Good Dispensing Practices.. 84 slides on GDP

Good Distribution Practice…

1. GOOD DISPENSING PRACTICES MRS MABEL JOHNSON

2. INTRODUCTION Dispensing is the process of preparing and providing prescribed medications to patients It also refers to the process of preparing and supplying medicines to person with clear instruction and counseling where necessary on the use pf the medicine.

3. DISPENSING Is an important part of pharmacy, in which the pharmacy aide (under the direct supervision of the pharmacist) interprets the physician’s requirements on the prescription and accordingly supplies for the treatment of his patient(s) Involves the correct interpretation, accurate preparation and labeling of medicine for use by the patient. Dispensing is the act by a validly registered pharmacist of filling a prescription or doctor’s order on the patient’s chart.

4. GOOD DISPENSING PRACTICE (GDP) Good dispensing practicing refers to a set of guidelines and standards designed to ensure the safe, accurate and consistent dispensing of medications and other healthcare products to patients Good Dispensing Practice ensures that the right medicines of desired quality are delivered correctly to the right patient with the right dose, strength, frequency, dosage form and quantity, together with right instruction, both written and verbal and with appropriate packaging suitable for maintaining the quality and efficacy of the medicine.

5. GDP Good medicine dispensing practice refers to the delivery of the correct medicine to the right patient, in the required dosage and quantities, in the package that maintains acceptable potency and quality for the specified period, clear medicine information counseling and appropriate follow up. This practice is a key step for effective treatment outcome. Though rational medicine therapy requires the concerted efforts of all health care professionals, the role of pharmacy professional is immense

6. KEY ELEMENTS OF GDP Accurate Prescription Handling Proper Medication Storage Labeling and Packaging Patient Counseling Safe Handling of Controlled Substances Hygiene and Cleanliness

7. DISPENSING ENVIRONMENT The dispensing environment includes; Trained or Qualified staff Appropriate physical surroundings Adequate shelving and storage areas Proper work surface Suitable equipment Necessary packaging materials

8. DISPENSING ENVIRONMENT Staff members involved in dispensing must maintain good personal hygiene and should wear appropriate clean cloth (lab coat) Physical surroundings must be kept free from dirt Although the dispensary must be accessible to patients, care should be taken to locate it in a protected place and not beside, or open to, a road or other area where dust, dirt, and pollution are commonly present

9. DISPENSING ENVIRONMENT Prescription counter Ideally Prescription counter should: Be accessible to the patients. Preferably be separate and in a quite location. If there are other separate section (e.g., cosmetics, general items, OTC section), it should be slightly away from them. Be clean, orderly attractive, and with an identifying sign or symbol, which can easily be identified and seen from others parts of the pharmacy. Feedback mechanisms .

10. Dispensing Environment Waiting area An ideal waiting area provide: Comfortable chair/places to sit at least for the elderly/disabled/sick patient to rest). Current popular health magazines, and carefully selected material related to good health to keep the client busy/occupied, and prevent boredom while waiting to receive medicines. Pamphlets, and posters related to public, family and other individual health problems prominently displayed as the waiting area could be used as a health education center) Maintain a high standard of cleanliness and hygiene through regular cleaning and sanitizing .

11. DISPENSING ENVIRONMENT The premises on which a dispensing service is provided would reflect the quality of service and inspire confidence on patients in the nature of pharmaceutical service delivered. Therefore, working conditions are recommended to take into considerations the safety and health of the public and people working on the premises. Dispensing environment must be clean, because most medicinal products are for internal use, making it important that they be hygienic and uncontaminated The environment must also be organized so that dispensing can be performed accurately and efficiently.

12. DISPENSING ENVIRONMENT Ideally, the dispensary should be designed so that access to the dispensing area itself is restricted to authorized personnel only Maintaining a clean environment requires a regular routine of cleaning shelves, daily cleaning of floors and working surfaces and daily removal of waste

13. REQUIREMENT OF A GOOD DISPENSING ENVIRONMENT The dispensing environment should possess: • Appropriate temperature and Optimum humidity control • Sufficient lighting • Cold storage facilities • Adequate number and type of shelves • Lockable cabinet for Narcotic medicines , Psychotropic substances and poisons

14. • Patient/care provider waiting area • Dispensing aids, etc. No loud music playing, talking or television Careful consideration is to be given to the overall security of the dispensary and the stores. Special attention must be paid to controlled medicines and flammables, which must be kept separately from other medicines and be locked properly.

15. SIGNIFICANCE OF GOOD DISPENSING PRACTICE Patient Safety: The primary reason for adhering to GDP is to ensure patient safety. Accurate dispensing reduces the risk of medication errors, which can lead to harmful consequences for patients, including adverse reactions, ineffective treatment, or even life-threatening situations. Preventing Medication Errors: GDP practices help minimize the occurrence of medication errors caused by factors such as illegible prescriptions, incorrect dosing, drug interactions, or misunderstanding patient instructions.

16. *  Effective Treatment: Properly dispensed medications are essential for achieving the desired treatment outcomes. Incorrect dosages, substitutions, or interactions can compromise the efficacy of treatment, affecting patient recovery and well-being. * Professional Reputation: Healthcare institutions and professionals are judged based on their commitment to patient safety and quality of care. Adhering to GDP helps maintain a positive reputation and fosters trust among patients and the broader healthcare community. Minimizing Adverse Events: Accurate dispensing minimizes the occurrence of adverse drug reactions, allergic responses, and other unexpected effects that can arise from incorrect medications or dosages.

17. Healthcare Costs: Medication errors and related adverse events can lead to increased healthcare costs due to hospitalizations, additional treatments, and prolonged patient care. Patient Adherence: Clear instructions and patient counseling during the dispensing process improve patients' understanding of their medications, leading to better adherence to prescribed regimens. Ethical Responsibility: Healthcare professionals have an ethical duty to provide safe and effective care to patients. Good dispensing practices reflect this commitment to patient well-being.  

18. DISPENSING PERSON Responsibility for the accuracy and quality of the medicines supplied lies on the persons overseeing the dispensing process. It is important that the staff dispensing medicines are trained and equipped with the technical knowledge and the skills necessary to dispense the range of medicines prescribed and to communicate effectively with patients/ caregivers.

19. DISPENSING PERSON In addition to reading, writing, counting and pouring, the dispenser or dispensing team needs specific additional knowledge, skills, and attitudes to complete the dispensing process These include; Knowledge about medicine being dispensed Good calculation and arithmetic skills Skills in assessing the quality of preparation Attributes of cleanliness, accuracy and honesty Good communication skills

20. CONT’D Pharmacy professionals involved in dispensing of medicines have the need for medicines information in order to keep themselves up to date with developments related to medicines and to provide such information to patients, other health professionals and to the general public. Because of an increasing number and complexity of medicines, the need for up-to-date information is greater than ever.

21. CONT’D The provision of medicines information to prescribers and other professionals is mainly directed at improving prescribing and medicines administration. On the other hand, because counseling of patients on medications is an integral part of the medicines dispensing process. Medicine dispensers should be adequately equipped with up-to-date medicine information

22. CONT’D Lack of knowledge and information by patients about the medicines they take leads to incorrect use which in turn results in loss of efficacy or occurrence of adverse effects. Communication skills are very important for dispensers dealing with patients or health care professionals to convey relevant medicine information effectively and clearly, which can be done verbally and/or in written form. Medicine dispensers must have the ability to explain information clearly by the language the patient or care provider can understand and check whether the information is being understood

23. Who should be involved in the process of dispensing Screening of Prescription: Healthcare professional (Registered medical practitioner/ registered dentist/ pharmacist) Preparation of Medicines': Pharmacist, registered medical practitioner or a person under immediate supervision of a pharmacist/ medical practitioner Supplying the Medicines': Registered medical practitioner, registered dentist or pharmacist Counselling : By healthcare professional

24. DISPENSING EQUIPMENT The facility should make sure that the equipment on the premises are adequate and suitable for all the operations that have to be carried out. All equipment should be kept clean and should be checked for cleanliness prior to each use. With the exception of non -returnable containers, equipment must be of good material and be kept in such good condition as to enable it to be thoroughly cleaned to prevent any risk of contamination. Use of stainless steel and glass is recommended

25. CONT’D Equipment should include: • A dispensing bench of adequate size having a smooth, impervious working surface. • Tablets and capsules counting devices. • A refrigerator equipped with a maximum/minimum thermometer • A suitable range of dispensing containers for pharmaceutical products with separate sets for internal and external use. • Adequate shelves, lockable cabinet etc

26. DISPENSING PROCESS The dispensing process includes all activities that occur between the time the prescription or request for medicine is presented up to the time the medicines or other prescribed items are issued to the patient. Adherence to good dispensing procedures is vital in ensuring that medicines are dispensed correctly and any potential or real errors which may occur during the dispensing process are detected and rectified before medicines reach the patient.

27. DISPENSING PROCESS The dispensing of medicine involves interpretation of the prescription instruction, technical knowledge required to carry out the instructions & delivers with accuracy & safety to the patient by an authorized & qualified pharmacy professional. There are a considerable variety of factors that require close attention in dispensing, and proficiency requires the establishment of a routine system which can be followed safely even under stress.

28. CONT’D The development and use of written standard operating procedures (SOPs) for the dispensing process will improve consistency and quality of work and can be used for training and reference. The framework for such SOPs may be based on the six major areas of activity

29. AREAS OF ACTIVITY 1. Receive and validate the prescription 2. Understand and interpret the prescription 3. Prepare and label items for issue 4. Make a final check 5. Record the action taken 6. Issue medicine to the patient with clear instructions and advice

30. Step 1. Receive and validate the prescription Upon receiving a prescription, the staff member responsible should confirm the name of the patient. This action is particularly important when the clinic is dealing with a large crowd of people and when there is any risk that staff or patients may mix up prescriptions. Cross-checking the name and identity of the patient must also be done when issuing the medicines. The use of matching numbers or symbols (one attached to the prescription and one given to the patient) can also contribute to making sure the right patient gets the right medicines and is especially helpful in situations where many people share the same surname.

31. Parts of Prescription Patient Information Name, address, contact number, age, sex and weight 2. Date Time the prescription is written A lapse of time more than a couple of days between the date the prescription was written and the date it was brought to the pharmacy may be questioned by a pharmacist to determine if the intent of the physician and the needs of the patient can still be met 3. Rx Symbol or Superscription - "take thou" or "you take"

32. 4. Medication Prescribed or Inscription - body or principal part of the prescription contains the name, strength, route of administration, dose and of the prescribed drug 5. Dispensing Directions to Pharmacist or Subscription - Contains directions for the pharmacist for preparing the prescription 6. Directions for the Patient - As indicated by the prescriber, the directions for the patient's use of the medication

33. 7 . Refill, Special Labeling or Other Instructions - Indicate the number of authorized refills in the prescription by its prescriber If no refill information is provided, it is understood that no refills have been authorized. 8. Prescriber's Signature, Address, name, stamp, place of practice and Other Pertinent Information

34. Classification of Drugs 1 . Prescription or Ethical Drugs - these drugs can only be dispensed upon a written order of a validly-registered physician, dentist or veterinarian.  2. Non-prescription or Over-the-Counter(OTC) Drugs - purchased without a prescription

35. NOTE * Names of medicines prescribed should be written in generic name and abbreviations should not be used. Brand (trade) names should be avoided as far as possible. If a patient must be given a particular brand, it should be indicated on the prescription.

36. Step 2. Understand and interpret the prescription Interpreting a prescription must be done by a staff member who can— * Read the prescription * Correctly interpret any abbreviations used by the prescriber Confirm that the doses prescribed are in the normal range for the patient (noting sex and age) * Correctly perform any calculations of dose and issue quantity * Identify any common drug-drug interactions

37. It is assumed that the prescription will be in written form. Verbal orders for medications should be given only in exceptional and emergency situations. In such cases, the order should be repeated back to the prescriber to ensure accuracy, and written confirmation should be supplied within an agreed-upon period. Computerized prescribing and dispensing systems are becoming more widespread, especially in large hospitals. If the person dispensing the medicine has any doubt about what is required by the prescriber, he or she must check with the prescriber .

38. Illegible writing by prescribers has serious implications when many product names are confusingly similar. Checking a prescription may save a life. All calculations should be double checked by the dispenser or counter-checked by another staff member. An arithmetical error could be fatal.

39. The person receiving the prescription should check for: * Dose, frequency and duration * Drug interactions, medicine duplication, polypharmacy, inappropriate drug therapy, contra-indications. * Allergies * Unusual usage and suspected drug misuse or abuse. NB; For partial medicine supply, ensure that the second or subsequent supply does not exceed the quantity for the duration prescribed.

40. Handling Prescriptions which Require Clarification If an incomplete prescription or one which requires further clarification is received, attempts must always be made to contact the prescriber: i . If the prescriber can be contacted and is available on site, arrange for the incomplete/missing details to be inserted on the prescription by the prescriber. Remedial action for such prescriptions should be discussed with the prescriber prior to sending the prescription back to him/her

41. ii . If the prescriber is not available to amend the prescription himself/herself, authorization to make the change may be obtained verbally through the phone. ili . The amendments to the prescription should be repeated back to the prescriber to ensure accuracy. The amendments should be documented on the prescription and endorsed with "PRESCRIBER CONTACTED" (PC), dated and initialed by the pharmacist/person dispensing. iv. If the prescriber cannot be contacted, patient should be informed and the prescription must be sent back to the prescriber with information on the clarification/action needed. v. Prescriber should document any changes made to the patient's medical record.

42. Handling Prescriptions In A Stock-Out Situation  Stock-out is defined as a situation where the prescribed medicine is not available at the pharmacy when a prescription is being processed. This may be due to the medicine being temporarily out-of stock at that time or the pharmacy does not keep stock of that particular medicine.  If such situation occurs: Inform the prescriber. If the medicine cannot be substituted with another medicine that is available, inform the patient .

43. ii . If the patient agrees for it to be supplied at a later time, arrange to get stocks so as to enable prompt supply the medicine to the patient; iii. If the patient requires the medicine urgently, the pharmacist/person dispensing must communicate with the prescriber to discuss if the prescribed medicine can be substituted with another medicine which is readily available. iv. Any substitution of medicine must be approved by the prescriber and documented on the prescription. v. Prescriber should document these changes in the patient's medical record.

44. Step 3. Prepare and label items for issue Preparation of items for issue is the central part of the dispensing process, and it must include procedures for self-checking or counter-checking to ensure accuracy. This part of the process begins after the prescription is clearly understood and the quantity has been calculated. It is good practice to write the label at this point as a form of self-check. Select stock container or prepack. A good dispenser selects the item by reading the label and cross-matching the product name and strength against the prescription. The dispenser should check the stock to make sure that it has not expired and choose the oldest stock (first-in/first-out) or first expiry, depending on the stock rotation method used.

45. Most well-trained staff members deliberately read the container label at least twice during the dispensing process. Selecting according to the color or location of the container, without consciously reading the label, is poor dispensing practice and may have fatal consequences. Another dangerous practice that should be discouraged is having many stock containers open at the same time. In this situation, product selection is frequently made only according to appearance, which could lead to errors. In addition, medicines continuously exposed to the air eventually deteriorate in quality. It is important to open and close containers one at a time.

46. Measure or count quantity from stock containers. Liquids must be measured in a clean vessel and should be poured from the stock bottle with the label kept upward. Using this technique avoids damage to the label from any spilled or dripping liquid. Tablets and capsules can be counted with or without the assistance of a counting device. The most important rule to follow is that the dispenser's hands must not be in direct contact with the medicine. Using the hands is bad practice for both hygienic and product quality reasons .

47. Counting should be done using one of the following- * Clean piece of paper and clean knife or spatula * Clean tablet-counting device * Lid of the stock container in use * Any other clean, dust-free surface Immediately after measuring or counting, the stock container lid should be replaced and the stock container label should be rechecked for drug name and strength.

48. Pack and label medicine. Tablets or capsules should be packed into a clean, dry container, such as a bottle, plastic envelope, cardboard box, or paper envelope. Any of these containers are satisfactory in a dry climate. During the rainy season or in a humid climate, however, cardboard or paper will not protect tablets and capsules from moisture in the air, which can quickly ruin medicines and make them unfit for use. Capsules and sugar-coated tablets are the most vulnerable to moisture.

49. LABELING Every medicine containing any scheduled poison sold or supplied must be prepared and labelled by or under the immediate personal Ins supervision of the medical practitioner or dentist. All dispensed medicines should be labelled according to the requirement stated by law. It is advisable for labels to be printed. If handwritten, it should be neat and legible with clear instructions on use.

50. Label should contain: Name, address and contact number of hospital/ clinic/ pharmacy Patient’s name Name of medicines (generic and/or trade name) Dosage form with the strength and quantity per unit dosage form: mg/ml of liquid, mg/g for semi-solid preparations Directions for use: dose, frequency and duration (if necessary) Date of supply Expiry date (especially if dispensed medicine is not in its original packaging)

51. "Controlled Medicine" should be labelled for all controlled medicine Medicine for external use should be dispensed in suitable containers and should be labelled conspicuously with the words "Not to be Taken" or "For External Use Only" printed in red OR on a red background Special precautionary labels should be used where necessary (e.g., "Complete the course" for antibiotics, "May cause drowsiness" for sedating drugs, etc ) Whenever possible, always dispense the medicine in its original packaging so that patients will have access to the product information. If a medicine is not dispensed in its original packaging and it is not possible to include all the necessary information on the label, it should be written/printed separately and dispensed together with the medicine. Patient information leaflet (PIL) should be provided where available.

52. Selecting the Medicines • When selecting the medicine to be dispensed, prevent any medication errors by establishing an appropriate system to ensure that the correct medicine is selected, especially if there are medicines with similar names and packaging. Pick the medicine by reading the label at least twice and cross-checking the medicine name and strength against the prescription. * If a barcode system is available, it should be used to enable correct and accurate selection of the medicine. * Check the expiry date of dispensed medicines to ensure that they remain unexpired for the duration of the supply course.

53. * Medicines should be dispensed in original packaging as far as possible. * Tablets/capsules should not be removed from the strip/blister when dispensing. * Bulk loose packs for supply are not encouraged. Avoid direct contact with the hand if loose packs are to be used. • Medicines which need to be packed such as loose capsules/tablets should be packed into a clean, dry container, such as a bottle or plastic envelope which will not compromise the quality of the product after dispensing.

54. Extemporaneous Preparation/ Compounding Extemporaneous preparations should only be prepared if there is no equivalent product available commercially and the product has to be compounded based on the patient's needs. For compounding of psychotropic substance, no person shall dispense, compound or mix any psychotropic substance with any other substance, whether a psychotropic substance or not, for the purpose of it being used for medical, dental or animal treatment unless he is a licensed pharmacist; or a pharmacist in the public service. However, a pharmacy assistant or medical assistant employed in any government facility may also compound or mix any psychotropic substance for the purpose of medical treatment upon prescription prescribed by a registered medical practitioner or registered dentist.

55.  Compounding of extemporaneous preparation should only be done on a patient-specific basis. Ingredients used for compounding are sourced from recognized pharmaceutical suppliers. Ensure that the preparation is prepared according to formulation from a reputable reference. There should be worksheets for the compounding which should be checked by a staff member knowledgeable in compounding and counter-checked by a pharmacist/ another qualified staff member / doctor. Staff involved in compounding should be competent to perform this task under the supervision of pharmacist or registered medical practitioner. Availability of requisite facilities and equipment (Appendix 2) which are maintained in good order.

56. In a situation where hazardous substance, such as cytotoxic medicines (as listed under NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings 4) is to be handled, staff should use appropriate Personal Protective Equipment (PPE) and follow the stipulated procedures. Once the preparation is ready, label the product with necessary particulars including expiry date/ special requirements for safe handling and storage.

57. Keep worksheets or record books for a minimum of two years. The document should contain information as below: * Formula * Ingredients and quantity used * Manufacturer, batch number and expiry date of ingredients used * Patient & prescription details * Names of persons involved in preparing and counterchecking the product * Date of compounding Note: The MOH Extemporaneous Formulation" and Garis Panduan Pembancuhan (Compounding) Sediaan Ekstemporanus " can be used as references.

58. Step 4. Make a final check At this point, the dispensed preparation should be checked against the prescription and against the stock containers used. Although this step can be done as a self-check, it is valuable to have the final check done by another staff member. The final check should include reading and interpreting the prescription before looking at the dispensed medicines; checking the appropriateness of doses prescribed and checking for drug interactions; checking the identity of the medicine dispensed; checking the labels; and finally countersigning the prescription.

59. Step 5. Record action taken/ Record Keeping Records of issues to patients are essential in an efficiently run dispensary. Such records can be used to verify the stocks used in dispensing, and they will be required if a need arises to trace any problems with medicines issued to patients. Three different methods can be used to keep a record of medicines dispensed. When the prescription is retained, the dispenser should initial and annotate the prescription with strength and quantities dispensed and either file it or enter the details into a record book as soon as time is available.

60. When the prescription is returned to the patient, details of the medicines dispensed must be entered into a record book before the items are issued to the patient. The date, the patient's name and age, the medicine name and strength, the amount issued, and the dispenser's name should be entered into the register. When dispensers use computers to record the dispensing details, the computer program should retain the information, which can then be recalled to generate summary reports.

61. Proper record keeping is an essential part of dispensing as it facilitates good management and monitoring of services provided. Such records can be used to verify the stocks used in dispensing, and will be required if a need arises to trace patients dispensed with a particular medicine. All sale or supply of poisons in private facilities must be recorded in a "Prescription Book" on the day of the sale or supply? The following particulars need to be recorded: 1. Date of sale or supply and the serial number of the entry of the prescription (if any); 2. Name of the active ingredients of the medicine or in the case of a proprietary medicine, the name of the medicine and the quantity supplied 3. Name and address of the patient

62. • All sale or supply of Psychotropic Substances must be recorded in a "Prescription Register for Psychotropic Substances" on the day of the sale or supply". The following particulars need to be recorded: 1. Date and serial number of sale or supply 2. Name and strength of the psychotropic substance and the quantity sold/ supplied/ administered 3. Name, identity card/passport number and address of the patient

63. 4. The balance stock should be updated for each supply of the psychotropic substance in possession 5. The required entry must be in chronological order with respect to the previous entries in the register 6. Any c orrection to the entry must be made by way of a marginal note or a footnote which must specify the date on which the correction is made. Correction should not be made by cancellation / deletion /using liquid paper. 7. Each strength or type of psychotropic substance must be recorded in a separate register or a separate part of the register All record books must be in the form of a bound book". Records kept as soft copy must be printed daily (if there is a transaction) and form a bound book.

64. Step 6. Issue medicine to the patient The medicine must be given to the named patient, or the patient's representative, with clear instructions and any appropriate advice about the medicine. The appropriate level of informational detail about possible side effects varies from patient to patient. Verbal advice is important, because illiteracy and poor labeling may both be problems. Apart from information on the dose, frequency, length of treatment, and route of administration, priority should be given to providing information that will maximize the effect of the treatment.

65. dispensing the medicine ensure the 5Rs: Right Dose Right Medicine Right Dose Right Route Right Time Check the name and ID to verify the patient Medications supplied for a person under 18 years of age is for the purpose of his medical treatment only?. Ask about allergies or known adverse drug reactions (ADR). Give clear instructions and proper advice on how to take/ use the medicines dispensed.

66. Ensure the patient is made aware if there are special requirements during transportation, proper storage conditions and usage requirements for the medicines. Compliance aids (e.g. measuring spoon or syringe) for the appropriate dose should be provided, if required. Every effort must be made to ensure that the recipient understands the information/instructions and advice provided. Advise patients to inform the clinic/pharmacy should they encounter any adverse drug reactions (ADRs) when taking the dispensed medicines. Supply of medicines based on prescription, the name of the person who dispensed the medicines, address and the date of supply should be written on the prescription above the doctor's signature as a form of endorsement.

67. MEDICATION COUNSELING Advice should therefore concentrate on: * When to take the medicine (particularly in relation to food and other medicines) * How to take the medicine (chewed, swallowed whole, taken with plenty of water, etc.) * How to store the medicine Warnings about possible side effects should be given cautiously. Common but harmless side effects (nausea, mild diarrhea, urine changing color) should be mentioned to prevent a frightened patient from stopping the treatment .

68. More serious side effects should be mentioned only with the agreement of the prescriber, who needs to take those risks into account when prescribing the medicine. Every effort must be made to confirm that the patient understands the instructions and advice. This can be difficult to do if someone other than the patient is collecting items for the patient or for several patients, particularly when the same medicines are prescribed in different dosages. Whenever possible, the staff member dispensing the medications should have the recipient repeat back the instructions

69. Every patient must be treated with respect. The need for confidentiality and privacy when explaining the use of some types of medicine must be recognized, and efforts should be made to structure medicine collection so that advice to patients can be as individual as possible. The person receiving the instructions may be feeling ill, and the success of treatment depends on the accuracy and effectiveness of the dispenser's communication with the patient. It is encouraged to counsel patients with chronic diseases on multiple medications. Maintain records of the counselling done.

70. . Maintaining Pharmaceutical Stocks Store all medicines in the original containers as supplied by the manufacturer. If the contents need to be transferred to other containers (pre-packing), care must be taken to avoid contamination and mix up. The new containers of the pre-packed / repacked medicines should be labelled appropriately with: * Name, address, and contact number of clinic/pharmacy * Name of medicines (generic and/or trade names) * Dosage form with the medicine strength (mg of tablet, mg/ml of liquid, mg/g for semi-solid preparations) * Manufacturer batch number * Manufacturer expiry date

71. * Store medicines under suitable conditions, taking into consideration the general usage of the medicine (internal/ external item should be segregated/ store separately), stability of the drug and manufacturer recommendations. * Protect medications from contamination, sunlight, moisture and adverse temperatures. * All psychotropic substances must be stored in a locked cabinet, safe or receptacle and can only be locked or unlocked by the registered medical practitioner or pharmacist. * Application of Tallman Lettering, Handling of Look Alike, Sound Alike Guideline and High Alert Medications Guideline in arranging medication stocks is encouraged in order to prevent medication error.

72. Disposal of Pharmaceutical Stocks * Segregate deteriorated/ recalled/ expired/ returned medicines for proper disposal and store in an appropriate bin/ container to prevent unauthorized access. * Management of disposal of expired/ returned medicines should follow as below: 1. Poisons (Psychotropic Substances) Regulations 1989ª for disposal of psychotropic substance - needs to be witnessed by a Pharmacy Enforcement Officer, Ministry of Health. 2. The Guidelines on the Management and Handling of Clinical Waste in Malaysia" by the Department of Environment, Ministry of Natural Resources & Environment for disposal of medicines.

73. Supply of Medicines on Long-term Prescription • Partial supply of medicines is based on the validity of the prescription and duration for its supply. • ensure that a copy of the original prescription is kept for recording purposes. Also, ensure that the quantity supplied by the pharmacy is recorded on the original prescription as reference for the next supply. • The original prescription should be returned to the patient as it will be required for the next supply.

74. Delivery of Repeat Medicines by Post First time supply must always be dispensed at the pharmacy counter. Delivery service should only be provided for prescription that is partially supplied. The delivery service is only applicable when it has been established that the patient/caregiver understands the use of the medicines and direct face-to-face contact with the patient or caregiver is deemed not necessary for subsequent refills of the prescription.

75. Criteria for eligibility: Only stable and compliant patients should be eligible to receive medicines through the delivery service. Only partial supply medicines for chronic diseases should be considered for delivery services. Only medicines that do not require specific storage conditions can be delivered through post. Psychotropic drugs and medicines containing pseudophedrine , ephedrine, codeine and tramadol should not be delivered by post.

76. iv. Agreement from the patient must be obtained prior to providing the delivery service and appropriate records of request for the service must be kept. v. The delivery mechanism used must be secure and medicines delivered promptly to the patient so as not to compromise on the quality of medicines and to ensure continuity of their medicines

77. . Non-Prescription Medicines When non-prescription medicine is supplied, ensure that: 1. Sufficient information is gathered from the client to assess nature of problems, symptoms and past medical / medication history (if any) 2. Select an appropriate medicine 3. Label for the medicines prepared 4. Checking of the medicine before issuing it 5. Recording done 6. Medicine is supplied with proper instruction  

78. Promoting efficient management in dispensing Good dispensing practices are most threatened when dispensing staff face a crowd of patients demanding immediate attention. The need for speed must be balanced with the need for accuracy and care in the dispensing process. At this point, the patient's care, or even life, is in the hands of the dispenser. In dispensing, accuracy is more important than speed. Prior agreement with the prescribers to prescribe only items that are available at the pharmacy or listed on the hospital or clinic formulary prevents unnecessary delay and confusion for the patient and improves efficiency in the dispensing process.

79. Organizing patient flow, such as establishing systems to receive payment and prescriptions and issue medicines, can reduce the potential for dispensing errors by removing the dispenser from the intense scrutiny of ten or more patients anxiously waiting at the dispensary window. Strategies such as giving information on the current waiting time and issuing numbers linked to the order in which prescriptions will be dispensed can encourage patients to use the waiting time to access other hospital or clinic services, helps to prevent long queues and crowding at the dispensary window, and can improve patient satisfaction. One good way to reduce dispensing time and improve safety is to prepackage and label commonly used medicines. This process also distributes some of the dispensing workload to less busy periods of the day.

80. Another way to prevent staff from making errors when under pressure is to organize the work so that more than one individual is involved in the dispensing process for each prescription. This method introduces a system of using counter-checks, which is a wise precaution in most situations. One example of such a system assigns one person to receiving and checking prescriptions, another to preparing the medicines, and a third person to handing them to the patient with advice; the team members then rotate responsibility for these activities at regular intervals.

81. Techniques to ensure quality in dispensing include Requiring that all staff work in accordance with written SOPs Maintaining records on what medicines and products have been issued Scheduling worker shifts to make best use of staff: providing more staff at peak hours, maintaining enough coverage to keep the dispensary open during breaks, and coordinating shift starting/ending times with patient flow * • Involving the pharmacy staff in hospital/facility committees to identify and resolve problems involving patient flow, communication, and other areas

82. POINTS TO REMEMBER * Containers used in dispensing should be appropriate to the particular product being dispensed. * It is important to open and close containers one at time Note: air eventually deteriorate quality of medicines. Labels of medicinal products should be legible and clear. A prescription record book should be used for recording dispensed prescriptions. It should be open for inspection anytime when the pharmacy is open for business and must be preserved for a period of two years after the last entry in it has been made.

83. POINTS TO REMEMBER * All fully served prescriptions must be recorded in the prescription record book, numbered consecutively and shall be put on file for two years. * Smoking and eating should not be permitted in the dispensing area. Patients should receive the appropriate medicine, in the proper dose, for an adequate period of time, and at the lowest cost to them and their community.

84. THANKS FOR YOUR ATTENTION………..