-weigh solid & measure solvent
-consider solubility of drug & solvent
-may need to heat gently, stir, or shake

Nonaqueous Solutions

-contain solvents other than water; include elixirs, tinctures, spirits, fluid extracts, glycerates, collodions, liniments, & oleaginous solutions
-dissolving alcohol-soluble ingredients in alcohol & & water-soluble ingredients in water
-add alcohol portion to aqueous portion & stir

Suppositories

-may be oleaginous, water soluble, hydrophilic
-compression mold: mix suppository base & drug ingredients. Force mixture into special mold
-fusion mold: active ingredients dispersed or dissolved in melted base. Suppository base melted at low temp. & drug dissolve in it. Base poured & overfilled into special mold (metal, plastic, or rubber) & left to harder. Excess material removed from top of mold

Suspensions

-solid drug to be suspended is weighed & levigated in mortar & pestle with alcohol or glycerin
-portion of vehicle added to mortar & mixed with levigated drug until uniform consistency occurs -> placed in final container
-mortar & pestle rinsed with balance of vehicle & suspension is added up to final volume with vehicle being used
-"shake well" label affixed to container
-flocculating & thickening agents may be used

Syrups

-Heat Method: heat needs to be controlled, works fastest but not all ingredients can be used with heat
-Without Heat Method: must use container that's twice the size of final volume. syrup needs to be shaken/stirred

Procedures To Prepare Ready-To-Dispense Multidose Packages

Preparing Ointments:
-prepared on ointment slab
-weigh quantities of each ingredient
-use geometric dilution & 2 spatulas to mix
-transfer final product into ointment jar by spatula
-remove air pockets of ointment by spatula
-ointment bases chosen based on their characteristics to deliver a drug

Aseptic Techniques For Technicians

-no jewelry worn in hood (includes artificial nails)
-long hair tied back
-hands washed after entering IV area & before entering laminar flow hood
-hands, wrists, & arms to elbow wash with antimicrobial soap & hot water for 30-90 seconds
-gloves can be worn but wash down with 70% isopropyl alcohol after being put on
-surface of hood washed down with 70% isopropyl alcohol
-hood run 30< before medications placed in
-all vials & ports wiped down with alcohol, not sprayed
-hands or any object within hood cannot block airflow at any time
-work 6< inches into horizontal hood; keep pens & other objects out
-all needles, syringes, vials, & other by-products must be disposed of in proper receptacles
-no sneezing, talking, or coughing can be directed toward airflow in laminar flow hood

Universal Precautions

-apply to all individuals in any institution who may come in contact with blood, body fluids or substances
-latex gloves must be worn
-hands must be washed after removing gloves
-blood-soaked or contaminated materials disposed in wastebasket lined with plastic bag
-specially trained individuals must be notified for cleanup or removal of contaminated waste
-first-aid kit must maintained & adequately stocked for use if individual comes in contact with contaminated waste or body fluids.
-First-aid kit: adhesive bandages, alcohol, antiseptic or disinfectant, bleach, disposable latex gloves & towels, medical tape, sterile gauze, plastic bags for waste disposal

Requirements For Handling Hazardous Products and Disposing Of Hazardous Waste

-sharps containers for used syringes, needles, ampules, & vials. Needles should be clipped or snapped
-biohazard containers: other refuse like gloves, gowns, masks, shoe & head coverings, any clothing or linens that come in contact with body fluids

Documentation Requirements For Controlled Substances, Investigational Drugs, and Hazardous Wastes

-DEA Form 224: register a pharmacy with DEA to be able to stock controlled substances
-DEA Form 222: to order Schedule II drugs
-DEA Form 41: to destroy outdated or unused controlled substances
-DEA Form 106: to report theft of controlled substances
-power of attorney: authorizes a pharmacist to order Schedule II durgs

Pharmacy-Related Software For Documenting The Dispensing Of Prescriptions Or Medication Orders

-software customized to meet requirements of pharmacy
-outpatient dispensing software used to reduce errors, increase productivity, & perform inventory management
-impatient dispensing software: used to reduce staff, accessible to medical staff & regulates controlled substances, must interface with various computer systems in hospital.
-Hospitals use robotics possess capability of scanning unit-dose labels & filling patients' orders

Customer Service Principles

-customer satisfaction is the goal of customer service
-pharmacist called to handle any difficult situation
-technician listen carefully, make eye contact, repeat what customer had said, use positive language to emphasize what can be done rather the opposite.
-If using phone, maintain a pleasant & courteous manner, state name of pharmacy, his/her name, adhere to standard procedures est. by pharmacy, refer any questions requiring pharmacist's judgement to the pharmacist

Communication Techniques

-appearance
-empathetic responses to customer
-listening
-nonverbal communication
-phone skills
-verbal communication
-writing skills

Patient Confidentiality Requirements

-HIPAA requires any personally identifiable info be protected as being confidential
-patients allowed to access & request copies of their medical records & entitled to complete discussion of health care options from health care provider (can request confidentiality)
-health care provides & organizations must provide written statement that states how medical info will be handled
-every organization must have a written privacy procedure

Cash-Handling Procedures

-technician may be required to ring into cash register Rx & other purchases
-should accept & count payment within sight of patient
-etc... common sense

Average Wholesale Price (AWP) Applications

-form or reimbursement: AWP plus/minus percentage plus dispensing fee
-most commonly used & encourages pharmacy to dispense generic medications bc percentage of return is greater for generic than brand-name

ACC

-actual acquisition cost
-price pharmacy actually paid for medication after receiving any discounts
-may be used instead of AWP

MAC

-maximum allowable cost
-maximun price insurance company will pay for generic medication

Capitation Fee

-reimbursement system
-pharmacy receives fixed payment each month per patient, regardless of # of Rx filled or cost of Rx filled
-commonly used by health maintenance organizations (HMOs)

Deductible

-set amount that must be paid by patient for each benefit period before insurance will cover additional expenses

Per Diem

-predetermined amount of money paid to an individual/institution for daily service

Copayments

-fixed: patient pays fixed/set dollar amount
-percentage: fixed percentage of total cost of Rx
-variable: different dollar amount charged based on type of drug dispensed; could be for lifestyle drug, nonformulary drug, or medication with DAW2 code
-DAW2 code: indicates prescriber has authorized use of generic medication but patient has requested brand-name medication

Health Maintenance Organization (HMOs)

-purpose: keep patient healthy, control costs by mandating generic usage
-composed of network of providers employed by HMO or signed contracts with HMO
-expenses not covered outside network unless referral has been made

Preferred Provider Organization

-network of providers contracted by insurer that offers most flexibility to patient
-costs outside network may be partially reimbursed
-do not require physician within network to make referrals

Point Of Sale

-network of providers under contract by insurer
-patients required to choose a primary care physician & obtain referral from primary care physician for services outside network

Medicare

-federally funded program for individuals 65<, disabled individuals <65, & patients with kidney failure

Medicaid

-federally funded program administered by states
-states determined eligibility & services rendered
-Rx drug formularies used, not all drugs covered

Patient Assistance Programs

-special programs offered by pharmaceutical manufacturers for patients with specific needs who may be unable to afford their medication

Worker's Compensation

-federal & state laws require compensation for patients who have been accidentally injured on the job
-Rx for medications from injury are billed to state bureau of workers' compensation or employer

Legal Requirements For Pharmacist Counseling Of Patient or Patient's Representative

-offer to counsel must be made for every patient
-counseling: name & description of medication, dosage form, route of administration, duration of drug therapy, action take if dosage missed, common side effects, interactions & contraindications, self-monitoring for drug therapy, Rx refill info, proper storage, & special directions

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