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.