Pharmacy Practice Part 2: Furnishing, Administering, and Clinical Services

Question 1

The California Pharmacists Association has developed guidelines for pharmacists ordering and managing tests to ensure safe and appropriate medication therapy. The key principles are reviewed below:

Answer 1

• Testing should be for ensuring safe and effective medication therapy in coordination with the patient’s PCP or with the diagnosing prescriber
• Tests must only be ordered when necessary
• Test results must be managed appropriately and promptly, and patients should receive feedback on their tests in a timely manner
• Quality assurance should be integrated into the processes for test ordering, interpretation, and management.

Question 2

Pharmacists are individually responsible for personal competence in ordering tests and interpreting results. Variables that may impact test results should be considered when interpreting results, including the timing of testing, medications, renal or liver function, fluid status, and lab error. Examples of appropriate tests for a pharmacist to order include:

Answer 2

• Serum levels for narrow therapeutic index drugs (e.g., antiarrhythmics, antipsychotics, anticonvulsants)
• INR for patients taking warfarin
• Renal and liver function tests for patients taking medications requiring renal or liver dose adjustments
• Culture and sensitivity results for selection of appropriate antibiotic therapy

Question 3

Pharmacists who order tests should be available, or have back-up available, to respond promptly to critical results. At a minimum, a pharmacist should relay the critical value to the provider with primary responsibility for that aspect of the patient’s care. Critical values must be…

Answer 3

reported in the time frame indicated in the protocol for the management of the condition, if present. If a test result does not appear reasonable, it should be repeated. Pharmacists should refer patients to other healthcare professionals as problems are identified that require additional care.

Question 4

All actions related to test ordering, interpretation, and management, including changes in drug treatment, must be documented within 24 hours in a system accessible to the healthcare team members. Preferably, the Electronic Health Record (EHR) should be…

Answer 4

available to the pharmacist. A large benefit with the use of EHRs is a reduction in unnecessary or duplicate testing.

Question 5

Pharmacists should include each of the following items when they document changes in care:

Answer 5

• Interpretation of the result
• Rationale for the decision
• Information provided to the patient and the healthcare team members

A quality assurance (QA) assessment should be used to document the quality of the pharmacist’s care.

Question 6

Prior to SB 493, pharmacists could give only oral and topical drugs that have been ordered by a prescriber, and pharmacists who were trained in immunizations could give vaccines. The passing of SB 493 allows…

Answer 6

pharmacists to give drugs and biologics by other routes, including by injection. Pharmacists who wish to administer drugs or vaccines must receive adequate training in the possible routes of administration.

Question 7

In adults, intramuscular (IM) injections are given in the deltoid muscle at the central and thickest portion above the level of the armpit and below the acromion. Make sure to give in the thickest, most central part of the deltoid. Adults require a 1” needle (or a 1 1/2” needle for women > 200 pounds or men > 260 pounds). Use a 22-25 gauge needle…

Answer 7

inserted at a 90-degree angle. The higher the gauge, the thinner the needle. Subcutaneous (SC) injections are given in the fatty tissue over the triceps with a 5/8’’, 23-25 gauge needle at a 45° angle.

Question 8

Multiple injections given in the same extremity should be separated by a minimum of 1 inch, if possible. For patients that require frequent injections, SC and IM injection sites are rotated to avoid irritation. In most cases…

Answer 8

the concurrent use of injectable vasoconstrictors is not recommended due to the risk of abscess, except when localized drug administration is desired (eg, epinephrine and lidocaine for anesthesia when a localized area).

Question 9

Some injectable drugs can be absorbed faster with heat or massage. For example, the instructions for EpiPen administration include massaging the area for 10 seconds after injecting. With drugs that can cause easy bruising:

Answer 9

such as anticoagulants, it is important not to massage the area.

Question 10

Pharmacists in California can independently administer routine immunizations to adults and children 3 ages and older. The routine immunizations are those recommended by the Advisory Committee on Immunization Practices (ACIP) and published by the Centers for Disease Control and Prevention (CDC). A physician-directed protocol…

Answer 10

can be used if administering non-routine immunizations. A pharmacist can also initiate and administer epinephrine or diphenhydramine by injection to treat a severe allergic reaction.

Question 11

Pharmacists and interns who initiate and give vaccines must:

Answer 11

• Complete a CDC or ACIP-approved immunization training program
• Maintain basic life support (BLS) certification
• Complete 1 hour of CE on immunizations and vaccines every 2 years

Question 12

In order for intern pharmacists to give vaccines, both the supervising pharmacist and the intern must have completed an approved immunization training program. This is true for other activities that require special training or certification. If the pharmacist is not trained or certified in the activity…

Answer 12

they will not adequately supervise the intern performing the activity.

Question 13

The pharmacist must also comply with the following recordkeeping and reporting requirements:

Answer 13

• Pharmacists must notify each patient’s primary care provider (PCP) and each pregnant patient’s prenatal care provider (if applicable) within 14 days of the administration of any vaccine. If the patient does not have a PCP, the pharmacist should advise the patient to consult with a healthcare provider of their choice.
• Pharmacists must report the administration of any vaccine to the California Immunization Registry (CAIR). Pharmacies (not pharmacists) must be enrolled in CAIR. It is optional for individual pharmacists to enroll in CAIR.
• A patient vaccine administration record must be kept and readily retrievable during the pharmacy’s normal business hours. A pharmacist must provide each patient with a vaccine administration record.

Question 14

Effective January 2016, all children (kindergarten to 12th grade) in public or private schools (i.e. not home-schooled) must be immunized before admittance. Medical exemptions may be permitted, but…

Answer 14

personal belief exemptions have been eliminated. Schools should be able to review the student vaccination history of the immunization registry.

Question 15

The two types of medications approved for emergency contraception (EC) are levonorgestrel and ulipristal. Alternatively, a pharmacist can furnish high-dose birth control pills off-label to be used as EC. Plan B One-Step…

Answer 15

and its generic equivalents are given as a single dose of levonorgestrel 1.5 mg.

Question 16

Ulipristal (Ella) is a single dose, one-tablet EC product…

Answer 16

available only by Rx.

Question 17

Levonorgestrel and ulipristal have similar efficacy during the first 72 hours (3 days) after unprotected intercourse. Ulipristal is more effective from…

Answer 17

72-120 hours (3-5 days) after unprotected intercourse.

Question 18

If a woman has taken EC and does not have a menstrual period within 3 weeks, she should take a pregnancy test. EC can be obtained in 1 or 3 ways:

Answer 18

• Over-the-counter (OTC)
• Rx
• Furnished by a pharmacist in California under the board’s EC protocol

Question 19

Plan B One-Step and similar products can be purchased OTC, without sex, age or identification requirements. The FDA requests that OTC levonorgestrel products be placed in the aisle with other family planning items, such as condoms and spermicide. This placement allows customers to purchase EC even when…

Answer 19

a pharmacist is not duty. EC can be purchased at any time the store is open, including times when the pharmacy department is closed.

Question 20

A prescriber can issue a Rx for EC to a patient. If a Rx is received, the pharmacist can process it through insurance and dispense it as they would other prescription drugs. The Affordable Care Act (ACA) requires coverage for “essential health services.” This includes “women’s preventive services” (eg, contraception, EC) with no cost-sharing for the patient. Under ACA, EC is covered…

Answer 20

only with a Rx written for a female patient. The only insurance plans under the ACA (which can be found in the health insurance marketplace called “Covered California”) that may not cover EC are grandfathered health plans (which have some permitted to retain some of their orginal features for a set time period) or religiously-exempt employer health plans.

Question 21

A pharmacist can furnish EC under the board’s protocol. A patient might choose this option if she does not have a Rx from a prescriber and wishes to use insurance coverage. A patient might choose this option if she does not a have a Rx from a prescriber and wishes to use insurance coverage. In order to furnish EC under the protocol, the pharmacist must have completed 1 hr of CE on EC. The pharmacist must ask and communicate the following to the patient:

Answer 21

• Are you allergic to any medications?
• Timing is an essential element of the product’s effectiveness. Emergency contraception shoud not be taken ASAP after unprotected intercourse. Treatment can begin up to 5 days (120 hours) after unprotected intercourse.
• EC use will not interfere with an established or implanted pregancy.
• If > 72 hours have elapsed since unprotected intercourse, the use of Ella may be preferred. For other emergency contraception others, consult with your healthcare provider.
• Please follow up with your healthcare provider after the use of EC.

Question 22

EC can be furnished for future use, meaning a patient can receive a supply to keep on hand in the event that…

Answer 22

unprotected intercourse occurs in the future. There are no product quanity limits.

Question 23

A Fact Sheet (see image on the following page) must be provided to the patient when furnishing EC. The board’s website provides the Fact Sheet in 10 languages. The pharmacist should…

Answer 23

answer any questions the patient may have and record the necessary information in the patient’s medication record as required for any Rx. If a pharmacist has a reasonable belief that the patient will not continue to obtain Rxs from the pharmacy, such as an out-of-town patient who is visiting the area, a medication profile is not required.

Question 24

The pharmacy should maintain an inventory of EC medications and adjunctive OTC medications (eg, meclizine, dimenhydrinate) indicated for nausea and vomiting (N/V). There is a higher incidence of N/V with estrogen-containing EC compared to levonorgestrel (progestin-only) formulations. Patients will need to be…

Answer 24

given information concerning dosing and potential AEs. Medication for N/V should be taken 30-60 minutes before the EC dose.

Question 25

A pharmacist can provide up to 12 non-spermicidal condoms to each Medi-Cal and Famliy Planning, Access, Care, and Treatment (PACT) beneficiary who obtains EC. Medi-Cal and Family PACT are…

Answer 25

programs for low-income residents of California. Family PACT focuses on family planning and provides contraception coverage.

Question 26

If a pharmacist refuses to dispense EC, the pharmacy must have a protocol in place to ensure that the patient has timely access to the drug. If EC is not immediately available at the pharmacy (eg, if it is out of stock or if the only pharmacist on duty refuses to dispense it), the pharmacist…

Answer 26

will need to refer the patient to another EC provider.

Question 27

Naloxone is an opioid antagonist that binds to and displaces the opioid from its receptor sites. Naloxone reverses the action of the opioid, including overdose symptoms and analgesia. In chronic users, the abrupt reversal with naloxone will…

Answer 27

cause opioid withdrawl symptoms, which can be severe.

Question 28

The statewide protocol covers the use of FDA-approved naloxone formulations, including the injection and nasal spray (Narcan). Naloxone can be given if opiod OD is suspected due to respiratory symptoms and/or symptoms of CNS depression. Prescribers must now…

Answer 28

offer naloxone

Question 29

If naloxone is given, 911 must be called since emergency care will be required. Symptoms of opioid overdose include:

Answer 29

• Extreme or unusual somnolence (cannot be awakened verbally or with a firm sternal rub)
• Respiratory difficulty, ranging from slow or shallow breathing to complete respiratory arrest
• Miosis (very small “pinpoint” pupils)
• Bradycardia

Question 30

California pharmacists can furnish naloxone without a Rx pursuant to the protocol and billed to Med-Cal, Medicare Part B or private insurance. A pharmacist must complete…

Answer 30

1 hour of CE on the use of naloxone or an equivalent curriculum-based training program form a board-recognized school of pharmacy. The board also provides a free webinar training program.

Question 31

Naloxone should be offered to those who request it (eg, those on opioids or their friends/family members) and opiod users at the highest risk for overdose. The highest risk criteria include:

Answer 31

• History of a prior overdose
• Use of ≥ 50 morphine milligram equivalents (MME) per day (convert the home opioid daily dose to morphine if using a different opioid)
• Concurrent benzodiazepine use
• A recent period of opioid abstinence
• Chronic illnes that affects the lung, liver, or kidney

Question 32

Pharmacists furnishing naloxone according to the protocol must follow these steps:

Answer 32

• Ask if the recipient uses opioids or knows someone who does
• Ask if the recipient has a known naloxone hypersensitivity
• Provide the recipient with training in opioid OD prevention, recognition, response, and the administration of naloxone. When dispensing naloxone, patient counseling cannot be waived. It is best to avoid the word “overdose” when discussing naloxone with patients and family members. “Toxicity” and “antidote” are preferable.
• Provide the board-approved Fact Sheet.
• With the patient’s permission, the pharmacist must notify the patient’s PCP that naloxone was furnished.
• Keep records of furnishing the naloxone for 3 years.

Question 33

Pharmacies can furnish naloxone to a school district, county office of education or charter school pursuant to a prescriber’s Rx. School nurses and trained volunteers can…

Answer 33

administer the naloxone to treat opioid overdose

Question 34

Tobacco dependence is a chronic illness that typically requires repeated interventions and multiple attempts to quit. Effective treatments exist that can significantly increase rates of long-term abstinence. There are several OTC tobacco cessation products that pharmacists can recommend to patients without requiring a Rx (eg, nicotine patch, gum and lozenges). The California Board of Pharmacy has a standing protocol that allows pharmacists to…

Answer 34

furnish prescription nicotine replacement therapy (NRT), including the inhaler and nasal spray.

Question 35

A pharmacist can furnish NRT once they complete a minimum of 2 hours of an approved CE program specific to…

Answer 35

smoking cessation and NRT, or an equivalent curriculum-based training program within the last 2 years at an accredited California school of pharmacy. The pharmacist must complete ongoing CE focused on smoking cessation therapy every 2 years.

Question 36

Before selecting and furnishing NRT, the pharmacist must screen the patient using the following criteria and questions:

Answer 36

• Review the patient’s current tobacco use and past quit attempts
• Ask the patient a series of screening questions:
• Are you pregnant or planning to become pregnant? (If yes, do not furnish and refer to an appropriate healthcare provider)
• Have you had a heart attack within the last 2 weeks? (If yes, furnish with caution and refer to appropriate healthcare provider)
• Do you have any history of heart palpitations, irregular heartbeats, or have you been diagnosed with a serious arrhythmia? (If yes, furnish with caution and refer to an appropriate healthcare provider)
• Do you current expereince frequent chest pain or have you been diagnosed with unstable angina? (If yes, furnish with caution and refer to an appropriate healthcare provider)
• Do you have any history of allergic rhinitis (eg, nasal allergies)? (If yes, avoid nasal spray)
• Have you been diagnosed with temporal mandibular joint (TMJ) dysfunction? (If yes, avoid nicotine gum)
• Counsel patients on therapy and refer patients for further smoking cessation support
• Notify the patient’s PCP of the drugs or devices provided or enter the information in a shared patient record system. If the patient does not have a PCP, the pharmacist should provide the patient with a written record of what they received, and advise the patient to consult a PCP of their choice.
• The records of furnishing the NRT are kept for 3 years.

Question 37

A pharmacist can furnish self-administered hormonal contraceptives, which includes oral formulations (birth control pills), transdermal (the patch, such as Xulane), vaginal (the ring, such as NuvaRing) and injection (such as Depo-SubQ Provera 104). Pharmacists who participate in this protocol must…

Answer 37

complete at least one hour of a board-approved CE program. The program must be specific to self-administered hormonal contraception, application of the United States Medical Eligibility Criteria (USMEC) for contraceptive use and other CDC guidance on contraception. An equivalent curriculum-based training program, completed on or after the year 2014 in an accredited California school of pharmacy, is also sufficient training to participate in this protocol.

Question 38

The protocol requires that the pharmacist complete these steps:

Answer 38

• Ask the patient to complete the self-screening form: the form is based on the current USMEC, developed by the CDC.
• The self-screening form should be available in languages commonly seen in the pharmacy
• The patient will need to complete the self-screening form initially and again annually, or whenever the patient indicates a major health change.
• The form includes questions that can identify the use of drugs that could decrease contraceptive effiacy, such as drugs for epilepsy which are enzyme inducers.
• The pharmacist reviews the answers and clarifies responses. The use of contraception may be prohibited based on the responses, such as having a history of breast cancer, heart disease, DVT or tobacco use.
• If the pharmacist finds that it is not safe to provide the contraception or that the effiacy could be impaired, the patient should be referred their PCP or to a nearby clinic for further assistance.
• Measure and record the patient’s seated BP if combined (estrogen and progestin) hormonal contraceptives are requested or recommended.
• Ensure that the patient is trained in administration and has received counseling on the product: including (1) the dose, (2) the effectiveness, (3) potential side effects, (4) safety concerns, (5) the importance of receiving preventative health screenings, and (6) the lack of protection against STIs. The medication dispensed will be documented in the patient’s profile.

Question 39

Furnishing self-administered hormonal contraceptives:

Answer 39

• Provide the patient with 3 Fact Sheets: (1) a birth control guide such as the one from the FDA; (2) the patient package insert (PPI), and (3) and administration Fact Sheet for the specific formulation
• Refer all patietns to their PCP or to a nearby clinic for follow-up. Notify the patient’s PCP of any drugs or devices furnished. If the patient does not have a PCP, the pharmacist must provide the patient with a written record of drugs/devices provided.
• If self-administered hormonal contraception services are not immediately available or the pharmacist declines to provide them based on a conscience clause, the pharmacist must refer the patient to another pharmacist or facility to get the product the patient has requested.
• State mandatory reporting laws must be followed if sexual abuse is suspected.
• Keep records for 3 years

Question 40

A pharmacist can furnish travel medications that do not require a diagnosis. This covers medications for travel outside of the US. The Rx drug must be for either a condition that is both self-diagnosable and self-treatable, according to the CDC, or for prophylaxis. Examples of these conditions and some of their tx options are provided:

Answer 40

• Motion sickness: prochlorperazine, scopolamine
• Travelers’ Diarrhea: azithromycin, ciprofloxacin, rifaximin
• Urinary Tract Infection (UTI): nitrofurantoin, SMX/TMP
• Vaginal Candidiasis: fluconazole

Question 41

In order to furnish travel medications, the pharmacist must meet the following requirements:

Answer 41

• Complete an approved immunization certificate program
• Complete an approved travel medicine training program, which must consist of at least 10 hours and cover each element of The International Society of Travel Medicine’s Body of Knowledge for the Practice of Travel Medicine (2012)
• Complete the CDC’s Yellow Fever Vaccine Course
• Have current BLS certification
• Complete 2 hours of CE focused on travel medicine (separate from CE on immunizations and vaccines) every 2 years

Question 42

The pharmacist must follow these steps to furnish travel medications:

Answer 42

• Provide a “good faith evaluation” and assess the travel needs according to the patient’s health status and the destinations they will visit. The travel history must include all the information necessary for a risk assessment during a pre-travel consultation; this is outlined in the CDC’s Yellow Book.
• Notify the patient’s PCP of the drugs dispensed within 14 days of furnishing, or enter the information in a shared record system, or provide the patient with a written record of the drugs received to provide to a PCP of their choice.
• Provide the patient with a written record of the drugs provided.

Question 43

Before furnishing pre-exposure prophylaxis (PrEP), the pharmacist must…

Answer 43

complete a board-approved training program.

Question 44

Pharmacists can furnish at least a 30-day supply (up to a 60-day supply) of tenovofir disoproxil fumarate (TDF) 300 mg/emtricitabine (FTC) 200 mg once daily (Truvada) to patients who meet the following criteria:

Answer 44

• A negative HIV test within the last 7 days using an HIV antigen/antibody test, antibody-only test or rapid point-of-care fingerstick blood test. If recent HIV results are not available, the pharmacist must order an HIV test and ensure a negative result before furnishing PrEP.
• All positive HIV tests should be referred to a PCP.
• No signs or symptoms of acute HIV infection (eg, fever, fatigue, sore throat, rash)
• Does not take any medications that are contraindicated with the PrEP regimen

Question 45

The pharmacist must provide counseling, which cannot be waived by the patient. The pharmacist may education about:

Answer 45

• Side effects
• Safety during preganancy and breastfeeding
• Adherence to the regimen
• Importance of timely testing and treatment

Question 46

The pharmacist must notify the patient that all future prescriptions for PrEP must be supplied by a PCP. The pharmacist can furnish a max of 60 days of PrEP to a single patient over a 2-year period. The services provided by the pharmacist must be documented in the patient record and the PCP must be notified. If the patient does not have a PCP or the patient refuses consent, the patient must…

Answer 46

be provided with a list of healthcare providers that can be contacted for follow-up care.

Question 47

Post-exposure prophylaxis (PEP) is the use of antiretroviral drugs after a single exposure to HIV in order to prevent transmission. PEP should be started ASAP after the exposure, ideally within 72 hours. Before furnishing PEP, the pharmacist must…

Answer 47

complete a complete a board-approved training program.

Question 48

Pharmacists can furnish a complete course of treatment (28 days) with one of the following PEP regimens to a patient who reports an exposure within the past 72 hours:

Answer 48

TDF 300 mg/emtricitabine 200 mg daily (Truvada)
+
raltegravir 400 mg BID (Isentress) OR
dolutegavir 50 mg daily (Tivicay) OR
darunavir 800 mg daily (Prezista) AND ritonavir 100 mg daily (Norvir)

Question 49

The pharmacist must offer HIV testing to the patient. If the patient refuses an HIV test, the pharmacist may still furnish PEP. The pharmacist must provide counseling, which cannot be waived by the patient. The counseling may include the same content as listed for PrEP. For patients who are at high risk of developing HIV, the pharmacist must…

Answer 49

educate about the option of a PrEP regimen for prevention. The services provided by the pharmacist must be documented in the patient record and the PCP must be notified. If the patient does not have a PCP or the patient refuses consent, the patient must be provided with a list of healthcare providers that can be contacted for follow-up care.

Question 50

A pharmacist can perform blood glucose, hemoglobin A1C (referred to as A1C), cholesterol and PT/INR tests that are wavied under the Clinical Laboratory Improvement Amendments (CLIA); no California Department of Public Health (CDPH) registration is required. All other CLIA-waived clinical laboratory tests…

Answer 50

require CDPH registration

Question 51

Pharmacies can offer bone density screenings with an ultrasound densitometer that measures the bone density in the heels. The gold standard for measuring bone density is the dual-energy X-ray absorptiometry (DXA) scan. Screening for osteoporosis can be performed with an ultrasound densitometer following these steps:

Answer 51

• Have patient sit down and remove shoe and sock from the foot that will be tested
• Apply gel to machine and bare heel, if necessary
• Place patient’s heel in machine
• Membranes will fill with warm water and surround heel and ankle
• Results appear in ~ 1 minute; record reading
• Wipe off excess gel and clean membranes

Question 52

There are several recommended screeening forms that have been
well-validated and which vary based on patient group. The one used commonly for adults, the Patient Health Questionnaire (PHQ-9) is…

Answer 52

simple check-off form that correlates to a score that indicates depression risk.

Question 53

The purpose of The Joint Commission’s National Patient Safety Goals (NPSGs) is to foster improvements in patient safety in Joint Commission-accredited facilities. The NPSGs highlight problematic areas in healthcare:

Answer 53

(such as the lack of consistently following CDC hand hygiene recommendations, or harm from the improper use of anticoagulants). Each NPSG targets one area and recommends steps to improve safety and reduce risk.

Question 54

The use of standard order sets can promote best practice, decrease medication errors, improve workflow, improve patient outcomes and standardize patient care. Standard order sets reduce the need to call prescribers for clarification about an order. Standard order sets provide a benefit only…

Answer 54

when they are carefully developed and implemented at the facility. Standard order sets should be evidence-based and should not include non-formulary medications, drugs withdrawn from the market or equipment no longer available at the facility. Baseline tests, monitoring frequency and when emergency tx (eg, the use of reversal agents with anticoagulants) is required should be included in the order set.

Question 55

The ASHP defines a medication-use evaluation (MUE) as a “performance improvement method that focuses on evaluating and improving medication-use processes with the goal of optimal patient outcomes.” MUEs can be conducted for a specific drug (eg, morphine), drug class (eg, opioids), disease state (eg, pain) or a process (such as prescribing, dispensing or administration). A MUE can be used when…

Answer 55

a drug is especially toxic, when it is used in a group at high risk ADRs, when a medication is being considered for addition to or removal from the formulary or to identify poor and/or costly prescribing habits. The purposes for MUEs include: determining optimal medication therapy, preventing medication-related problems, evaluating the efficacy of a medication and improving patient safety.

Question 56

A performance evaluation process conducted by peers and/or oneself is part of the quality assurance process. Evaluation can include standard objective criteria and position-specific criteria. Peer experts are commonly involved in…

Answer 56

establishing competencies required for granting privileges, such as granting some type of practice designation or the use of a high-risk agent. The standards involved with any type of privileges are continually updated as needed.

Question 57

Although pharmacists practice with the best intentions, medication errors occur. The most common type of error in community pharmacies is dispensing the wrong medication to a patient. It is estimated that the overall dispensing accuracy rate in community pharmacies is 98.3% (~ 4 errors per 250 prescriptions). California requires all…

Answer 57

pharmacies to have a quality assurance (QA) program to document, assess, and prevent medication errors. There must be a readily-retrievable policy and procedure (P&P) for the QA program so the pharmacy staff knows what to do when a medication error occurs.

Question 58

Investigation of pharmacy medication errors must begin within 2 business days from the date the medication error was discovered; otherwise, the sequence of events leading up to the event will be forgotten. The sooner the incident is documented, the better. Preferably, and especially if the consequences of the error are severe, the assessment should be conducted…

Answer 58

using a root cause analysis (RCA). An RCA is used to discover the causes in the system (i.e. the dispensing process) that led to the error and design changes to avoid making the same mistake.

Question 59

The record of the QA review should be immediately retrievable in the pharmacy (ie. it cannot be stored off-site) and must be kept in the pharmacy for at least one year from the date it was created. The record must contain the following information:

Answer 59

• Date, location, and participants in the QA review
• Pertinent data related to the medication error
• Findings and determinations of factors that could have contributed to the error
• Recommended changes to the pharmacy policy, procedure, systems or processes to avoid a repeat of the medication error

The pharmacist must inform the patient that a medication error has occurred and should inform the patient of any steps that can be taken to avoid further injury (such as the use of another agent to lessen the effects of a drug taken in error). The pharmacist must also inform the prescriber that a medication error has occurred.

Question 60

Medicare is a federal heatlh insurance program for people ages ≥ 65 or < 65 with disability, and patients with end-stage renal disease (ESRD). Medicare Part D is the drug benefit for Medicare enrollees. Medicare enrollees can…

Answer 60

apply for a Low Income Subsidy (LIS), which pays for the Part D monthly premium, the annual deductible and medication copays.

Question 61

In addition to federal Medicare, lower income children, pregnant women, families and low-income adults may qualify for state Medicaid. Enrollees in Medicaid…

Answer 61

do not have copays. In California, the state Medicaid is called Medi-Cal.

Question 62

All Medicare recipients in California are able to obtain drugs at the Medi-Cal reimbursement rate. There are Medicare plans with Rx drug coverage, including many of the Medicare Advantage plans, which are offered…

Answer 62

offered by private companies as alternatives to traditional Medicare.

Question 63

Medicare uses a Star Rating System (on a scale of 1 to 5 stars) to determine how well Medicare Advantage and Medicare Part D prescription drug plans perform. Plans with higher ratings get perks, such as an additional “special enrollment period” (versus once yearly enrollment). Medicare Part D ratings are based on several quality measures and can change from year to year. Examples of quality measures that may be included in the ratings related to drug therapy include:

Answer 63

• Annual comprehensive medication review (CMR) for patients enrolled in an MTM Program
• Adherence to diabetes medications, statins, and renin-angiotensin system antagonists (including ACE inhibitors, ARBS, aliskiren)
• Ensuring statin use in patients with diabetes age 40-75 years old
• Appropriate use or avoidance of high-risk medications in patients > 65 years

Question 64

Covered California is the name of the health insurance “marketplace” in California. This includes a website where:

Answer 64

patients can compare the different ACA plans and enroll for coverage. All of the plans offered through Covered California provide Rx drugs, which are included as one of the “essential health benefits” that the ACA plans must include, in addition to contraception, described previously, and other services.

Question 65

Covered California was launched in 2014. Covered California plans are sold in 4 levels of coverage: Bronze, Silver, Gold, and Platinum. For patients under 30 years of age, another option, called the minimum coverage plan, is also available. The higher-cost plans pay:

Answer 65

a higher percentage of covered medical expenses than what a patient would be expected to pay in copays and annual deductibles.

Question 66

Patient assistance programs (PAPs) help low-income, uninsured patients get free or low-cost, brand-name medications. These programs are typically provided by the drug manufacturer that makes the drugs. There are several online directories that help patients find a specific patient assistance program, including the popular RxAssist site at www.rxassist.org. If the patient meets the requirements, they qualify to receive the drug at no cost. Ex. Eligibility Information:

Answer 66

• Must not have prescription coverage and must not be eligible for state or federal programs such as Medicare and Medicaid.
• For most medications, patients with Medicare Part D might be considered if they are ineligible for Low Income Subsidy and have spent at least 5% of their annual household income (out-of-pocket) on medications
• Patient must be under the care of a licensed healthcare provider who is authorized to prescribe, dispense, and administer medicine in the U.S.
• For vaccines, patient must be at least 19 years of age

Question 67

Splitting tablets can save patients and health plans money because manufacturers sometimes charge the same prices for higher and lower doses of the same drug. The easiest tablets to split are the ones that are scored. Patients should use…

Answer 67

commercially available devices (“pill cutters” or “pill splitters”) specifically designed to split tablets.

Question 68

Not all drugs can be safely or practically split. There are some tablets that crumble easily and others that are coated to protect the GI lining or to prevent the drug from degrading in the stomach. Patients with manual dexterity problems (eg, arthritis, Parkinson disease), visual impairment, or cognitive impairment are not good candidates for tablet splitting. Capsules should never be split. Tablets that should not be split include those that are:

Answer 68

• Very small in size
• Asymmetrical in shape
• Narrow therapeutic index drugs
• Enteric-coated, film-coated or extended-release (ER)

There are no California laws or pharmacy regulations specifically forbidding tablet splitting. The pharmacist and patient should decide whether splitting tablets is appropriate.

Question 69

There are other ways a pharmacist can advise a patient to save money on drugs:

Answer 69

• The same drug can be less expensive at a different pharmacy; it may be useful to do a cost comparison
• Consider using the generic equivalent of a brand-name drug
• Suggest to the prescriber a therapeutically similar but less expensive drug. Keep in mind that drugs in advertisements are new and generally more expensive than older alternatives
• Consider purchasing a greater day supply (i.e. 90-day instead of 30-day) if the copay is the same

Question 70

Patients should not be swayed to purchase a branded drug, even with a discount, if a lower-cost generic equivalent is available and is covered by the insurance. In California, manufacturers are prohibited from…

Answer 70

offering drug discounts for the purpose of pushing a more costly branded drug on the patient.

Question 71

The exception is when the manufacturer is able to offer the drug at a discounted price which is less than the cost of the generic equivalent. Manufacturers are permitted to…

Answer 71

provide the drug free of charge to certain patients, such as those who are able to demonstrate a low income and who could otherwise not afford the drug.

Question 72

The consumer must be informed of the lower price of a covered medication, whether it is the retail price or the cost-sharing (co-pay) amount, unless the pharmacy automatically charges the lower amount. The insurance plan cannot…

Answer 72

require the consumer to pay more than the pharmacy’s retail price. Pharmacists must ensure that the patient gets the lowest price available.