(3) Supplying medication

1. (3)Supplying medication • The supply of medication has always been a core role for the pharmacist. • The importance of the supply function is underlined by thedefinition of dispensing as an essential service inpharmacy • However, as the community pharmacist moves towards more patientcentredservices, the practical issues surrounding the supply functionneed to be examined more closely.

2. Dispensary design and workflow • The ideal dispensary is tidy and clean with uncluttered work surfaces, alogical layout of dispensing stock and a natural workflow. The minimumstandards for any dispensary include: • a good basic standard of decoration for the walls, ceilings and allpaintwork • a cleanable floor • adequate fixtures and fittings, uncluttered surfaces that are smooth andimpervious to dirt and moisture • a clean refrigerator that is regularly defrosted and contains aminimum/maximum thermometer • clean sinks with both hot and cold water available • the proper storage and disposal of waste materials • Even when these basic minimum standards are met, there needs to beconsiderable thought about the way that the workflow of the dispensaryis arranged to be able to offer an efficient and safe dispensing service

3. Pharmacist based ‘front of house’ to interact directly with clients. Pharmacisthas access by laptop to patient medication records and a good view of theentire pharmacy. Any acute ‘waiting’ prescriptions are passed directly to thepharmacist for checking. • The client can walk into the consultation room easily from the shop floor tohave a confidential conversation. • There is a clearly defined administration area (access to email, fax andtelephone) where a designated member of staff can answer all queriesrelating to repeat prescriptions. A large area is available for filing paperwork. • Waiting prescription dispensing area. • Repeat prescription dispensing area. • Clear area for storage of prescriptions, out of view of the customer but closeto the reception desk.

4. The cost of labour is by far the greatest cost in running a dispensary. • With the potentially reduced involvement of the pharmacist in dispensingactivities, the day-to-day management of the dispensary shouldideally be delegated to a pharmacy technician. • An efficient workflow hasthe following advantages: • more economic and efficient use of labour • reduced waiting times for patients • increased time available for contact and interaction with patients • less likelihood of dispensing errors • more efficient stock-rotation procedures • reduced frustration in an ordered working environment, resulting inincreased staff morale.

5. The overall design of a dispensary should depend on the type of dispensingthat is taking place. • For example if there is a large proportion of repeatdispensing, there needs to be a large working area that is assigned to thisactivity. • When considering the design of the dispensary and arrangementof stock it is useful to refer to the standard operating procedure (SOP) fordispensing. • The SOP for dispensing will be specific for a pharmacy andshould take into account any specific design features that impact on thedispensing process. • The dispensing process can be divided into seven stages: • prescription reception • legal and clinical check • labelling of item(s) • assembly of item(s) • checking of item(s) • final check • hand to patient/counselling.

6. Prescription reception • An efficient dispensing service is dependent on a clearly definedprescription-reception procedure. • The area where prescriptions arehanded in should be clear and unambiguous. • Any support staff involvedin this process must have been trained to a basic minimum level. • Assisting in the supply of prescribed items, which involves taking in aprescription and issuing prescribed items, is part of the specific knowledgeand understanding required for the Pharmacy Services

7. To ensure a smoothprescription process the member of staff receiving a prescription shouldbe able to: • recognize different types of prescription form. The Prescription PricingDivision of the JFDAAuthority has a useful website thatoutlines all the different types of prescription and the legalrequirements for prescriptions • ensure that the patient’s name, including forename and address arelegible • establish if the prescription is being handed in by the patient or theirrepresentative • verify the age of the patient if the prescription is for a child

8. take any prescription charge that is due or deal with any exemptionprescription queries. In practice this will mean that the member of staffshould be able to recognize contraceptive items that are exempt fromprescription charges and items that attract a multiple prescription charge,and be fully aware of the procedure for completing the back of theprescription form. Point-of-dispensing checks act as an importantdeterrent for patient fraud and have contributed to a 60% reduction inpatient prescription fraud in recent years. It is vital that the member ofstaff receiving a prescription is fully aware of theprocedures involved inchecking exemption from prescription charges. • access the patient medication record (PMR) system. It is useful if themember of staff can access the PMR system to confirm patient details,and change any administrative details such as address. Sometimes at thisstage of the process a patient may ask a non-clinical question such as thetiming of their repeat prescription. This type of query should beanswered promptly without interrupting the dispensing process • determine the time it will take for the prescription to be dispensed andcommunicate this to the patient.

9. Legal and clinical check • This part of the process must be performed by the pharmacist, preferablyin an area free from distractions. • Some of the legal checks may havealready been carried out at the reception stage. • For example the assistantmay have spotted that the prescription is out of date or a repeat directionon a private prescription is invalid. It is important that any legal issues areconfirmed by the pharmacist before communicating with the patient. • Extra care needs to be taken with prescriptions for controlled drugs (CDs)to ensure that all legal requirements are satisfied. • Once the pharmacist issatisfied that the prescription is legally valid they should proceed to theclinical check.

10. The clinical check involves interpreting the wishes of the prescriberand making a pharmaceutical assessment of the prescription. • Thisinvolves checking the prescription for safety, quality and efficacy. • A systematicprotocol should be developed by the individual pharmacistcovering such areas as: • name, strength and form of the drug. Is it clear what is intended? • what dose form is required? • is the dose appropriate for the indication and age of patient? • What typeof dose has been prescribed – starting dose or maintenance dose? • is it an intended unlicensed ‘off-label’ prescription • are there any allergies, contraindications or possible interactionsindicated on the PMR? • is the formulation appropriate? • is the quantity appropriate?

11. Any queries about the prescription should be highlighted at this stageand the prescriber contacted for further clarification or information. • Anypotential problems should be resolved before proceeding any furtherwith the dispensing process. • A vital role of the community pharmacist isto intercept problem prescriptions. One study demonstrated that nationally280 000 potentially serious prescription errors are detected everyyear. • The pharmacist is using their clinical and pharmaceutical knowledgeto ensure that the patient receives the best possible pharmaceuticalcare and receives the correct drug in an appropriate formulation anddose. • Barriers to this process are that the pharmacist is not always awareof the diagnosis and does not have access to the patient’s medicalrecords. • In the case of problem prescriptions, the pharmacist shouldcommunicate directly with the prescriber and not delegate this task. • Once the prescription has been validated by the pharmacist it can bepassed to the dispensary team to complete the remaining stages of thesupply process.

12. Labelling of item(s) • The location of the labeling equipment should ideally be in a speciallydesignated area that is free of interruptions, as this part of the processrequires considerable concentration. For accurate label production thefollowing areas need to be considered: • the patient’s details such as the correct spelling of the name. It isnecessary to check that any incorrect spelling is not being propagatedfrom a previous PMR entry • an awareness of drugs with similar names. if the prescription is handwritten the name of the drugneeds to be looked at carefully. Similar names such aschlorpropamide/chlorpromazine or disopyramide/dipyridamole needparticular attention • when selecting repeat medication from a patient’s PMR it is important tocheck carefully if there are any dose or quantity change • the additional cautionary labeling automatically added by the PMR willneed to be checked • the quantity of the product prescribed needs to be considered inrelation to the pack sizes available and whether multiple labels arerequired • if an active stock control system is in place on the PMR it will benecessary to check remaining stock levels • any owing medication will need to be recorded and the appropriatedocumentation produced for the patient. • There should be provision in the SOP for an emergency procedure to dispenseprescriptions without the PMR, in the event of a power failure orcomputing problems

13. Assembly of item(s) • Both the prescription and the labels should then be passed on so that theprescription items can be assembled. • Many busy pharmacies have asystem of clipping the labels to the prescription and placing the prescriptionsin order. • It is vital that items are selected and assembled from theoriginal prescription and not the labels. • This avoids repeating any errorsmade at the labelling stage. • The layout of dispensary stock and the typeof storage systems used will have a big impact on this part of the dispensingprocess. • Purpose-designed sloping shelves with easier back fillingwill facilitate good stock rotation. • Location of commonly used items nearto the dispensary bench will result in a significant reduction in movementin the dispensary and increase efficiency. • When designing a newdispensary, some thought needs to be given to the overall size of the dispensary. • If the floor area is too large it can result in unnecessary walkingto locate items. If the dispensary is too small and the stock is located inonly a small area this can lead to dispensary congestion and slow downthe assembly process.

14. Checking the item(s) • The member of staff who has assembled the product needs to carry out acareful check of the product and label against the prescription. • Conscientious checking of the dispensing at this stage will result in areduced number of problems at the final checking stage. • It is good practicefor the dispensing label to be initialed by the member of staff whoperforms this check. • The completed item(s) and prescription should thenbe placed in the final checking area. • In a high-volume dispensary eachcompleted prescription should be placed in a suitable plastic container inreadiness for the final check. • This process ensures segregation of itemsfrom different prescriptions.

15. Final check • The final accuracy check should be carried out by either the pharmacist or the accredited checking technician (ACT). • The mnemonic ‘HELP’ may be useful when a final check is being made to ensure that all the necessary checks have been made.4 Help is an acronym for: • H: ‘how much’ has been dispensed (open all unsealed blister cartons to check the contents are of the correct product at the correct strength) and check that the correct leaflet is present • E: an ‘expiry date’ check • L: ‘label’ checks for the correct patient’s name, the correct product name, the correct dose and the correct warning(s) • P: ‘product’ check to ensure that the correct medication and strength has been supplied. • A useful practice is to use a pencil to physically point to different parts of the label as the prescription is finally checked. • If there are any errors it is important that the problem is immediately recorded in the dispensing error record as a ‘near miss’ for future analysis. • The final check should be carried out in a designated area of the dispensary, and ideally the person carrying out the final check should not have been involved in the dispensing process. • If this separation of duties is not possible, it is useful to take a short mental break to separate the dispensing and checking process. • It is good practice to initial the label to indicate that a check has taken place and identity the person carrying out the final check.

16. Hand to patient/counselling • It is surprisingly easy to hand out a prescription to the wrong person!! • This may be due to patients with similar names or because the patient has a problem with hearing when their name is called out. • The safest system is to ask the patient to confirm another piece of information such as their address before handing across the prescription. • At this final stage of the supply process, care and attention to detail is vital to ensure the correct prescription is handed to the right patient with appropriate information and counseling. • Pharmacists have a legal obligation to provide a manufacturer’s patient information leaflet (PIL) each time a medicine is sold or supplied. However, the pharmacist should not let the PIL become a substitute for counseling but a means of providing supporting additional information. • The area where prescriptions are collected needs to be clearly defined and separate from the handing-in point. An established prescription- collection area provides a more logical work pattern. • If the final checking and handing out form part of the same process, it is a useful practice to perform a final visual check as the items are packaged and handed to the patient. • If the patient is calling back for their prescription, it will need to be packaged and stored securely near to the prescription-collection area. • Completed prescriptions are normally stored alphabetically in a sealed bag with the accompanying prescription attached to the bag. • Some pharmacies package each prescription in a polythene bag so that the items can be easily examined at the handing-out stage. • Ideally the prescription should be handed out by the pharmacist. The patient or their representative should be offered the opportunity to ask any questions about their prescription. • If the pharmacist is unable to hand out the prescription personally, the completed prescription can only be handed out under their supervision. It is important that the pharmacy team is aware of this requirement if the pharmacist has to temporarily leave the dispensing area. • The pharmacist supervising the handing out of a previously completed prescription needs to be aware that although the item may have been dispensed and checked by another pharmacist there is a shared responsibility to ensure that the patient receives the correct item. • It is only through compliance with robust risk-management policies and safe systems of work that potential problems are minimized at each stage of the dispensing process.