LECTURE 05 Prescription Handling .pptx

Pharm D

1. PRESCRIPTION HANDLING (Parts of a Prescription) Lecture # 05 PHARMACY PRACTICE-IIA (DISPENSING PHARMACY) PHM-6503

2. REFERENCE BOOK Jannie Watson, Rees J, Smith I. Pharmaceutical Practice . 5th Ed. Churchill Livingstone; 2014. Chapter # 20 (Pg. 187-193) RAHAT FATIMA (LECTURER, DOP, IIUI) 2

3. THE PRESCRIBING PROCESS & EVIDENCE-BASED MEDICINE RAHAT FATIMA (LECTURER, DOP, IIUI) 3

4. INTRODUCTION The prescribing of medicines is the most common medical intervention in patient care and drug costs are a major component of NHS expenditure. Ensuring optimum benefits for patients and value for money for taxpayers and other individuals and organizations paying for health care are priorities and a model of ‘good prescribing’ has been proposed that has four aims. These aims are to: Maximize effectiveness Minimize risks Minimize costs Respect patient choice RAHAT FATIMA (LECTURER, DOP, IIUI) 4

5. INTRODUCTION Maximizing effectiveness is about selecting a drug therapy that will achieve its therapeutic objective in a suitable timescale. Minimizing risks is recognizing that all drug treatments carry an element of risk of causing harm to the patient and that selection of the drug should be about managing these benefits and risks. The cost of therapy should also be taken into account by the prescriber although such consideration should go beyond a simple review of the drug costs but also consider any costs of monitoring treatment such as blood tests, length of treatment and any additional items that could be required such as prescribing an additional drug to protect the gastrointestinal tract from adverse effects caused by the first. RAHAT FATIMA (LECTURER, DOP, IIUI) 5

6. INTRODUCTION Establishing the views of the patient is a vital part of the process of assessing the relative importance of the first three aims in this model. Patients may differ in their views regarding managing the symptoms of a condition, living with the consequences of a condition, exposing themselves to risks of harmful effects and the amount of money they would be willing or able to pay for treatment. In addition, patients may wish product selection to take their lifestyle into account such that the frequency and route of administration of the selected product fits in with their daily routine. It is accepted that ‘good prescribing’ involves trade-offs between these four aims and that this often involves delicate balancing between each of the aims. RAHAT FATIMA (LECTURER, DOP, IIUI) 6

7. Parts of a Medical Prescription RAHAT FATIMA (LECTURER, DOP, IIUI) 7

8. Patient's Address: Diagnosed With: Blood Pressure: Pulse Rate: Weight: Allergies: Disabilities if any: R x Patient´s Name: Date of Birth: Age: Sex: Occupation: Health Insurance Number: Health Care Provider: Health Card Number: Patient ID Number: DRUGS Unit (Tablet/Syrup) Dosage (Per day) 1 2 3 4 5 6 Diet to Follow: Brief History of Patient: Medical Prescription Doctor´s Signature Date:

9. THE PRESCRIBING PROCESS RAHAT FATIMA (LECTURER, DOP, IIUI) 9

10. The prescribing process will be considered under five headings although there is some overlap between these and their sequence may not be the same in all cases. The first is concerned with all the things that must be in plac e before a prescriber can start to prescribe; the second with collecting infor mation; the third with analyzing the information and making the prescribing decision and the fourth with making appropriate records and plans for monitoring the patients progress and the last with auditing and evaluating prescribing practice. RAHAT FATIMA (LECTURER, DOP, IIUI) 10

11. PRE-REQUISITES Prescribing can only be carried out by healthcare professionals that have the appropriate prescribing qualifications and these will vary depending on the type of prescribing to be carried out. To prescribe prescription only medicines on the NHS or privately the prescriber, if not a medical prescriber, must have successfully completed the training to allow them to act as a supplementary or an independent prescriber. The training course consists of a taught element (around 26 days) and learning in practice (around 12 days), which includes prescribing under the supervision of a medical prescriber. To participate in a minor ailment scheme and prescribe pharmacy only medicines at NHS expense the pharmacist will likely have had to complete appropriate accreditation set by the local primary care organization. RAHAT FATIMA (LECTURER, DOP, IIUI) 11

12. PREREQUISITES Patients that are to receive their prescriptions from a supplementary prescriber must give informed consent. Patients do not need to sign this informed consent but is good practice to make a note in the patient’s medical notes when informed consent was given. The exact nature of informed consent is difficult to define and it is likely that the input from the healthcare professional will vary between patients when obtaining consent. Observation of disputes between patients and physicians regarding whether informed consent was given show that simply handing the patient a leaflet does not discharge the physician from their obligation to obtain informed consent. RAHAT FATIMA (LECTURER, DOP, IIUI) 12

13. PREREQUISITES In any legal dispute it is up to the courts to decide which party they believe but the disputes that found in favor of the physician tended to be those where the physician was able to demonstrate that they had given the information to the patient because they had documented the advice they gave in the patient’s medical records. Prior to the patient consultation, the prescriber should ensure that they are suitably prepared. Part of this preparation includes ensuring they have sufficient indemnity insurance that covers their prescribing and that their job description clearly shows that prescribing is part of their role. Another part of the preparation is acquiring the appropriate knowledge and skills. RAHAT FATIMA (LECTURER, DOP, IIUI) 13

14. RAHAT FATIMA (LECTURER, DOP, IIUI) 14 Checklist for knowledge and skills required by pharmacist prescribers Legal restrictions effecting which medicines can be prescribed Independent pharmacist prescribers can prescribe any licensed or unlicensed medicine except diamorphine, dipipanone or cocaine for treating addiction but may prescribe those drugs when treating organic disease or injury. Supplementary prescribers can prescribe any licensed or unlicensed medicine including controlled drugs provided it has been specified in the clinical management plan. Professional restrictions effecting which medicines can be prescribed It is vital that each prescriber only prescribes within their own area of competence. Knowing one’s own limitations is a key skill for a prescriber. In addition, they must also have an appropriate level of experience dealing with the condition and it might be appropriate to refer a patient presenting with a condition rarely experienced to another prescriber for assessment and any prescribing

15. RAHAT FATIMA (LECTURER, DOP, IIUI) 15 Checklist for knowledge and skills required by pharmacist prescribers Administrative arrangements regarding payments for the service The administrative arrangements regarding the prescribing process must be fully understood. In the case of minor ailments schemes these arrangements could include a description of records that should be kept and how payment for the service is to be made. For NHS prescribing the prescriber should be aware of the categories of patient that are exempt from NHS charges and what payments should be made by those that are not exempt. Patient confidentiality Pharmacist prescribers must maintain patient confidentiality and take steps to ensure that no unauthorized personnel can gain access to patient medication records by securely storing the data either via lock and key or via appropriate electronic security measures such as passwords for data stored electronically.

16. RAHAT FATIMA (LECTURER, DOP, IIUI) 16 Checklist for knowledge and skills required by pharmacist prescribers Ethics Prescribers should be aware of the good practice guidance from the DH and the GPhC before they start to prescribe. The DH guidance addresses prescribers not prescribing for themselves, not normally prescribing for members of their family and also covers accepting gifts and hospitality for suppliers. Pharmacist prescribers must also comply with the GPhC Standards of conduct, ethics and performance. Security Prescribers must be aware of security issues surrounding prescribing and take steps to minimize the risks. Blank prescription forms could be used by drug misusers to try and obtain supplies of prescription medicines for abuse or to sell to others. Care must be taken to ensure that the forms are securely stored. Personal security must also be considered if the prescriber is visiting patients in their own homes or other locations in the community.

17. RAHAT FATIMA (LECTURER, DOP, IIUI) 17 Checklist for knowledge and skills required by pharmacist prescribers Therapeutic management of conditions A pharmacist’s knowledge and skills required for the management of a therapeutic area must be up to date and based upon the best evidence available at the time. The knowledge should extend to non-drug approaches to treatment as sometimes these could be the most appropriate Other members of the healthcare team Prescribers should be aware of other professionals they could refer patients to, e.g. general practitioner, the accident and emergency department in the hospital, dentists, the community nursing service (district nurses and health visitors) social services and self help groups

18. PRESCRIBING DECISION-MAKING Upon analysis and interpretation of the patient’s signs, symptoms and laboratory test results, the prescriber must consider the treatment options including the option of offering no treatment to the patient. The consideration of therapy options must include concurrent diseases and concurrent medication, the patient’s lifestyle (would the treatment regime fit in with the patient’s schedule or would side-effects of drugs affect their ability to perform their usual activities, e.g. driving). A key component of this phase is involving the patient in the decision-making in order to achieve concordance. The prescriber must communicate the benefits and risks of the different treatment options to the patient or their carer The principles of concordance dictate that patients should fully participate in the decision making process and a consultation style where patients are treated as equals and have the opportunity to ask questions and to raise any concerns or worries they might have helps to achieve this. RAHAT FATIMA (LECTURER, DOP, IIUI) 18

19. PRESCRIBING DECISION-MAKING Following selection of the drug and formulation, the dosage regime must be determined. The dosage guidance in the summary of product characteristics, BNF or local and national clinical guidelines should be used to work out the dosage to be prescribed. In general it is recommended that dosage be started at the lower end of the dosing schedule and that the dose should be gradually increased until the required therapeutic benefits are seen and side effects are minimized. However, there are many exceptions to this such as prescribing a loading dose for certain antibiotics or prescribing drugs where the therapeutic benefits are not obvious such as drugs used in prophylaxis. RAHAT FATIMA (LECTURER, DOP, IIUI) 19

20. PRESCRIBING DECISION-MAKING The prescriber must also indicate the quantity to be supplied on the prescription. The quantity to be supplied will depend upon whether the treatment is likely to be acute or chronic. If the treatment is acute then the quantity is likely to be enough for the recommended course of treatment. When determining the quantity to be supplied for a chronic condition the prescriber should bear in mind the frequency that they would wish to review the patient, whether the patient has to pay for the item, the patient’s ability to pay the prescription levy and whether there are any dangers from accidental or deliberate overdose. RAHAT FATIMA (LECTURER, DOP, IIUI) 20

21. PRESCRIBING DECISION-MAKING In general, smaller quantities offer the opportunity to review patient’s therapy more frequently and reduce waste if patients are unable to take their medicine through the occurrence of troublesome side effects or adverse drug reactions. However, smaller quantities can cause greater patient inconvenience as patients will to visit healthcare professional more frequently and greater expense if they have to pay for their medication, as well as increasing the prescriber’s workload. RAHAT FATIMA (LECTURER, DOP, IIUI) 21

22. RECORDING & MONITORING It is important to realize that the responsibilities of the prescriber do not end with signing the prescription. The prescriber must make appropriate records of the medicine(s) prescribed and any advice given to the patient in the patient’s medical notes. For paper held records the prescriber will obviously have to write the name of the prescribed item, the formulation, the strength, dosage instructions in the notes. In the case of electronic prescribing the details of what was prescribed, the date of prescribing and the directions will be stored automatically in the patient’s records. However there may be a need to record additional information such as when the patient should next be reviewed and the monitoring that is recommended. RAHAT FATIMA (LECTURER, DOP, IIUI) 22

23. AUDITING PRESCRIBING PRACTICE Prescribing audits involve reviewing prescribing activity against a set of explicit criteria such as a set of local or national clinical guidelines. For example, this could involve reviewing the prescribing for all patients registered with a practice that have a diagnosis of angina and comparing this with the guidance published by NICE. The audit should specify the standard of compliance with the guideline that is expected (e.g. 90% or 100%). If the audit reveals that expected standard of compliance has not been met then there should be a review of practice to identify why the standard has not been met. Prescribers should reflect upon the findings of the review and agree what action is required. The audit should then be repeated to determine whether the action has had an impact on the compliance with the standard. An audit cycle involves repeating the audit, review and action RAHAT FATIMA (LECTURER, DOP, IIUI) 23

24. EVIDENCE-BASED MEDICINE RAHAT FATIMA (LECTURER, DOP, IIUI) 24

25. EBM Evidence-based medicine (EBM) has been described as ‘a means of closing the gap between research and everyday practice and ensuring that clinical decisions are based upon the best available scientific evidence’. It allows healthcare professionals to compare the evidence for different treatment options. This comparison may sound easy but unfortunately the available evidence is frequently of variable quality, which makes comparisons difficult. The process of EBM involves four stages. RAHAT FATIMA (LECTURER, DOP, IIUI) 25

26. STAGES OF EBM The first involves identifying the question to be answered such as: Does treatment with drug X prevent more cardiovascular events than drug Y? The second stage involves searching the literature to find studies that have compared drug X with drug Y. The third stage is a critical appraisal of the studies that have been identified which involves making judgements about the quality of the studies, comparing the evidence supporting drug X with the evidence supporting drug Y and determining whether the balance of evidence favors one drug over the other. The final stage is about applying the evidence to clinical practice, which could involve recommending one drug be prescribed by clinicians rather than the other. RAHAT FATIMA (LECTURER, DOP, IIUI) 26

27. Prescription Dispensing (Good Dispensing Practices) RAHAT FATIMA (LECTURER, DOP, IIUI) 27

28. RAHAT FATIMA (LECTURER, DOP, IIUI) 28

29. Receiving the Prescription The patient walks into the pharmacy and presents the prescription. At this stage, communication and interaction with the pharmacy staff take place. In the modern age of electronic documents, e-prescribing is already being practiced in some countries and is expected to develop even further. In electronic prescribing, the prescription is transferred electronically and the pharmacist receives an electronic document. Once the patient presents at the pharmacy and provides the required details for retrieval of the electronic prescription, the process of communication and interaction with the patient commences. RAHAT FATIMA (LECTURER, DOP, IIUI) 29

30. Reading & Checking of Prescription Prescription is reviewed to see which medicines are required and to note patient details. Pharmacy staff should check: Patient’s name and address Age of patient if under 12 years Name, dose and quantity of medicine Date Prescriber’s name and address S ignature of prescriber L egality and authenticity of document. RAHAT FATIMA (LECTURER, DOP, IIUI) 30

31. Collection of Medicine This step may be carried out either manually, where the pharmacy or pharmacy assistant picks up the required product from the pharmacy storage section, or mechanically, where the pharmacist requests the product through a machine interface and the product is selected from the magazine and delivered at the dispensing bench. During this step, pharmacist intervention to decrease occurrence of dispensing errors includes: C are in selecting appropriate medicine; there are some medicines that have very similar names (e.g. amlodipine and amiloride, Lescol and Losec ) C are in selecting the appropriate strength; there are medicines that are available in different strengths (e.g. amoxicillin 250 and 500 mg capsules, atenolol 25, 50 and 100 mg tablets) C are in selecting the appropriate dosage form; there are medicines that are available in different dosage forms (e.g. diclofenac gel, tablets, modified-release tablets, suppositories). RAHAT FATIMA (LECTURER, DOP, IIUI) 31

32. LABEL PRODUCTION RAHAT FATIMA (LECTURER, DOP, IIUI) 32

33. CONTAINER SELECTION If, during the dispensing process, there is a requirement to repack the medicines, the appropriate container should be chosen for the medication. This includes taking into consideration stability of the product and interaction of the product with the material used for the container. Usually repacking takes place in a controlled area under a quality assurance system and pre-packs are produced to be available for the pharmacist during the dispensing. In the UK, original pack dispensing is required, whereby the pharmacist can dispense branded or generic products as packaged in the original form as produced by the manufacturer. RAHAT FATIMA (LECTURER, DOP, IIUI) 33

34. RECHECKING Recheck that the prescription and the medicine prepared are consistent and that the right medicine in the right dosage form and strength has been identified, that the right label is attached and that the right patient instructions are provided. RAHAT FATIMA (LECTURER, DOP, IIUI) 34

35. HANDING OVER MEDICINE The pharmacist hands over the medicine and explains to the patient when and how to take the medication . RAHAT FATIMA (LECTURER, DOP, IIUI) 35 PATIENT COUNSELING ACTIVE PASSIVE

36. COMMON ABBREVIATIONS USED IN PRESCRIPTIONS RAHAT FATIMA (LECTURER, DOP, IIUI) 36

37. PRACTICE SUMMARY The pharmacist should ensure that the dispensing process implemented in the pharmacy implies the correct attitude and transfer of knowledge from reading the prescription to the handing over of the medicine to the patient. The dispensing process includes communication and interaction between the patient and the pharmacist. The way that this interaction takes place may influence the efficacy of the dispensing process. The dispensing process employed could be outlined in good dispensing procedures to ensure standardization of the dispensing process within a pharmacy. RAHAT FATIMA (LECTURER, DOP, IIUI) 37

38. PRACTICE SUMMARY Pharmacist intervention should ensure that the process eliminates dispensing errors. Factors that decrease dispensing errors include: dispensary layout and workflow, systems of drug storage, lighting, limitation of noise and use of electronic equipment (e.g. scanners). Pharmacist intervention should ensure that the patient understands the use of the medicine, its correct application and information about any side-effects expected and action that might need to be taken in the case of missed doses. When the customer is not the patient but a proxy, emphasis should be placed on the need for correct onward transmission of the information to the patient or carer. RAHAT FATIMA (LECTURER, DOP, IIUI) 38

39. CLASS ACTIVITIES RAHAT FATIMA (LECTURER, DOP, IIUI) 39

40. ACTIVITY # 01 For each of the following abbreviations, which may be used on prescriptions, give a brief explanation and an example of a product for which this abbreviation is used, stating generic name and dosage form(s): p.c., p.r.n. RAHAT FATIMA (LECTURER, DOP, IIUI) 40 p.c. – after food, ibuprofen (tablets, suspension). p.r.n. – when required, paracetamol (tablets, soluble tablets, suspension, suppositories).

41. ACTIVITY # 02 For each of the following cautionary and advisory labels, give one example of a drug where the label should be used: (a) May cause drowsiness (b) Do not take milk, indigestion remedies and medicines containing iron or zinc at the same time of day as this medicine (c) Take at regular intervals. Complete the prescribed course unless otherwise directed. RAHAT FATIMA (LECTURER, DOP, IIUI) 41 (a) May cause drowsiness – hydroxyzine. (b) Do not take milk, indigestion remedies and medicines containing iron or zinc at the same time of day as this medicine – ciprofloxacin. (c) Take at regular intervals. Complete the prescribed course unless otherwise directed –co-amoxiclav.

42. ACTIVITY # 03 Give two examples of products that should be taken after food. Give reasons for your choice. RAHAT FATIMA (LECTURER, DOP, IIUI) 42 Diclofenac potassium tablets – should be taken after food to minimize gastrointestinal irritation. Itraconazole capsules – should be taken after food to ensure optimal absorption.