1. Ch 24: Preparation & Delivery - Retail
Big differences in Retail vs. Hospital
In retail, the medicine will leave with the patient, and they are responsible for proper use and storage
That means we are responsible to prepare the product as best we can through packaging, and preparing the patient through auxiliary labeling and counseling ©

2. Poison Prevention Packaging Act
Passed in 1970
Requires locking caps on prescription bottles
Exceptions include SL nitroglycerine & SL isosorbide (used for angina)
Physicians can override by noting “no safety caps” on the prescription order
Patients can override by signing a waiver stating they request no safety caps ©

3. The Pharmacy Bottle
Protects the contents from light, moisture, and air ©

4. Prescription Labels Mandatory Information
Class 5 Slides
Mandatory Information
Pharmacy Name, Address, Phone
Date of Filling
Prescription Number
Initials or Name of Pharmacist
Patient’s Name
Complete Instructions
Drug Name and Strength
Expiration Date of Medication
Quantity in Package
Prescriber’s Name
Prescription Labels ©
copyright Mark Greenwald - all rights reserved

5. Auxiliary Labels Used to reinforce counseling on the medication
Gives Information on:
Proper Storage
Side Effects
Directions for Use
Refill Status
Legal Warnings ©

6. Medication Guides Mandated by the FDA when:
Certain information is necessary to prevent serious adverse effects
Patient decision making should be armed with information about a known serious potential side effect
Patient adherence to directions is critical
Know the common classes of medications that require medication guides ©

7. Special Packaging Unit of Use Monthly Packs Therapeutic Packs
Single dose in a single package
Monthly Packs
Monthly dose contained in one package
Therapeutic Packs
Entire course of therapy contained in one package
Metered Dose Inhalers (MDI)
Aerosol spray container
Bulk Packaging
Ointments, creams, eye and ear drops, etc. ©

8. Robotic Dispensing Systems in the Pharmacy
Come in many types and sizes ©

9. Common Characteristics
May be tied directly to pharmacy software
Cassettes hold individual medications
One drug, one strength, one manufacturer
ONE NDC NUMBER
Cassettes may contain more than one lot number and beyond-use-date ©

10. Common Characteristics
Systems vary in volume
Many can fill several hundred prescriptions per hour
Capable of complete preparation
Select container, fill with correct contents, close the container, apply labels
But still dependent on proper care by staff ©

11. Common Characteristics
Since cassettes may hold more than one lot number and beyond-use-date, we must occasionally let the cassette run out of medication to know when only new medication is contained in the cassette
Expired drugs
Recalled drugs
Proper and complete documentation is essential
Complete cleaning according to manufacturers direction is mandatory to prevent cross contamination
Patient Allergies! ©

12. Dispensing Kiosks
Recent development is prescription dispensing machines in doctors offices and other public places
Very popular in pediatric offices
Doctor sends order to the unit and when the patient arrives, the Rx is dispensed ©

13. Compounding Prescriptions
Compounding is the process of making a final product that is not commercially available, from ingredients that are
Three types of compounding you need to be aware of
Extemporaneous Compounding
Bulk compounding
Bulk Manufacturing
The technician may only participate in two out of the three ©

14. Extemporaneous Compounding
No written directions or “recipe”
Technicians are not allowed to compound extemporaneously ©

15. Bulk Compounding Uses written directions or “recipe”
Made for one specific patient’s therapy
With oversight by the pharmacist, a technician may do bulk compounding ©

16. Bulk Manufacturing
Same as bulk compounding except this is made for several treatment courses or several patients
Technicians may also do bulk manufacturing with pharmacist oversight ©

17. Ch 25: Preparation & Delivery - Hospital
In the hospital, the patient never gains control over their medications
Therefore, the packaging and labeling requirements are very different ©

18. Unit Dose Medications
Contains a single dose in a self contained package
Can come from the manufacturer already unit dosed, or can be done in the pharmacy ©

19. Unit Dose Labeling
Each unit dose package must contain the following information:
the name of the drug
the strength of the drug
the beyond-use date of the drug
the manufacturer’s lot number
The manufacturer’s name and place of business
any required storage conditions
bar code & NDC Number
any special characteristics of the drug (ie, sustained release
The DEA schedule and warning, if applicable
Note – there is nothing about the patient! .....Why? ©

20. Unit Dosing in the Pharmacy
When unit dosing is done in the pharmacy we must keep records including:
The assigned “in-house” lot number
The date of packaging
The amount of drug contained in the package
The manufacturer’s lot number on the bulk product
The manufacturer’s beyond-use date of the bulk product
Identification of the pharmacist and technicians who compounded the product ©

21. Computerized Medication Access Systems
Process of Drug Distribution using a Medstation
Prescriber sends drug order to pharmacy
Once pharmacist checks and accepts the drug order, the medication is listed in the patient’s orders in the computer
Nurse finds the correct patient, selects the medication
If information matches the computer order, the medstation will unlock the drawer that contains the drug needed
Will also tell the nurse which area it is located
Replenishment of the Medstation
Running inventory
Pharmacy is responsible to check the medstation for accuracy ©

22. Medication Administration Record
The MAR is a single central record of all medications the patient is currently receiving, who prescribed them, how they are to be taken, and who is administering those doses
Medication orders and use is automatically entered into the patient’s computerized MAR
If the institution uses a bar coded wrist band for the patient, once the medication and patient bar code have been scanned and found to match, the dose is entered automatically into the computerized MAR ©

23. Introduction to Intravenous Fluids
IV Products can be characterized by
Amount of solution
Duration to be run
Type of base fluid
Type of additives if any ©

24. Introduction to Intravenous Fluids
IV Compounding is a life and death situation
When you administer an oral product there is always a lag time for absorption
When you administer an IV product fluid, there is no delay. It enters the bloodstream immediately!
You must be SURE when compounding IV’s! ©

25. Large Volume Parenterals (LVP)
IV’s meant to be run over an extended period of time
Replacement of body fluids
Delivery of medications over a prolonged period of time
Runs through its own IV administration line ©

26. Small Volume Parenterals (SVP)
Meant for delivery of medications over a shorter period of time
Faster delivery of a drug
Runs through its own IV administration line ©

27. Piggyback Infusions
IV’s run through the same infusion line as another IV product ©

28. Labeling of LVP Products
LVP’s must be labeled with:
- patient’s name
- patient’s location
- patient’s billing number
- date & time of compounding
- initials of pharmacist
- base fluid type & volume
- name & amount of additives
- intended time of administration
- rate of administration
- expiration date & time of IV
- spaces for recording the initials of RN and time IV was started
- bar code identification ©

29. SVP Labels
In addition to the information on a LVP label, the following must appear:
-the exact dosing schedule for the medication contained within it ©

30. IV Fluids that Require Special Handling
Almost all IV’s that are compounded require refrigeration
Two drugs that require special attention you should know:
Nitroglycerin  requires a special administration set
Sodium Nitroprusside  requires wrapping in aluminum foil immediately after mixing ©

31. Ch 26: Ordering Pharmacy Inventory
Methods of Ordering
Manual
Automatic
Sources for Drug Products
Wholesalers
Company Warehouse ©

32. Wholesalers
They buy medications from the manufacturers and resell to pharmacies
Primary Wholesale
Always use the primary before secondary
Secondary Wholesalers
Used if the primary is out of stock ©

33. Company Warehouse BIG money maker for the company
Volume pricing
Manufacturer Rebates
ALWAYS use the company warehouse whenever possible ©

34. Ordering Non-Controlled Drugs
Walking the Shelves
Computer Generated
“trigger” figures & order points
on-hand quantities are critical for accurate ordering ©

35. Ordering Schedule III – IV Drugs
Done exactly as you would for non-controlled drugs ©

36. Ordering Schedule II Drugs
Requires the use of a special DEA form- DEA form 222
Can be done in writing or electronically
Forms are sequentially numbered
Issued to state approved practitioners
The DEA Form 222 ©

37. The PAPER DEA Form 222 Comes pre-printed Three copies
Copy #1 Brown – goes to supplier
Copy #2 Green – goes to DEA
Copy #3 Blue – stays at ordering pharmacy
Issued only to DEA license holders
Sequentially Numbered
The person requesting the drugs uses their form
No strikeouts or changes are allowed!
if you make an error, the form must be voided ©

38. The DEA Form 222 Who can sign a 222? What if an item is not in stock?
the person who signed the original application for DEA licensure or any person who holds power of attorney from that individual
What if an item is not in stock?
if a supplier is out of an item, or does not have enough to completely fill an order, they can ship what they have now and send the balance later….. if it is within 60 days
if they can not supply it within 60 days, that line on the 222 form is voided ©

39. The ELECTRONIC DEA Form 222
Uses the Controlled Substance Ordering System (CSOS)
User must register with the DEA and have compliant software
All the same information required on the written form is required
CSOS Ordering Process ©

40. Drugs “For Office Use”
Drugs ordered for use in a practitioner’s office can not be ordered using a prescription blank
Since there is no specific patient involved, there cannot be a valid prescription
So how can we supply these drugs? ©

41. Drugs “For Office Use” We use an invoice as our wholesalers do for us
If the item ordered is a schedule II product, the practitioner must order using one of THEIR DEA 222 forms ©

42. Ch 27: Receipt of Pharmacy Inventory
A Supplier Invoice should accompany all orders received at the pharmacy
The law requires 3 individual files of invoices:
Non-controlled
Schedule 3-5
Schedule 2
Products received in the order should be verified against the invoice
Any item that is on an invoice will be assumed to have been received in the pharmacy – SO CHECK! ©

43. Receipt of Schedule 3-5 Drugs
Invoices and received items should be checked by the pharmacist
The pharmacist must the sign and date the invoice containing the Schedule 3-5 drugs
This signed invoice is required to be saved ©

44. Receipt of Schedule 2 Drugs (Printed Form 222)
Retrieve your copy of the DEA Form 222 used to order the drugs
The pharmacist must view the 222, invoice, and drugs received
The pharmacist will then sign and date the invoice and record the number of each product received on the 222
The pharmacist should draw a diagonal line across the face of the 222 form then sign and date it
Failure to record items received in the manner above can result in a fine from the DEA of $10,000 PER LINE! ©

45. Receipt of Schedule 2 Drugs (Electronic Form 222)
The CSOS system will generate the electronic 222 for verification
Pharmacist will electronically “sign” the form and indicate which drugs were received
Print off a hard copy for your records and file accordingly ©

46. Controlled Drug Shortages
Any shortage of a controlled substance must be reported to the supplier IMMEDIATELY
If the supplier can not correct the situation, the DEA must be notified using a DEA Form 106 ©

47. Ch 28: Maintenance of Pharmacy Inventory
Goals in Maintenance
maintain optimal storage conditions
remove outdated products
follow controlled substance storage requirements
New Terminology- “expiration date” is now known as “beyond-use date” ©

48. Drug Stability All drugs degrade, but the rates will vary
The product’s beyond- use date will show the last date the product should be taken, used, or administered ©

49. Beyond-Use Dates May be listed in two formats
MM/YY (ie, 05/18) expires the last day of the month listed
MM/DD/YY (ie, 05/30/18) gives the exact day after which the product should not be used
Beyond-Use dates are valid only when the drug is stored under its recommended storage conditions
Inspection for expired products
Your pharmacy should have a regular inspection procedure ©

50. Lot Numbers Identify an exact batch that the product was made in
Important for identification in recall situations
Never cover the lot number ©

51. Storage Conditions
Proper storage conditions will be listed on the product label ©

52. Storage Conditions Frozen – below 0° C Refrigerated – 0 to 5° C
Controlled Room Temperature – 15 to 25° C
Warm Room – 30 to 35° C
Extreme Heat – above 35° C ©

53. Dehydrated Medications
Class 5 Slides
Dehydrated Medications
These medications degrade extremely fast in the presence of moisture
All moisture is removed
Water must be added before dispensing
Short beyond-use dates
most are 14 day dating after mixing
exceptions to know are Augmentin and Biaxin (10 days) ©
copyright Mark Greenwald - all rights reserved

54. Stock Rotation
New products are always placed BEHIND the existing stock on the shelf
Then as we use the product, we select items from the front of the shelf
This insures we use the oldest product first ©

55. Storage of Controlled Substances
The CSA allows us two ways of storing controlled substances in our pharmacy
interspersed throughout the non-controlled inventory on the shelves
together in a locked area
Most retail pharmacies use a combination of the two
Most institutional pharmacies lock all of their controlled drugs ©

56. Pharmacy Environmental Effects
The condition of the pharmacy can have an effect on the risk of contamination of drug products
Risk factors:
dirty counting trays
food and drink on the pharmacy counter
food and drink in the pharmacy refrigerator
medications stored on the floor or in the attic
dirty equipment in the sink
dirty graduates or other glassware ©

57. Would you want your medication counted on this tray?
This is how it looks after counting one prescription for a sulfa antibiotic!
Many people are VERY allergic to sulfa drugs, and just a trace of powder on their medications can be LIFE THREATENING! ©

58. Ch 29: Temperature Conversions
Pharmacy must deal with two temperature scales
Fahrenheit
Celsius
You should be able to convert between scales for the examinations, although you would rarely use this in the workplace ©

59. Temperature Scales Fahrenheit Celsius the household temperature scale
water freezes at 32° F
water boils at 212° F
Celsius
the scientific scale
water freezes at 0° C
water boils at 100° C
FOR ANY GIVEN TEMPERATURE °F > °C ©

60. Temperature Conversion Formulas
Celsius  Fahrenheit
°F = °C x (9/5) +32
Fahrenheit  Celsius
°C = (°F-32) x (5/9) ©

61. Example Convert 5° C to °F The formula °F = °C x (9/5) + 32
(45/5) +32 =
= 41° F ©

62. Example Convert 86° F to °C The formula °C = (°F -32) x (5/9)
(86 – 32) x (5/9) = °C
54 x (5/9) = °C
270/9 = 30° C ©

63. Questions? ©