PHARM 303 LEC: Dispensing 2 LEC

Course Outline - SE (what to do if there is unexpected SE

I. Prescription Analysis 2. Pharmacist
1. Analysis of Medication & Prescription Order  Drug Procurement

3. Extemporaneous Compound & ℞cal PDTs.

2. Dosing Schedule - Buy drugs that are in good quality
 Drug Distribution
II. Medication Review - Moving the drug safely wherever they will be
1. Goals of Medication Review dispense
2. Components - Eg. Vaccines are stored in the ice box
III. Medication Related Problems  Drug Prescribing
1. Classification - OTC drugs
2. Factors  Drug Monitoring
3. ADRs & its Corresponding Intervention - pharmacist are called for long term tx / chronic
4. Side Effects & Toxicities & Its Corresponding condition such as TB, HTN, heart failure and etc. for
Intervention further monitoring / adjustment of dose
5. Medication Adherence  Communication with Physician
IV. Physico- Chemical Incompatibilities - For clarification
A. Physical - Act professional
B. Chemical  Patient Counselling
C. Therapeutic - Acquired skills that provide opportunity to elicit
a. Pharmacokinetic necessary info.
b. Pharmacodynamics - To enable safe and effective use of medicines
V. ADR (ABCDEF) Prescription Analysis
VI. Patient Medication Counseling PRESCRIPTION
INTRODUCTION TO DISPENSING - An order for medication issued by a physician, dentist,
Dispensing veterinarian or other properly licensed medical
- The act, by validly – registered pharmacist, of filling a practitioner.
prescription or doctor’s order on a patient’s chart (DOH - Prescriptions may be written by the prescriber on pre-
A.O. No. 63 s. 1989) printed pads or forms and given to the patient for
- It encompasses the pharmacist’s role of receiving the presentation at the pharmacy.
prescription or medication order, compounding or - It may be telephoned or communicated directly to the
preparing the medicine and providing medication advice pharmacist by means of a fax machine or may be
to the patient, representative of the patient or other electronically sent from a physician’s computer to a
health professionals upon delivery of the medication pharmacist’s computer(e-prescribing).
(Briones et al., 2000) - A prescription written by a veterinarian generally
- The preparation, packaging, labeling record keeping and includes the animal species and/or pet’s name and the
transfer of a prescription drug to a patient or an name of the owner.
intermediary, who is responsible for administration of 2 Boards Categories of a Prescription:
the drug. 1. Those written for a single component or prefabricated
The Prescriber & the Pharmacist’s Role in Dispensing product and not requiring compounding or admixture by
1. Prescriber the pharmacist.
 Diagnosis 2. Those written for more than a single component and
- ensure correct diagnosis and explain it to the pt.
requiring extemporaneous compounding.
[compliance]
PART OF A PRESCRIPTION
 Prescribing
- Prescribe few d. as possible since it can cause
interaction to the other d. it can also lessen the
toxicity, side effect and lessen the cost of the
medication.
 Drug Information
- explain how each d. should be taken
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PHARM 303 LEC: Dispensing 2
  Where generic name is not written
 Where the generic name is not legible and a brand
name which is legible is written
 When the brand name is indicated and instructions
added (such as the phrase “no substitution"] which
tends to obstruct, hinder or prevent proper generic
dispensing.
What to do with violative prescriptions
Violative prescriptions shall not be filed. They are kept and
reported by the pharmacist of drug outlet or any other
interested party to the nearest DOH office for appropriate
action. The pharmacist shall advise the prescriber of the
problem and/or instruct the customer to get the proper
prescription.
(1) Prescriber Information and Signature
3. Impossible Prescription
- Clarification purposes; Verification
 When only the generic name is written but it is not
- Signature makes the Rx a legal doc; Validity
legible.
(2) Patient Information
 When the generic name does not correspond to the
- For identification, calculation of dose and record
brand name
purposes
 When both the generic name and the brand name are
(3) Date Prescription was written
not legible
- To determine if the Rx is current
 When the drug product prescribed is not registered with
- Duration of the d.
FDA
* Doxycycline for Acne – 2 months
What to do with impossible prescriptions
* TB- 6 months – 1 Year Impossible prescription shall not be filed. They shall be and
* Yellow Rx – 1 Month reported by the pharmacist of drug outlet or any other
(4) Rx symbol (Superscription), meaning “take thou”, “you interested party to the nearest DOH office for appropriate
take”, or “recipe” action. The pharmacist shall advise the prescriber of the
- Rx symbol make it an official doc. problem and/or instruct the customer to get the proper
(5) Medication Prescribed (Inscription) prescription
- Dose, Strength, dosage form B. According to Preparation
(6) Dispensing instruction to the pharmacist (Subscription) 1. Compounding
- no. of dose to be dispense - There is a list of ingredients found in the prescription and
(7) Direction to the Patient (Signa) the pharmacist has to compound and prepare.
(8) Special Instruction. Refill. - Should contain the quantities of each ingredient
Types of Prescription required.
A. According to Generics Act - Eg. Paper Tabs
1. Erroneous Prescription
2. Non-Compounding/ Ready-To-Use Medications/ Ready
 Where the brand name precedes the generic name
-To-Dispense
 Where the generic name is the one in parenthesis
- Dosage Forms are already available for dispensing or use.
 Where the brand name is not in parentheses
- Eg. Tablet, Syrups, Capsule
 Where more than one drug product is prescribed on
C. According to Content
one prescription form 1. Ethical Drug
What to do with erroneous prescriptions
- Drugs that require prescription (Rx Prescription)
Erroneous prescriptions shall be filed. Such prescription
- Cardiac drugs, antimicrobial drugs, antidepressant
shall also be kept and reported by the pharmacist of the
2. Narcotic or Exempt Drug
drug outlet or any other interested party to the nearest
- Prescribed by a physician with an S2 License
DOH office for appropriate action.
2. Violative Prescription - Anxiolytics – Benzodiazepines (valium, Xanax)
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PHARM 303 LEC: Dispensing 2
 RULES IN WRITING IN A PRESCRIPTION
- A whole number should be shown without a decimal
point and without a terminal zero.
5.0
- Leave a space between the number and the unit.
50mL / 50 mL
- Use USP designations for units of measure.
mL, Grams, Tablespoon
- Spell out “units”
- All written prescriptions must be legible
- Avoid use of abbreviations for drugs and directions with
ambiguous meaning
- All dosage strength should be written using the metric
system including the dose
- Provide the age of the patient and when appropriate, the
weight
- A leading zero should always precede a decimal point. In
quantities less than 1 a trailing zero should never be 1. Patient’s full name, address, age, weight, sex
used. 2. Physician’s name
Leading Zero - 0.5
3. Patient’s room number
Trailing Zero – 5.0
- When possible, include the purpose of the medication – 4. Date and time of the order
found in the signa 5. Name of the medication (order)
- For drugs that are SALAD preferably print the name of 6. Ordered dosage
the drug 7. Form of the medication
MEDICATION ORDERS 8. Route of administration
- Written directions in a hospital setting provided by a 9. Time or frequency of administration
prescribing practitioner for a specific medication to be 10. Signature of the ordering physician or licensed
administered to an individual individual
- The medication order should be given by a licensed Types of a Medication Order
person Stat Orders
- These orders should be co-signed by the prescribing - Administered immediately and only once
practitioner for verification purposes  Epinephrine 0.3 mg IV – Administer immediately for
- A medication order can be given verbally for emergency an acute allergic reaction or anaphylaxis.
cases only and should be written thereafter by the  Demerol 100mg IM stat – opioid analgesic
licensed person  Naloxone 4 mg IV – Administer immediately in case of
The Seven Important Questions opioid overdose.
1. What is the name of the medication? Single Orders
2. What is the purpose of the medication? - Only given once but not necessarily immediately
3. What effect will the medication have on the individual?  Seconal (general anesthetic) 100mg hs before surgery
4. How long will it take the medication to work?  Midazolam 2 mg IV – Administer once before a
5. What are the side effects, adverse reactions and/or signs
procedure for sedation
of over dosage of this medication?
6. Are there any interactions with the medications that the  Dextrose 25% 50 mL IV – Administer once for a
individual is taking? hypoglycemic episode.
7. Are there any special administration or storage Standing Orders
instructions for this medication? - Order for a medication that will be given at specific times
Parts of a Medication Order until it is discontinued by a doctor’s order or by default
when a facility’s policy states that all standing orders are

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PHARM 303 LEC: Dispensing 2
automatically discontinued after 7 days unless the c. What routes could be used to administer the
physician has reordered the medication. acetaminophen based from the order?
The acetaminophen is administered orally (p.o.).
 Multivitamin 1 cap po daily
“Hydrocortisone 1% cream thin layer to (L) inner wrist
 Acetaminophen 500 mg oral every 6 hours
area tid”
 Albuterol 2.5 mg nebulized every 4 hours
a.What is the concentration of the hydrocortisone cream?
PRN Orders The concentration of the hydrocortisone cream is 1%.
- Indicates that the ordered medication is only given when b.What is the route?
a specified condition, like pain, discomfort or nausea is The route is topical.
c. Where should the cream be applied?
present
The cream should be applied to the left (L) inner wrist area.
 Ibuprofen 1 cap q4h for pain d.How many times per day?
 Diphenhydramine 25 mg po hs for insomnia/ allergy The cream should be applied three times per day (tid).
 APAP 500mg q4h for fever
Medication Log Entry “Dilantin Infatabs 150 mg tabs, 2 tabs p.o. tid”
- Medication Log is a legal document where the a.What is the Dilantin dosage that needs to be given in
medication administered is written. The individual who milligrams?
150 mg per dose
administered the drug should always sign and place the The dosage per administration is 300 mg (2 tabs × 150 mg each).
date and time of administration b.How often should it be given?
- This is to check if the drug administered matches the It should be given three times per day (tid).

prescribing practitioner’s order and pharmacy label

“Erythromycin 333 mg 1 tablet p.o. qid x 10 days”
- All medication log should contain the following:
a.What is the route?
 Individual’s Name The route is oral (p.o.)
 Guardian’s name and contact information, if b.How many times per day will you give the erythromycin?
applicable Erythromycin will be given four times per day (qid).
 Allergies, if applicable c. Over the 10-day period, how many total dosages of
erythromycin will be given?
 For each medication prescribed: Over the 10-day period, a total of 40 doses will be given (4 doses per
✓ Name day × 10 days).
✓ Dosage
✓ Frequency Dosing Schedule
✓ Route Frequency Standard Time of Administration
✓ Prescribing Practitioner Name Daily 9AM
BID 9AM 9PM
✓ Order Date
TID 9AM 1PM 5PM
✓ Special Considerations in administering the
QID 9AM 1PM 5PM 9PM
medication, if applicable, as directed by the Q12H 7AM 7PM
prescribing practitioner or the pharmacist Q8H 7AM 3PM 11AM
✓ Date and time of administration Q6H 7AM 1PM 7PM 1AM
✓ A place for you to sign or show your initials and Q4H 7AM 11AM 3PM 7PM 11PM
signature hs (bedtime) At bedtime, typically around 10 PM to
How to Read and Interpret a Medication Order midnight.
- One must be familiar with the medical abbreviations ac (before 6:30 11:30 4:30
frequently used in a prescription and medication order meals)
Pc (after 7:30 12:30 5:30
Examples:
meals)
“Acetaminophen 325 mg tabs 2 p.o. or 650 mg prn
q4h for HA or fever” Pharmacist’s Role in a Medication Order
a.How many milligrams are in each acetaminophen tablet? - Pharmacists have a critical role in the prevention of
Each acetaminophen tablet contains 325 mg
adverse drug events. Every medication order should be
b.How long should the patient be given acetaminophen?
The acetaminophen should be given as needed (prn) every 4 hours for reviewed by a pharmacist to ensure appropriate
headache (HA) or fever, as long as symptoms persist or as directed by a selection of drug, dose, route and frequency as well as to
healthcare provider.
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PHARM 303 LEC: Dispensing 2
 check for interactions with other medication.
Pharmacists can conduct the reviews either in the
pharmacy or on patient care units if they have access to
patients’ profile information.
- Pharmacists are obliged to review each medication order
in a step-by-step manner to detect errors of omission
and commission.

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PHARM 303 LEC: Dispensing 2
 Medication Management Services such as adverse effects, drug interactions, incorrect dosages, or non-
- Professional activities needed to meet the standard of compliance.
6. Develop a care plan addressing recommended steps,
care which ensures each patient’s medications (whether
including therapeutic changes needed to achieve
they are prescription, nonprescription, alternative,
optimal outcomes
traditional, vitamins, or nutritional supplements) are
7. Patient agrees with and understands care plan, which
individually assessed to determine that each medication
is communicated to the prescriber/provider for his or
is appropriate for the medical condition being treated,
her consent/support.
that the medication is being effective and achieving the
8. Document all steps and current clinical status versus
goals established, that the medication is safe for the
goals of therapy
patient in the presence of co-morbidities, and other
9. Follow-up evaluations with the patient are critical to
medications the patient may be taking, and the patient is
determine effects of changes, reassess actual
able and willing to take the medications as intended.
In pharmacy practice, assessments are completed in a systematic and
outcomes, and recommend further therapeutic
comprehensive manner to ensure that all aspects of a patient's changes to achieve desired clinical goals/outcomes,
medication therapy are thoroughly evaluated. other team members and personalized goals of
- Medication management services include an
therapy are understood by all team members.
individualized care plan that utilizes the patient’s
10. Comprehensive medical management is reiterative
medication experience and preferences to determine the
process-care is coordinated with personalized goals of
desired goals of therapy with the patient, as well as
therapy are understood by all team members.
appropriate follow-up to evaluate actual patient
outcomes that result from the care plan.
Medication management services are the activities which
Appropriate follow-up to evaluate patient outcomes is essential because
it ensures that the patient understands, agrees with, and actively are recognized by nonpractitioners as evidence that care is
participates in their treatment regimen. This collaborative approach being provided; it is what is recognized as valuable by a
helps to optimize both the medication and the overall clinical
experience for each patient.
payer, and are deemed necessary to achieve success if you
- Medication management services must be Delivered and are an administrator.
documented in a manner that adds unique value to the Approaches to Medication Management Services
care of the patient and integrates easily with the medical 1. Prescription Approach
team caring for the patient. - Activities performed at the time of dispensing the drug
Ten Steps to Achieve Comprehensive Medication product to the patient.
Management - Activities include:
1. Identify the patients who have not achieved clinical  Generic substitution
goals of therapy.  Drug Formulary Reconciliation (determine the
2. Understand the patient’s personal medication available drug in the establishment)
experience/history and preference/beliefs  Provision of D info
Gather information about the patient’s past experiences with  Dse. Education focused around the D pdts (explain in
medications, including any issues or successes, and understand their
preferences and beliefs regarding treatment. Eg: Jehovah's Witnesses
layman’s terms)
typically refuse blood transfusions, Muslim (halal medicines)  Population based clinical rules for the use of the
3. Identify actual use patterns of all medications including patient
over-the-counter, bioactive supplements, and  Some drug specific monitoring
prescribed medications - Performed depending on the available time of the
This includes evaluating dosage, frequency, and adherence to ensure pharmacist and the patient at the moment of dispensing
that the medications are being used as intended.
4. Assess each medication for appropriateness, - These activities begin with the prescription and are
effectiveness, safety and adherence focused on almost exclusively focused on a specific drug product
achievement of the clinical goals for each therapy. - Advantages:
Evaluate whether each medication is suitable for the patient’s condition,  Limited training of the pharmacist is required
whether it is achieving the intended effects, if it is safe for the patient,  Only those that are most comfortable for the
and if the patient is adhering to the prescribed regimen.
pharmacist and can be delivered with confidence are
5. Identify all drug therapy problems
the ones that are offered. This is seen as an advantage
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PHARM 303 LEC: Dispensing 2
 for those wanting a quick and easy approach to - Pharmacists contribute essential and new knowledge to
providing these services the care of patients; however, the ability to do this has
- Disadvantages been limited by the lack of recognition and payment for
 No standard service-which should be delivered by all these services. This is now changing with the acceptance
pharmacists in a similar manner of medication management services as a necessary
 Activities can be disruptive to the dispensing process- component for optimal patient care.
make the dispensing process more inefficient and less The Patient Care Process
accurate because of the disruption - Completion of all steps is necessary to practice
 Has limited impact to the pt pharmaceutical care and to have a positive impact on
 Payment service is relatively low for the pharmacist. your patient’s medication experience.
2. Patient-Centered Approach - Process is continuous and occurs over multiple patient
- Delivers medication management services completely visits
separate from the dispensing process  The Foundation of the Patient Care Process: The
- Includes a specially trained practitioner who is usually a Pharmacotherapy Workup
pharmacist working in a clinical setting  A rational decision-making process used in
- Includes the patient-the practitioner works face-to-face, pharmaceutical care practice to identify, resolve
or telephonically, usually on an appointment basis, in a and prevent drug therapy problems, establish
systematic manner to deliver a consistent service, and goals of therapy, select interventions and evaluate
applies specific standards of care to each patient outcomes
encounter  In contrast, the patient care process, is what the
- Starts with understanding each patient’s patient experiences when he or she receives
- Advantages pharmaceutical care; where the practitioner’s
 Delivered in a manner that is consistent with, and can unique knowledge and clinical skills are applied to
be easily integrated into, the delivery of care by a solve health care problems for the patients.
medical team 1. Assessment
 It is easy for a prescriber to refer patients to particular - Purpose:
practitioner a. To understand the patient and the patient’s
 Documentation is extensive (all details are written) medication experience well enough to make rational
- Disadvantages drug therapy decisions with and for him or her
 Training of practitioners in the practice of b. To determine if the patient’s drug therapy is
pharmaceutical care is not yet the focus of most appropriate, effective, safe & if the patient is
colleges in pharmacy compliant
 Approach requires that pharmacists to have a c. To identify drug therapy problems
dedicated time to deliver the service - Information required to make clinical decisions with your
 Meaningful Documentation is required (don’t skip patient includes patient data, disease data, and drug
some details data
Taking Responsibility for Medication Management - Three major activities that occur during the assessment:
Services [1] Gathering of info. From the pt & pt past health record
- Drug therapy has been the focus of the pharmacist. [2] Elicit the pt’s medication experience
Dispensing the medications has been the primary [3] making clinical conditions about the pt’s medication
responsibility for most pharmacists for the past six & identifying D therapy problems
decades; however, since the 1960s pharmacists have - Assessment begins by getting to know your patient by
been expanding their responsibilities in the patient care discussing the patient’s medication experience
arena  Patients relate to the impact that taking medications
- Medication management services are meant to have on their everyday lives as their medication
complement and not replace the existing patient care experience
practices to make drug therapy more effective and safer.

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PHARM 303 LEC: Dispensing 2
  Medication experience-patient’s personal approach to - If the patient has multiple medical conditions, the care
taking medication plan will have to be integrated and a single care plan
- Sum of all events in a pts life that involve medication use presented to the patient
- pt’s belief, perception, understanding, attitude & behavior about D
therapy.
- First and most important step in the care planning
 The more you know about the patient’s medication process is to
experience, the more likely you are to have a lasting - Goals of therapy consist of parameter, a value and a time
and positive influence on it. frame.
Most directly influence the pt’s decision about whether to take the  Used to describe the future desired endpoint
medication or not, how much of the medication to take & how to take  Guide all subsequent decisions, actions, interventions
the medication
 Medication experience – includes technical aspects as and patient education
well  Must be understood and agreed upon by the
 Pharmaceutical care practitioner has a responsibility practitioner and patient
to understand the patient’s medication experience - Each care plan contains a plan of action to be taken on
because it directly impacts the decisions a patient behalf of the patient.
makes about his or her drug therapy. - Care plans contain interventions designed to:
- Although physicians, nurses, and pharmaceutical care  Resolve drug therapy problems
practitioners can make suggestions to a patient, it is the  Goals of therapy cannot be achieved until and
patient who ultimately decides what he or she will do unless the patient’ drug therapy problems are
about taking the medication. successfully patient’s
- Major decisions that the pharmaceutical care  Most common interventions are to:
practitioner makes during the assessment  Initiate new D therapy
 Whether the patient’s drug related needs are being  Discontinue D thx
met at this time  Increase dose
 Whether the patient is experiencing drug therapy  Decrease dose
problems  Provide pt specific education
2. Care Plan  Refer the pt to another HCP with the experience
- To organize all of the work agreed upon by the needed to solve the pt’s HC problem
practitioner and the patient to achieve the goals of  Achieve the stated goals of therapy
therapy  include changes in drug therapy regime
- Requires interventions to resolve drug therapy problems,  individualized patient instructions to the optimal
to meet these goals, and to prevent new drug therapy use of medications, related technology, and/or diet
problems from developing, thereby optimizing the and exercise to increase the probability of success
patient’s medication experience with the mediation regimen
- Consulting a care plan which is done in collaboration  Interventions made to prevent the development of
with other HCP and with the pt. drug therapy problems are necessary to complete
- Care plan is developed primarily to help the pt. achieve a care plan. These interventions are especially
the established goals of the thx for his/her medical more important for patients who have a higher-
condition/ illness than-normal probability of developing a drug
- Care plan id organized by condition (separate care plan therapy problem due to some identified risk
for each condition) factors
- Organized by medical condition, and a separate care plan  Prevent new drug therapy problems from developing
is constructed for each condition or illness. 3. Follow-up Evaluation
- Involves three steps: - To determine the outcomes of drug therapy, compare
[1] Establish the goals of therapy of each D these results with the intended goals of therapy,
[2] Selecting appropriate individualize intervention determine the effectiveness and safety of
[3] Scheduling the next follow up pharmacotherapy, evaluate patient adherence, and

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PHARM 303 LEC: Dispensing 2
 establish the current status of the patient’s medication
conditions being managed with drug therapy
The result of their clinical action are judge by their (+) or (-) impact to
the pt.
- Decision regarding when to schedule the next follow-up
evaluation needs to incorporate the timing of the
expected positive outcomes, achievement of the goals of
therapy, and the probable timing of any negative
outcomes including side effects and/or adverse reaction
from the medication
- Where clinical experience and new knowledge are
gained because the practitioner sees which medication &
dose were must effective or cured the most harm.
- In a well-conducted follow-up evaluation, the
practitioner evaluates the patient’s response to drug
therapies in terms of effectiveness, safety and
adherence.
- Specific activities performed at a follow-up evaluation
are described as follows:
 Observe or measure the positive results the patient
has experienced from drug therapies
 Observe or measure any undesirable effects the
patient has experienced that were caused by a drug
therapy
 Determine the actual dosage of medication the
patient is taking that is producing the results observed
Reassess the patient to determine if he or she
developed any new drug therapy problems

An important goal of completing the patient care process is

to establish a meaningful, therapeutic relationship with the
patient

Reference: Cipolle, R., Strand, L. & Morley, P. (n.d.)

Pharmaceutical care practice: The patient-centered
approach to medication management.

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PHARM 303 LEC: Dispensing 2