DISPENSING AND PRESCRIPTIONS Flashcards
What do the legal classes of medicines affect
- how patients can obtain them
- who can order, give AND administer the medicines
what are the 3 legal classes of medicines + 1 extra
GSL = General sale list (e.g. in gas stations etc)
P = Pharmacy meds
POM = Prescription only medicine (only under authorised prescriptions)
- under POMS → some are PGD = Patient group direction: can be given to patients without needing prescriptions e.g. flu vaccine
PO - legally classified as a GSL med, but usually advice needed to be given with them, so can only be sold from a pharmacy
what is a prescription? what does it do etc.
a document detailing medicine to be dispensed either paper or electronic
- written by authorised prescriber / practitioner
- each medicine listed is prescription item
- fulfils three roles: clinical document, legal document, invoice
- most valid for 6 months
examples of prescribers
Doctors
Dentists
Vets
examples of non medical prescribers
pharmacists
nurses
opticians
specialists with training
What colour are FP10 GP prescriptions
green
What colour are FP10D dentist prescriptions
yellow
NHS Community vs hospital prescriptions;
Community:
1. only to be used for NHS patients
2. differ in colour and format by devolved nation
3. e.g. doctors, dentists
Hospital:
1. only for NHS patients,
2. Inpatient and outpatient ones
3. May include electronic prescribing systems → format varies
4. the drug chart (known as the prescription) also includes administrative record.
inpatient vs outpatient
Inpatient (STAY IN HOSPITAL) & outpatient (VISITING E.G FOR A CLINIC)
private prescriptions traits:
- mostly same info as nhs scripts, just no set template
- no standard format except controlled drugs
- has qualifications of the prescriber e.g. doctors etc
->example: all vet prescriptions
NHS prescription journey - community
- Patient visits GP
- Prescription is issued as appropriate
- Patient takes to community pharmacy or accesses electronic prescription
- Prescription is clinically checked and medicines dispensed & accuracy checked, plus check details e.g. DOB, if they’re medically exempt
- Patient counselled and takes medicines away
- Prescription goes to NHS Business Services Authority (NBSA) for pricing & payment
Some examples of medical exemptions:
- low income
- benefits
- medical conditions like diabetes
- maternity leave / after birth
- armed forces
- age e.g. under 18 & full time education
PRESCRIPTION REQUIREMENTS for a standard legal one
- Signature of appropriate practitioner (indelible ink)
- Address of the appropriate practitioner
- Appropriate Date on which signed
- Particulars of the prescriber
- Patient NAME
- Patient Address
- Patient Age if under 12 years old
→ the same requirements apply to private prescriptions
what prescriptions may require more requirements than the usual 7
- controlled drugs like morphine
- scripts from another country
Medical Abbreviations - Time: days, weeks, months
- x /7 indicates a number of days
- x/52 indicates a number of weeks
- x/12 indicates a number of months
where 1 month is 28 days
What is a clinical check of a prescription?
“The purpose of a clinical check by a pharmacist is to ensure that the medicine supplied is both safe and effective for use by a particular patient in relation to the risk and benefit to the patient”
Aspects of a clinical check:
- is the medicine right for the presenting patient
- is the medicine right for the presenting condition
- is the dosage appropriate
- is the formulation appropriate
- are there any interactions with the patients existing meds
THE 3 KEY ELEMENTS OF A CLINICAL CHECK
- the patient
- the medication
- adminstration & monitoring of the prescribed medication
- Patient factors: the type of patient: what do we consider before we give a med
- who are they? do they fall into a group where treatment is cautioned or contra-indicated
- specific patients that fall into these groups = children, pregnant/breastfeeding, and elderly
- consider gender, certain ethnic groups, and past or present drug use
- consider intolerences / preferences: allergies, dietary intolerances & religious beliefs
- if there are any co-morbidities (conditions to check as we may have to adjust doses etc)
cautioned meaning
when the drug should be used with care to avoid any danger or personal risk
contra-indicated meaning
when the drug should not be used because it may be harmful to the patient: can be relative & absolute
- Medication factors: what do we look at in a clinical check?
- it’s indication of the medication, whether treatment is appropriate, if its within recommended guidelines
- if the prescription or it’s strength or dose has changed
- whether the medication has any interactions with the patients other drugs, maybe even antagonistic ones
checking if the dose, freq & strength is appropriate includes looking at
- age
- renal or hepatic function
- weight
- lifestyle patterns
- co-morbidities
- other drug treatments
- whether it’s appropriate for the formulation
Administration & monitoring of the prescribed medication: what do we look at
e.g. if the route selected is appropriate: e.g. oral or topical
e.g. if they have to take it on an empty stomach
e.g. if they get any adherence aids to help them take medicine
what is the role of the pharmacists in making simple interventions
- Ensure that our clinical check is robust
- Actively make interventions when an interaction/error is identified
- Ensure that our knowledge is up-to-date so that we are aware of solutions to any interactions/errors we find
- Be resourceful, by knowing where to find key information if we do not know it already
what is an intervention:
- an act performed to prevent harm to a patient
- Recommendation initiated by a pharmacist
- Response to a drug‐related issue
- Occurs in any phase of the dispensing process
- Can occur when responding to symptoms over the counter
- Refer to prescriber when necessary
examples of interventions:
- Double-checking doses prescribed for patients in ‘high risk’ groups
- Penicillin-allergic patient: query if penicillin-based drugs prescribed
- Some stroke patients: aspirin dispersible aspirin
- A laxative when a patient is taking an opiate medication
- Reviewing this and potentially suggesting an alternative
- Polypharmacy Over prescribing of medicines
types of intervention:
- Dose optimisation and synchronisation
- Allergies
- Formulation changes
- OTC interventions
- Identifying major drug interactions
- Suspected adverse drug reactions
- Public health – lifestyle interventions
- Non - adherence
what interventions do I record:
- Prescription interventions
- Signposting interventions
- Public health advice offered
- Self – care advice
- Medication reviews
These records are kept on the PMR or use of an online template
The role of pharmacist led interventions include… what?
- Reduction of the frequency of prescription and mediation monitoring errors
- Improvement of patient adherence and patient care.
- Cost savings to the NHS.
- Demonstrates the importance of community pharmacists
- Reduce drug interactions via prescription screening
What is the meaning of drug interactions
- When one drug alters the pharmacological effect of another drug. The pharmacological effect of one or both drugs may be increased or decreased, or a new and unanticipated adverse effect may be produced.
- Drug interactions may result from pharmacokinetic interactions (absorption, distribution, metabolism, and excretion) or from interactions at drug receptors.
interactions don’t just occur between drugs; certain food, juices, and herbs can interact with medicines too
What’s the plan after identifying a drug interaction?
- Identity the drug interaction
- Review the interaction, is it a common interaction?
- If yes: seek alternatives or recommendations for the best course of action
- If no: contact the prescriber to discuss your findings
As pharmacists, never ignore a drug interaction, no matter how insignificant the risk seems
common drug – food interactions
- Grapefruit/juice and statins
- Calcium channel blockers and Grapefruit
- Vitamin k rich food and warfarin
- Beta blockers and high K foods eg bananas, tomatoes, avocado and kale
- Alcohol and beta blockers
what are the key reference sources used in a pharmacist’s clinical decision-making process
bnf, sticklers drug interaction, national guidance, specialist guidelines, hospital formularies, pharmacy regulations etc
look at ur notion for more and their pros and cons
bnf pros and cons
pros
Concise resource using best practice guidelines
User friendly
Online assess
BNF app – updated monthly, internet access not required
Children version available
Gives doses of average patient
cons
lack of depth on analysis, focuses on UK practice, hard to nagivate
The legal requirements of a dispensing
label
- Name of the patient
- Name and address of the supplying pharmacy
- Date of dispensing
- Name of the medicine
- Directions for use
- Precautions relating to the use of the medicine
- ‘’For external use only’’ external liquid preparations
- ‘’keep out of reach of children’’ all dispensed medicines
Additional information can be added to the dispensing label if the pharmacist considers it to be necessary, e.g: what?
Shake the bottle/Store in a cool place/Do not use after…../Discard …… days after opening
just read ➢ Good practice advice for labelling
- All of the legal requirements of a dispensing label are met
- The patient’s name is spelt correctly and visible
- The pharmacy name and contact details are clearly visible
- The dose and frequency are written in block capitals, i.e. ‘Take TWO tablets TWICE daily’
just read ➢ Good practice advice for selecting medicines for dispensing
FOR SELECTING MEDICINES:
- NEVER dispense from the labels, always from the prescription
- Ensure that the pharmacy is laid out alphabetically with the drugs stored under their generic name
- Beware of look-alike& sound-alike drugs!
these are medicines for which the packaging or name is incredibly similar, but in reality the medicines have very different indications.
LASA errors are the most common cause of dispensing errors: why
- Impact on patient health and can be fatal
- Medicines with similar names propranolol &
prednisolone; atenolol & allopurinol; gabapentin &
pregabalin - Medicines with similar structural appearance of
letters: Carbamazepine & Carbimazole
Make a note of some LASA drugs commonly found in community pharmacy
- Gabapentin / Ganciclovir
- Lisinopril / Lithium
- Sertraline / Sildenafil
- Fentanyl / Loperamide
- Hydrochlorothiazide / Hydrocodone
Key elements of record-keeping in the pharmacy
- Confidential
- Legal
- Not kept for longer than necessary
- Legible
- Specific
What is a standard operating
procedure (SOP)
there is the risk of an error at every stage of prescription journey.
Pharmacies therefore implement Standard Operating Procedures (SOPs) which, after reading and signing, all members of the team
are legally required to follow
SOPs do what?
they are about writing down who does what and a set of fixed instructions or steps for carrying out routine operations.
Types of SOPs
- Dispensing
- Pharmacy practice
- Patient safety
- Controlled drugs
- Responsible pharmacist
e.g:
The roles and responsibilities of pharmacy staff
* Assembly and labelling of a required medicine or
product
* Record-keeping
* Dealing with complaints
* Covid -19
* Flu Vaccination
example:
SOP for the dispensing process
There are 6 steps in this process which needs SOPs
- Taking in prescriptions
- Pharmaceutical assessment
- Interventions and problem-solving
- Assembly and labelling
- Accuracy checking
- Transfer to the patient
Content of an SOP
A typical SOP should contain what….
- Name of the pharmacy
- Purpose and scope of SOP
- Title of the SOP
- Procedure
- Name, signature & date of the reader
- Name of person who prepared & approved the SOP
- Date SOP was prepared & approved
- Date of next SOP review
- Version of SOP
Why have SOPs
- Risk management and harm minimsation
- Continual improvement in standard of service reviewing
- Ensure good practice is always achieved
- Gives guidance to all support staff
- Pharmacist can delegate work
- Ensure consistency of the procedure at all times
apart of SOPs, how else can we, as pharmacists, reduce the risk of errors occurring?
- Reduce formulation mismatch
- Separate similar medicines on the shelf
- Staff training essential
- Prescriptions are legible and correct
- Follow risk management strategies
stages in dispensing a prescription to someone:
- receipt of prescription and clinical check
- creation of label
- medicines assembly
- accuracy check
- storing dispensed medicines
- medicines collection/final accuracy checl
- patient consultation
what is a dispensing error
when what is dispensed for the patient deviates in any way from what has been requested on the prescription: can only be caught by the pharmacist.
what are some common dispensing errors
- wrong drug dispensed
- given to wrong patient
- drug inappropriate e.g. allergies/interactions
- wrong strength/dose/freq
- transcription errors e.g. misread mg as mcg etc
Factors contributing to dispensing errors
- the team - understaffed? do they work well together
- the individual - are they feeling well / are they worried about anything and so not thinking clearly / sleepy
- the medicines - some are harder to dispense than others e.g. calculating and making them up
- the prescription - if it misses information, if anythings incomplete, can’t decipher handwriting?
dispensing errors - consequences
- goes to the patient - can lead to issues, depends on when its spotted etc
- not taken by patient - notice, bring back, redispense?
- caught by pharmacist at accuracy stage = near miss: redispense etc
root cause analysis - what could have affected the dispensing
C.H.A.P.S what does it stand for?
Conditions
Health of the patient
Assistance
Prescription
Systems
accuracy checking:
H.E.L.P stands for?
- HOW MANY
- EXPIRY DATE
- LABEL
- PRODUCT
THREE WAY CHECK: for dispensing errors: what are the steps
- Compare each label with the prescription:
- Checking each detail eg drug name, strength, dose,
patient’s name - Check each item with the prescription
– Looking at name, strength and quantity. - Check the label and the item
– Looking at drug name, strength, and quantity
Plus : check expiry date of each container
One item at a time
Labelling - Legal requirements and good practice
legal req’s
- Name of Patient
- Name & Address of the person supplying
- Date of dispensing
- Directions for use
- Keep out of reach of children
- For external use only
good practice
- Warning Labels / adapting to needs of patient
e.g child
- Labelling position: consider what you might be covering up
when providing the correct medication: what must be correct?
name, formulation, strength, quantity, expiry, PIL, not opened
What type of Records do we keep in a
Pharmacy?
- records of supply e.g. controlled drug registered entry
- clinical governance records e.g. dispensing incident reporting and audit
- consultation records e.g. giving advice on weight loss to diabetics
- pharmacists have access to summary care records as of 2015 - part of the national carer records service (2023)
why keep records?
- invoicing
- audit trail
- research
- monitoring standard e.g. error log
- improve quality
- ensure safety
- most records are legal requirements as part of the pharmacy’s contract with the NHS.
what to record?
- consultation records = relatively new to pharmacy practice: should be written so replicable with a different pharmacist
- needs 2 b concise, organised, factual, legible.
- no personal views and opinions.
- Patients have the right to request their records
**according the Data Protection Act
what are some barriers to record keeping?
- time
- knowledge - other healthcare professional such as GPs and nurses leave themselves time after a consultation to record it straight away
summary care records (SCR)
are an electronic record of important patient information, created from GP medical records. SCRs can be accessed through clinical systems or through the Summary Care Record application (SCRa).
summary care record application (SCRa)
iweb-based application that allows health professionals to view clinical & demographic information. SCRa users require a smartcard, passcode and relevant role for authentication and a Health and Social Care Network (HSCN) (N3) connection.
national care records service (NCRs)
new version of the Summary Care Record application (SCRa). It can be used in clinical, office or mobile environments. It does not require a smartcard and an HSCN connection, but it can still be accessed this way.
What is the National Care Record Service?
- NHS England retired the SCRa on 31 October 2023 for the majority of users. National Care Records Service is the improved successor to SCRa. Web-based application can be accessed regardless of what IT
system an organisation is using. - Summary of health & care information for care settings where the full patient record is not required to support their direct care. Gives access to range of clinical info.
- It includes access to more than 57.5 million Summary Care Records with patient additional information.
When should the NCRS be used?
- Where access to a summary of key patient information is required to support clinical decision making where full detailed patient records are not required.
- to compliment local shared records by giving access to key patient information across ICS boundaries.
- where a local shared care record is not available currently
- Patient safety concerns (FGM, child protection etc)
- COVID19 vaccination status/events.
When to use the NCRS?
- When dispensing an emergency supply (at the request of the patient)
to verify the name, form, strength and dose of medicine previously had
by the patient - Times when you would want to ask the GP practice for
medicines/allergies/ adverse reaction information - Supporting self-care for public health services and promoting healthy
lifestyles - During medicines review to verify and compare medicines currently
being prescribed and their allergy status, where this is not already
known - When supplying medicines under a locally commissioned service, e.g.
supply of medicines on NHS Patient Group Direction (PGD), during
common/minor ailments consultations
Common uses of National Record Locator include:
- ambulance staff viewing the end of life care plan for
a patient who has had an accident away from
home - care home staff viewing the end of life plan for a
patient from a previous care home - maternity nurse viewing a mental health crisis plan
for a patient giving birth in order to assess susceptibility to postnatal depression
Benefits of NRL
- Improve services for people with specific needs (e.g.
Mental health) who present to emergency services. - Cost efficiency by avoidingduplicate care.
- Support individuals’ needs / preferences (for example,
- End of Life patients who request to die at home).
- A better picture of local needs & demand, which can inform commissioning
