1. AFAMS Filling a Prescription Order (Dari) EO 003.04

2. AFAMS Purpose of Lesson (Dari) The pharmacy technician student will learn how to: (1)Confirm the availability of the ready form medication. (2) Prepare the ready-form medication/pharmaceutical for dispensing. (3) Label the prescription container according to the prescription order. AFAMS Insert Dari

3. AFAMS Purpose of Lesson (Dari) (4) Identify the difference in process when filling an inpatient prescription versus an outpatient prescription. This topic will be taught using a lecture format and students will be given a chance to practice these skills during an in-class assignment as well as during a skills lab. Note: Students should be provided with a copy of the ANA formulary for this lesson. AFAMS Insert Dari

4. AFAMS Overview of Lesson (Dari) (1) Confirming availability of medication (2) Prepare the medication (3) Label the medication (4) Check the prescription. (5) MoD Forms used (6) Process for filling in-patient medications. (7) In-class assignment AFAMS Insert Dari

5. AFAMS Confirming Availability of the Medication (Insert Dari)

6. AFAMS Is the medication available? (Insert Dari) Once you have received the prescription and verified the appropriate information with the patient the next step is to confirm that the medication ordered is available. This includes: (1)Verifying that the medication is listed in the ANA formulary. (2)Confirm that the medication is available in the correct dosage form, as ordered on the prescription. (3)Confirm that the medication is in stock and that there is sufficient quantity to fill the prescription.

7. AFAMS ANA Formulary (Insert Dari) The pharmacy should only carry the medications that are listed on the ANA formulary. For the most part, only medications that are listed on the ANA formulary can be prescribed for patients.

8. AFAMS ANA Formulary (Insert Dari) There will be times when a medication is prescribed that is not on the ANA formulary. This can be for one of two reasons: (1)The physician is unaware of what is listed on the formulary. (2)The physician feels strongly that the medication they have prescribed is the best treatment for the patient and is seeking special permission.

9. AFAMS A patient presents to the pharmacy with the following prescription: Is this medication on the ANA formulary? (Insert Dari)

10. AFAMS Answer: No it is not. (Insert Dari) Class discussion: As a pharmacy technician what do you do next? (Insert Dari)

11. AFAMS What you should do: (Insert Dari) You should present the prescription to the on duty pharmacist and inform the patient that there may be a slight delay in preparing their prescription. The pharmacist will likely then contact the physician to determine if this is a special request for a non-formulary medication or if an alternative medication that is on the formulary can be prescribed instead.

12. AFAMS Special request for a non-formulary medication (Insert Dari) If the physician is requesting special permission to prescribe a non- formulary medication the pharmacists can assist them in that process. This involves discussion with the chief of pharmacy and the P&T Committee. The patient will not be able to have their prescription filled that day as the approval process may take some time. Also the medication will have to be purchased as it is most likely not in stock in the pharmacy.

13. AFAMS Confirm that the medication ordered is in stock (Insert Dari) In order to confirm that the medication is in stock you must check the pharmacy shelves. You can verify that there is enough is in stock by checking the balance on the stock card. If there is not enough in stock, then the pharmacy technician should check with the quartermaster to see if there are any additional stores in the QM.

14. AFAMS Stock Cards tablets Remarks Metoprolol 100mg Date Issues Balance Expiry Date Out In W93A21 5199 0001 20024 Sep 14 05 Sep 13 0 0 Previous quantity 40031 Oct 14 05 Sep 13 200 0 To Pharmacy Dispensary 20024 Sep 14 08 Sep 13 0 200

15. AFAMS Selecting the appropriate dosage form (Insert Dari) It is very important that the correct formulation of the medication that has been ordered is the one that is given to the patient (i.e. tablet, liquid, inhaler, eyedrop). For example: if a patient was prescribed prednisolone eye drops and tablets were dispensed instead the patient may not receive the desired effect.

16. AFAMS Selecting the appropriate dosage (Insert Dari) Many medications come in different strengths/concentrations. For example: Naproxen Comes in 250mg and 500mg tablets. Pharmacy technicians must pay careful attention to ensure that they select the correct one.

17. AFAMS Selecting the appropriate dosage (Insert Dari) Physicans may prescribe a strength of medication that does not exist in ready- form. For example: Prednisone Usually comes in 5mg and 50mg tablets. If a doctor were to prescribe: Prednisone 30 mg od for 10 days You would have to make up the prescription using 5mg tablets. Therefore the patient would have to take 6 tablets per day = a total prescription of 60 tablets.

18. AFAMS Prepare the Medication (Insert Dari)

19. AFAMS Number of units dispensed (Insert Dari) In order to ensure that patients receive the appropriate length of therapy the correct amount of medication must be dispensed. Medication can be dispensed in number of tablets, capsules, mls, grams and units (i.e. inhaler, bottle etc.).

20. AFAMS Counting (Insert Dari) When counting pills and capsules we count in either 2’s or 5’s (depending on the amount required). Generally 2’s if the amount is less than 10. The rationale for counting by 5’s is that 5 is the largest number that the human eye can easily recognize. Counting trays are generally used when counting pills and tablets.

21. AFAMS Weighing medications (Insert Dari) Occasionally you will need to talk a bulk format product (i.e. a large tub of cream) and dispense a portion of it. For example: Hydrocortisone 1% cream Sig: AAA bid prn Mite: 30 g Hydrocortisone cream comes in a bulk container of 500 g. You will need to weigh out 30g of the cream to be dispensed to the patient. The details of weighing medication will be covered in PO 004.

22. AFAMS Selecting an appropriate container (Insert Dari) Many medications come in a ready- form that is appropriate to dispense to the patient. However, some medication come in bulk format and need to be placed in a smaller or more appropriate container to be dispensed to the patient.

23. AFAMS Label the Medication (Insert Dari)

24. AFAMS Why it is important to label a medication (Insert Dari) For clear identification of what the medication is and what strength it is. So the patient doesn’t have to try and remember what the directions are for the medication, they can simply read them off the label.

25. AFAMS What’s required on a label (Insert Dari) Patient’s name Prescriber’s name Drug name Drug strength Drug dose Patient instructions Quantity dispensed Date dispensed

26. AFAMS Labeling: Medication Insert (Insert Dari) This is a small piece of paper that the labeling information is written on. It can be inserted into the medication box, taped onto a bottle or simply handed to the patient with their prescription. These inserts should also have the pharmacy information (name and contact info pre-printed on the top). Insert Dari

27. AFAMS Auxiliary Labels : Pictograms (Insert Dari)

28. AFAMS Pictograms پکتوگرام ها Pictograms give health professionals a means of communicating medication instructions to people with no common language and / or who may be illiterate. Pictograms may also be used for those who have slight cognitive impairment or difficulties seeing such as the elderly. Pictograms may help the patient understand the instructions on how and when to take the medication prescribed. پکتوگرام ها برای اشخاص مسلکی صحی یک وسیله ارتباطی هدایات دوا را همراه با مردم قرار میدهد که زبان رسمی را نمی فهمند ویا بیسواد هستند. از پکتوگرام ها نیز برای اشخاص استفاده میشود که اندکی اختلال در شناخت یا مشکلات در دیدن دارند مانند اشخاص مسن. بمنظور بهبود ارتباطات، شکل های مختلف هدایات دوا را میتوان چاپ نموده و در دسترس مریض قرار داد. پکتوگرام ها میتوان برای مریض کمک کند تا هدایات را بفهمد یعنی چطور و چی وقت دوای توصیه شده را اخذ کند.

29. AFAMS Checking a Prescription (Insert Dari)

30. AFAMS What does ‘checking’ a prescription mean? (Insert Dari) Checking a prescription means to verify that the medication being given to the patient matches what is ordered on the prescription. This is a technical check. The Five rights: (1)Right drug (2)Right dose (3)Right formulation (4)Right directions (5)Right patient A pharmacist would take a further step to evaluate if the drug is appropriate for the patient and the indication.

31. AFAMS Who checks a prescription? (Insert Dari) If possible, it is ideal to have a pharmacist check a prescription to ensure that it is correct from both a technical and therapeutic or treatment point of view. However, it is not always possible to have a pharmacist check each prescription. Therefore, technicians can check other technicians work. This is commonly referred to in North American as tech-check-tech.

32. AFAMS Tech-check-tech (Insert Dari) First Technican

33. AFAMS Pharmacy Technician Rotations (Insert Dari) During the pharmacy technician practical rotations students will be required to check 100 prescriptions without error. This will be completed at the polyclinic and NMH pharmacy (to be covered in more detail during presentation on student rotations).

34. AFAMS MoD Forms Used (Insert Dari)

35. AFAMS MoD Forms (Insert Dari) There are two MoD forms on which prescriptions dispensed must be recorded: (1)Mod Form 9 (2)Stock Card (quantity dispensed) Both of these will be covered in further detail in EO 006.

36. AFAMS In-patient prescription processing (Insert Dari)

37. AFAMS In-patient prescriptions (Insert Dari) Inpatient prescriptions are brought to the pharmacy at the NMH twice a week from the wards. They are written on the MoD form 58. If a medication order for a patient changes between the twice weekly prescription submissions, the physician will write a single prescription (same format as the outpatient prescription). This prescription will be brought to the pharmacy by a nurse and filled in the same manner as an outpatient prescription.

38. AFAMS Reminder: MoD Form 58 (Insert Dari)

39. AFAMS Process for MoD Form 58 (Insert Dari) The MoD Form 58 will be review by the on duty pharmacist. If there are any problems encountered the pharmacist will deal with them. The patients listed on the MoD Form 58 are verified against the hospital bedroll. If the pharmacist is satisfied, they will sign the MoD Form 58, approving the medications to be filled. A technician will then fill the order.

40. AFAMS Filling an inpatient order Request for inpatient medications are not filled individually for each patient. Rather the total quantity requested for each drug will be filled. For example: On the order pictured patient # 5845 required 30 tabs of morphine and patient 5846 requires 10 tabs of morphine. To fill the this order you would count out 40 morphine tablets. You fill the total quantity requested for each of the medications listed.

41. AFAMS (Insert Dari) Insert Dari

42. AFAMS MoD Forms Required (Insert Dari) Just like outpatient prescriptions the stock card for each medication must be updated. Each inpatient will have their own MoD form 9 on which the medication issued must be entered. This is just a general understanding for now and how to enter the information on these forms will be covered in PO 006.

43. AFAMS Checking the order (Insert Dari) Ideally a pharmacist should check the order, however, a pharmacist may not always be available and often technicians will have to check eachother’s work. The technician filling the order will verify that they have filled: (1)The correct medications (2)For the correct total amounts requested The technician checking the order will also verify the information and sign off. The same stamp should be used as is used for the outpatient prescriptions.

44. AFAMS In-class Assignment (Insert Dari) Students will be given 30 min to complete this assignment. This assignment will consist of 5 prescriptions and from the prescriptions students must create the label (medication insert). Students are to be given copies of the blank medication inserts. (Insert Dari)

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50. AFAMS Answers (Insert Dari)

51. AFAMS Answers (Insert Dari) اسم مریض ___________________ اسم داکتر _________________ نام دوا _____________ دوز _________________________ تعداد ______________________ دستورات _____________________ ______________________________ اسم مریض ___________________ اسم داکتر _________________ نام دوا _____________ دوز _________________________ تعداد ______________________ دستورات _____________________ ______________________________ اسم مریض ___________________ اسم داکتر _________________ نام دوا _____________ دوز _________________________ تعداد ______________________ دستورات _____________________ ______________________________ اسم مریض ___________________ اسم داکتر _________________ نام دوا _____________ دوز _________________________ تعداد ______________________ دستورات _____________________ ______________________________ اسم مریض ___________________ اسم داکتر _________________ نام دوا _____________ دوز _________________________ تعداد ______________________ دستورات _____________________ ______________________________

52. AFAMS Questions? (Insert Dari)