Medication management

							      Medication
     Management:
Focused on Supplying Medication
                Outline

1. Medication Management
2. Patient Safety: Medication error
3. Need of Quality Care Standards
4. Dispensing Process
5. Compounding process
           Definition

Dispensing includes three activities:

    Evaluation of the prescription

    Preparation of medicines

    Advising the patient

Excludes: Compounding & Admixing
              Definisi

Compounding is the preparation, mixing,
assembling, packaging, and/or labeling of a
drug or device as the result of a practitioner’s
prescription drug order or initiative based on the
practitioner/patient/ pharmacist relationship in
the course of professional practice, or for the
purpose of, or as an incident to, research,
teaching, or chemical analysis and not for sale
or dispensing.
Compounding vs Manufacturing


 Compounding basically differs from manufacturing in that
 compounding involves:

      a specific practitioner-patient-pharmacist relationship,

      a relatively small quantity of medication prepared, and

      the conditions of sale (specific prescription order).
             Medication
            Management
Collaborate with patient and health care professionals to
maximize the benefit of prescribed medications

Prescribe, dispense, and administer medications
appropriately (safely)

Routinely assess the effectiveness of prescribed regimens

Help avoid or minimize drug interactions and medication-
related adverse reactions

Improve medication adherence
       Patient Safety:
       Medication Error
Medication error is any preventable event that may
cause or lead to inappropriate medication use or
patient harm while the medication is in the control of
the health care professional, patient, or consumer.

Such events may be related to prescribing, order
communication, compounding, product labeling,
packaging, dispensing, administration, education,
monitoring, and use.
   Patient Safety:
   Medication Error

Prescribing error

Dispensing error

Administration error
    Patient Safety: Medication
              Error




•   National Patient Safety Agency (UK, 2001; n=331)
    Patient Safety: Medication
              Error




•   National Patient Safety Agency (UK, 2001; n=331)
Need of Quality Care
    Standards
   Community pharmacy




• Quality policy and assessment

• Establishment of pharmacy
 standards




                                  7
     Quality Care Standards

   FIP Good Pharmacy Practice Guidelines
1993 Adopted in Japan.
1997 In Vancouver presentation of revised
     version endorsed by the WHO Expert
     Committee on Specifications for
     Pharmaceutical Preparations.
1998 In The Hague adoption of the guidelines
     on Good Pharmacy Practice in
     Developing Countries.
2003 In Sydney presentation of results from
     the Working Group on Quality Care
     Standards
                                               8
  Quality Care Standards
FIP Working Group Response (2003)
23 organisations replied (n=110, 21%)
21 organisations had quality care standards
                                 EUROPE
                                 Croatia
                                 Denmark
                                 Finland
                                 France
 Western Hemisphere              Germany
 Canada                          Israel
 USA                             Malta
                  AFRICA         The Netherlands
                  Uganda         Norway
                         JAPAN   Nordic Association
                         Japan   Portugal
           ASIA, PACIFIC         Serbia*
           Australia**           Sweden
           India                 Switzerland
           Indonesia*            United Kingdom
                                                      9
        Quality Care Standards
Areas included in generic standards (FIP working group, 2003)


                      No. of organisations
                      (n=18)
    Extemporaneous preparations 15 (83%)
    Handling of stock                          14 (78%)
    Interaction with patients                  13 (72%)
    Non-presc medicines                  13 (72%)
    Setting of the pharmacy                    13 (72%)
    Documentation systems                      12 (67%)
    Dispensing presc. medicines 11 (61%)
                                                                17
Dispensing
  Dispensary design &
       workflow
Ideal dispensary: bersih & rapi

Minimum standards:
  penampilan/ dekorasi dinding, atap dan cat yang cukup baik

  lantai mudah dibersihkan

  mempunyai perabot yang cukup

  kulkas yang bersih

  wastafel yang bersih

  tempat penyimpanan dan pembuangan barang yang baik.
Workflow is Important

•   to offer an efficient and
    safe dispensing service
Advantages of having
an efficient workflow
ekonomis dan meminimalkan SDM

mengurangi waktu tunggu pasien

meningkatkan waktu untuk berinteraksi dengan
pasien

mencegah dispensing error

meningkatkan kenyamanan bagi orang yang
bekerja
7 stages of Dispensing
       Process
1. Prescription reception
2. Legal and Clinical check
3. Labelling of items
4. Assembly of items
5. Checking of items
6. Final check
7. Hand to patient/ counselling
1. Precription reception
 recognise different types of prescription

 ensure that patient’s name and address are legible

 verify the age of the patient

 establish if the prescription is being handed in by the patient
 or their representative

 access PMR system

 determine the time it will take for R/ to be dispensed &
 communicate this to the patient

 use a numbered docket system.
  2. Legal & Clinical
        check

This process must be perform by the
pharmacist

In Indonesia: program “TATAP”

Legal check: illegal R/, narcotics
       Clinical check
Name, strength and form of the drug. Is it clear what
is intended?
What dose form is required?
Is the dose appropriate for indication and age of the
patient?
Is it an intended unlicensed ‘off-label’ R/?
Are there any allergies, CI or possible interactions?
Is the quantity appropriate?
     In the UK:
280 000 potentially
serious prescription
errors are detected
    every year.
Role of the Pharmacist
Pharmacist is using their clinical and
pharmaceutical knowledge to ensure that the
patient receives the best possible
pharmaceutical care and receives the
correct drugs in appropriate formulation and
dose.
             Barriers
Pharmacist is not always aware of the
diagnosis

Pharmacist does not have access to PMR

Pharmacist is not always available (mostly in
this country!!)
  In the case of problem
 prescriptions, pharmacist
   should communicate
directly with the prescriber
and not delegate this task.
3. Labelling of items


correct spelling of the name

awareness of drugs with similar names

Dose or quantity changes from previous R/
  4. Assembly of items
be aware of ‘look alike’ and ‘sound alike’ drug
names.
Contoh:
      Celebrex, Celexa, Cerebra
      Inderal, Isordil
      Bupropion, Buspirone
      Seroquel, Serzone, Serentil
      Zosyn, Zofran
      Paxil, Plavix
      Lamisil, Lamictal
4. Assembly of items
5. Checking the items


to reduce number of problem

should be checked by staff who assemble the
product and re-check by other staff before
handed to the patient.
             6. Final check
•   HELP mnemonic:

    H: ‘how much’ has been dispensed

    E: ‘expiry date’ check

    L: ‘label’ checks for the correct patient’s name,
    product name, correct dose and correct warning

    P: ‘product’ check to ensure that the correct
    medication and strength has been supplied
7. Hand to patient/
    Counselling
Compounding
  “One of the greatest services a
    compounding pharmacist
provides is problem-solving for the
      patient and physician”
     Compounding Process
•   1. Judging the suitability of the prescription in terms of its safety
    and intended use and the dose for the patient.

•   2. Performing the calculations to determine the quantities of the
    ingredients needed.

•   3. Selecting the proper equipment and making sure it is clean.

•   4. Donning the proper attire and washing hands.

•   5. Cleaning the compounding area and the equipment, if
    necessary.

•   6. Assembling all the necessary materials/ ingredients to
    compound and package the prescription.
Compounding Process
7. Compounding the prescription according to the Formulary record or
the prescription, according to the art and science of pharmacy.
8. Checking, as indicated, the weight variation, adequacy of mixing,
clarity, odor, color, consistency and pH.
9. Entering the information in the compounding log.
10. Labeling the prescription.
11. Signing and dating the prescription, affirming that all the indicated
procedures were carried out to ensure uniformity, identity, strength,
quality, and purity.
12. Cleaning and storing all equipment.
13. Cleaning the compounding area.
Standard for Extemporaneous
           Product

 Personal hygiene:
     hygiene standard should be as high as, or
     higher than those found in food kitchen.
 Personal protective equipment:
     clean white coat
     safety glasses
     safety equipments (face mask, gloves)
     long hair should be tied back
Standard for Extemporaneous
           Product

 Clean work area & equipment:
     risk of contaminating the final product with
     microorganism from previous preparation.
 Work area:
    cleanliness
    lighting
     ventilation
Standard for Extemporaneous
           Product

 Label preparation:
     the product should be labelled as soon as
     it has been manufactured & packaged, to
     prevent from possibility of being
     mislabelled & given to the wrong patients.
 Weighing & measuring procedure:

     accidental cross-over ingredients.
   Suggested Minimal
        Library
Remington’s Practice of Pharmacy
Secundum Artem
Pharmaceutical Dosage Forms and Drug Delivery Systems (Allen,
Popovich, Ansel)
Pharmaceutical Calculations (Stoklosa, Ansel)
Handbook of Pharmaceutical Excipients
American Hospital Formulary Service: Drug Information
Martindale’s The Extra Pharmacopoeia
The Merck Index
USP PHARMACIST’ PHARMACOPEIA
USP-DI
        References

FastTrack: Pharmaceutical Compounding and
Dispensing, Pharmaceutical Press, London,
Chapter 1.

Community Pharmacy Handbook,
Pharmaceutical Press, London, Chapter 7.

FIP, Good Pharmacy Practice in Developing
Countries.