SCHOOL OF PHARMACY
PHARMACY 301: PHARMACY PRACTICE 3
DISPENSING PRACTICAL MANUAL 2009
Dispensing Practical Manual 2009
1
Pharmacy 301: Pharmacy Practice 3
Part 1: Dispensing Practical Manual
1.
HEALTH AND SAFETY INFORMATION ............................................................................................ 3
2.
ORGANISATION OF THE DISPENSING PRACTICAL CLASSES ................................................. 4
3.
DISPENSARY PROCEDURES ................................................................................................................ 5
4.
DOSE AND DOSAGE................................................................................................................................ 6
5.
LABELLING REQUIREMENTS ............................................................................................................ 8
6.
EXPIRY DATES ...................................................................................................................................... 11
7.
CONTAINERS FOR DISPENSED MEDICATIONS .......................................................................... 12
8.
CHILD RESISTANT CLOSURES ......................................................................................................... 12
9.
ABBREVIATIONS USED IN PRESCRIPTION WRITING .............................................................. 13
10. SOME USEFUL DEFINITIONS: ........................................................................................................... 15
11. PHARMACY SOFTWARE ABBREVIATIONS FOR LABELING .................................................. 16
12. CHECKLIST FOR CHECKING PROCESS ........................................................................................ 19
13. INFORMATION ON MARKING PROCESS....................................................................................... 20
14. APPENDIX A: SCHOOL OF PHARMACY - LABELLING POLICY - 2008 .................................. 23
Dispensing Practical Manual 2009
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1. Health and Safety Information
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Food and drink are forbidden in the Laboratory.
Cell phones are forbidden and will be confiscated if found.
Please leave bags in the lockers outside the lab and only take essential equipment into the Laboratory.
You no longer need to where a white coat in the dispensing laboratory however if you wish to you
may. There will be a dress code for dispensing labs and this will be decided by the students as a
group at their first lab. The dress code will incorporate aspects of both safety and professionalism
and students may not be admitted if they do not adhere to the dress code.
Closed shoes must always be worn.
Gloves and safety glasses must be worn if instructed by the Tutors.
Please dispose of used gloves in the yellow bins, not the general rubbish bins.
Please check with the Tutors and Technicians for advice on disposal of chemicals and medicines.
If the fire alarm sounds please follow the instructions of the Laboratory Tutors and Technicians.
Leave the Laboratory immediately in an orderly manner. Do not stop to collect belongings.
Gather in the car park in front of the building.
If a bomb warning is given, leave the Laboratory immediately in an orderly manner, as above. Gather in the
Domain. Cross the road with care.
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2. ORGANISATION OF THE DISPENSING PRACTICAL CLASSES
As part of the Pharmacy Practice 3 paper you will undertake 9 x 3 hour Dispensing Practical Classes. The classes
will concentrate on the development of skills in the legal, ethical and professional dispensing of prescriptions, the
acquiring of information and the provision of advice to patients and their carers.
The ability of pharmacists to dispense and advise patients effectively is one of the cornerstones of pharmacy
practice and all pharmacists must maintain the ability to dispense a range of products to the highest standard of
quality and accuracy.
During this course you will continue to develop a philosophy of quality in dispensing practice and you should refer
to your Pharmacy Practice 201 dispensing laboratory coursework from last year. Although Pharmacy Practice 301
labs do not include extemporaneous dispensing, the philosophy of quality, accuracy and professionalism you
acquired last year is still relevant. You will learn about compliance with legal and ethical requirements and the
effective dissemination of information to patients will be developed. Skills such as searching reference texts,
searching web-based databases and developing patient information leaflets are also an integral part of this
course. These skills are at the core of modern pharmacy practice.
Students are expected to have completed the following prior to each dispensing lab
• Complete the medicines grid at the beginning of that dispensing lab. This will be marked for completeness
• Complete the required pre-work for that dispensing lab (see below).
Pre-work for dispensing labs
Generally, you will know in advance which area of health we will be covering. In 2009, you will be given preclass work and you are expected to complete this by the Friday of the week PRIOR to that dispensing lab
unless you are told otherwise. This requirement will take effect from Dispensing lab 3 onwards. For
example, you will be expected to complete your pre-work for Dispensing lab 3 by the Friday before those
labs start (Friday 7th August). Pre-work for earlier labs (Dispensing labs 1 and 2 only) will need to be completed
by the start of that lab. Pre-work will be in the format of pre-readings and online activities (e.g. multiple
choice questions, reflective exercises, peer review) available via Cecil. Pre-reading will sometimes include
relevant websites which often hold the answers to your pre-work. These websites can be incorporated into a
growing list of resources which you can continue to use in your professional practice as students and practicing
pharmacists. Please be aware that some of the websites provided may contain images of medical conditions such
as dermatological conditions depicting exposed skin.
In addition, where the subject matter is relevant, you will be expected to have reviewed the following materials.
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Pharmacotherapy 302 tutorial and lecture notes.
Relevant chapter(s) of Walker and Edwards
Relevant section(s) of the BNF
Relevant section(s) of the Dispensing Guide
Relevant section(s) of the Pharmacy Practice Handbook
Medsafe datasheets for drugs to be dispensed at each lab
New Zealand therapeutic guidelines for relevant topics (www.nzgg.org.nz)
During the first part of the class you will be given tasks related to the pre-work and pre-readings to work on as
small groups. You will then be given two prescriptions to dispense, and will discuss how to advise the patient
about their treatment. The last part of the lab will be a “round-up” session where we will review any issues which
have come up during the lab. During the course you will develop a variety of dispensary techniques such as
labeling, checking prescriptions for accuracy, legality and appropriateness and the products that you prepare will
be assessed during the course. You will receive feedback on this electronically once your work has been marked
and during labs from tutors. An outline of the dispensing skills that will be introduced for each lab is provided at
the beginning of the dispensing lab section.
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3. DISPENSARY PROCEDURES
The work of a pharmacist in a dispensary requires care and attention to detail. Only by working in a tidy and
organized fashion can this be achieved. Sloppy, unhygienic and untidy work will not be tolerated in the
dispensary or in professional practice. Your preparations should be dispensed as if for use by patients.
1. As students you will be working in a professional environment, the dispensing lab, and you should start to
think of yourselves as professionals and dress appropriately. This will mean adhering to an accepted dress
code which accommodates aspects of safety and professionalism. You no longer need to wear a white coat
to these labs however you may do so if you wish. A dress code for the dispensing lab will be decided by the
students at the first dispensing lab of the semester.
2. Plan your work area. Your work area must be kept clean, tidy and uncluttered whilst working. Bags, coats
and other items not required for dispensing are not to be brought in to the dispensing area, please use the
lockers provided. Keep your other belongings off the bench.
3. Use appropriate standards of hygiene during all stages of dispensing. Do not lick labels, suck pencils etc.
Do not sit on the benches. It is forbidden to eat, drink, smoke, chew gum etc. in the dispensing area. Mobile
phones are not allowed in the dispensing area – they must be turned off before commencing work or they
will be confiscated.
4. Report all spillages, breakages and accidents to the Tutor-in-Charge immediately.
5. For the much of the class discussions about the patient, giving advice and other related matters are
encouraged. However, you must dispense all products on your own. A pharmacist assumes total
responsibility for what he/she dispenses. It is essential you develop confidence in your own ability.
Furthermore, you must check and initial all steps and certain steps must be checked and initialed by a fellow
student. In many pharmacies you may find yourself making the initial prescription check for appropriateness,
legality etc, but another trained and accredited person may actually dispense it. Your responsibility will be to
check the final product and ensure it is correctly dispensed and provide advice to the patient.
Steps involved in the dispensing process during labs
6. Assess the prescription form and gather any missing information or seek clarification where required so you
can accurately interpret the prescription form. The tutors in the lab will role-play the part of a prescriber or
patient to enable you to gather the necessary information.
7. Enter the patient details into the Patient Medication Record (computer) before you start dispensing the
product. You should also prepare a label before dispensing. Do not leave unlabelled products in the
dispensing area at any time. A tutor will confiscate unlabelled products.
8. Dispensed products should be left with the prescription in the tray provided, and batch numbers and expiry
date for the product must be entered into the space provided on your worksheet next to the copy label.
9. Counting triangles and trays must be kept clean.
10. Benches, spatulas, etc., must be cleaned immediately after each product is completed, do not wait until the
end of the session before cleaning equipment.
11. Replace the lids on containers after use and ensure they are firmly closed. Make sure the outsides of
containers are clean.
12. Return all containers, reference books etc. to their proper places immediately after use.
13. If materials or equipment appear to be in short supply, please check with a tutor or laboratory technician.
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14. At the end of each dispensing session. Ensure that:
. Your equipment, bench, cupboard, shelves are clean and tidy.
. All medicines, equipment, books etc. are in their correct places.
. Lost property is taken to the tutor-in-charge.
19. Under no circumstances are students permitted to remove from the Dispensary any Student Preparations,
chemicals, medications, equipment, containers etc., unless you have the permission of the tutor-in charge.
You are reminded that Student Preparations sometimes contain placebo or expired materials, and are
certainly not fit for human or animal use.
4. DOSE AND DOSAGE
(TAKEN FROM PHARMACY PRACTICE 2 (201) DISPENSING MANUAL)
1. Dose
The amount of medicine to be taken taken, or given, at one time. The sum of doses may be the dosage or the
total dose.
2. Dosage
The amount of medicine to be taken, or given, in a period of time.
Notes on dose and dosage
Calculation of the dose is dependent on many factors, e.g. age of the patient, severity of the disease, route of
administration, concomitant drug therapy, and any underlying disease states. The pharmacopoeias are the main
source of dose information and generally give the dose ranges within which agents are generally therapeutically
useful for the average patient. The dose may have to be modified according to the factors mentioned above.
In the General Notices of the British Pharmacopoeia (1980), the section entitled “Doses” states;
“The statements given under “Usual dose range” in the Monographs of the Pharmacopoeia are primarily
intended for the pharmacist; they are not authoritatively enjoined as binding upon prescribers. They are
intended for general guidance and represent, unless otherwise stated, the usual range of quantities which
are usually regarded as suitable for adults when administered by mouth on one occasion. For some
substances a period is stated over which the whole dose is given, e.g. “daily in divided doses”, the division
being left to the prescriber. If it is usual to administer a drug by a method other than by mouth, the dose
suitable for that method of administration is stated.
It must not be assumed that the dose indicates the greatest amount of drugs that may be given. The
medical practitioner will exercise their own judgment and act on their own responsibility in respect of the
amount of any therapeutic agent they may prescribe or administer, or the frequency of its administration.
When, however, an unusually large dose appears to have been prescribed, it is the responsibility of the
pharmacist to satisfy himself that the prescriber’s intention has been correctly interpreted.
Following the statements of doses of preparations of some of the more active drugs, notes have been
placed to show the approximate quantities of active ingredients contained in the doses stated. These are
included for the guidance of the prescriber and are not to be regarded as statements of standard.”
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For large numbers of drugs and preparations the BP provides at the end of the monograph a statement of
“Actions and Uses” and (if applicable) “Usual Dose”.
A typical example is:
Aspirin
Actions and uses - analgesic antipyretic
Usual Dose Range - 0.3 g to 1g; up to 4g daily, in divided doses. In the treatment of acute rheumatism 4g
to 8g daily, in divided doses.
The Pharmacopoeia attitude to dose is very formal. A better appreciation of practical dosage schedules can often
be obtained from APF, BNF, Martindale or the Pharmaceutical Codex. Manufacturers’ literature and compendia
such as the New Ethicals Compendium provide also useful sources of information about dosage.
Terms used in describing doses.
3. Minimum dose
The lowest dose exerting the desired therapeutic effect in the average patient. The response of the patient will
indicate whether in continuing treatment this dose should be maintained or increased.
4. Maximum dose
The highest dose usually tolerated without undesirable effects in the average patient. This dose is not the
greatest amount that can be administered, as in certain specific treatments the official maximum dose may be
exceeded.
5. Toxic dose
The dose capable of producing marked functional derangement in the body.
6. Lethal dose
The smallest dose known to have produced a human death.
7. Prophylactic dose
The dose necessary to prevent the onset of a disease.
8. Therapeutic dose
The dose necessary to treat an established disease.
9. Loading dose
A dose higher than the maintenance, given on the initiation of therapy to give rapid drug plasma levels equivalent
to that reached after multiple dosing. This higher dosage is used for a short period of time only; often it only
involves a single dose.
10. Maintenance dose
A dose given to maintain the therapeutic level of a drug in the body.
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5. LABELLING REQUIREMENTS
No patient should leave the pharmacy without knowing HOW to use the medicine, how MUCH and how
OFTEN. At all times the written instructions should be primarily regarded as back-up to the pharmacist’s
oral counselling.
When producing a label, you should ensure that the information on the label is:
1. In a language appropriate to the patient’s needs. (KEEP IT SIMPLE)
2. Indelible and legible. (KEEP IT CLEAR)
3. Of the size and type of lettering appropriate to the patient’s needs.
4. In a uniform colour contrasting strongly with a uniform background. Directions such as “Not to be taken”
and “For External Use Only” may be in red lettering.
5. Not in the address panel or any other place where it could obstruct or be hidden by other information.
6. Is placed on the label in lines parallel to the base of the container.
7. Is placed on the primary container – this is the container that the patient will be using not the box that they
will throw away.
8. Free of errors and overtypes. (KEEP IT CLEAN)
9. Free of unnecessary decoration and embellishment. (KEEP IT PLAIN)
Record quantity dispensed on label
This is a requirement for:
1. All solid dose preparations.
2. All liquid preparations when the quantity specified does not fill the bottle.
It is however, strongly recommended that the quantity be stated on each preparation.
The name or description of the nature of the contents
This is legally required and should give the name or the official abbreviation of the name of the medicine as stated
in the prescription, unless:
1. The contents are extemporaneously prepared and contain more than a single active ingredient. In this
case the batch number and expiry date should also be on the container.
2. The medical practitioner has stated;
a. NNP or Not NP (non nomen proprium)
b. He/she wants some other designation.
Note:
1. If a preparation comes in more than one strength, the label should give the strength supplied (it is
preferred that the strength is always stated on the label).
2. Extemporaneously compounded preparations containing more than one active ingredient do not need to
be labeled with a precise name. If the prescription calls for an official preparation – e.g. BNF, BPC, BP,
APF – use their short title on the label to identify them – e.g. Potassium Citrate Mixture APF.
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Directions for use
It is legally required to give:
1. Dose, and frequency of dose (Internal preparations)
Please note that you need to word the directions according to the formulation of the product.
For example: ‘Take one tablet’
‘Dissolve the contents of one sachet in water and..’
‘Insert the contents of on aplicatorful..’
2. Method and frequency of use/application (external preparations)
3. Special individual directions as per the prescription form.
Please note that the directions on the label should exactly reflect the prescription. There is no need
for additional information (e.g. take for pain relief) unless it is specified in references such as C& A
labels from the Dispensing Guide.
Some useful things to note when preparing labels for medicines:
1. A prescription with non-specific directions, such as “use as directed” (mdu) or when required (prn), the
pharmacists must ensure the patient understands the directions clearly and correctly, and where
necessary provides written guidance. The pharmacist may have to find out from the prescriber the exact
medication instructions. It is advisable to know the normal dosing regimen before contacting the
prescriber.
2. The nature of the contents may be such that ancillary labeling is required. Think of what the additional
label is saying and position it to do its job – e.g. if the preparation is to be shaken before pouring the dose,
put “Shake the bottle” above the main label. If ancillary labels need to be attached, place them
horizontally, and avoid placing them on the main label or obscuring any writing on the label. If you choose
to put some of these on the medicine label using the computer, make sure that the font is large enough to
be read clearly by the patient.
3. The Pharmaceutical Society of New Zealand has produced a series of Cautionary and Advisory Labels
(CALs) and References, to be included in the direction labels of dispensed medicines, with a view to
reducing undesirable side effects and ensuring maximum therapeutic affects. The Society has also
produced an official instruction booklet – The Dispensing Guide - containing the lists of medicines requiring
labels and references. If the practitioner does not wish a CAL to be attached, he/she must endorse the
prescription “NCL”. The use of CALs is not a legal requirement. Use your professional judgment in their
application.
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4. Keep the wording simple and specific:
Tell the patient what to do with the medicine (e.g. Take two tablets), how often (e.g. four times a
day) and then additional information (e.g. after food).
Example:
“Take”
rather than
“to be taken”
“Do not swallow”
rather than
“Not to be taken”
“Spread thinly”
rather than
“Use sparingly”
“Put TWO drops into”
rather than
“Instil TWO drops”
“Place a patch”…….. (transdermal patches)
“Inhale TWO puffs TWICE a day” (inhalers)
Try to avoid having the number to be taken and the times of taking adjacent:
Example:
“Take TWO tablets FOUR times a day”
rather than
“Take TWO 4 times a day”
“Take TWO tablets TWICE a day”
rather than
“Take TWO TWICE a day”
Fractions should be expressed in words rather than in figures.
Example:
TWO AND A HALF ML
rather than
2.5 mL
or both words and figures i.e. TWO and a HALF ml (2.5ml)
Distinguish between different drug delivery forms:
Example:
“Swallow whole”
Sustained release preparations
“Dissolve under the tongue” Sublingual tablets
“Chew”
Chewable tablets
5. “Give” is preferred when the dose is prescribed for a young child or an animal
Example:
“Give ONE 5mL spoonful THREE times a day.”
6. Measures: Only metric measures may be used, imperial must not be used.
1. weights: g
is the official abbreviation for
gram
mg
is the official abbreviation for
milligram
mcg
is preferred to ug
microgram
It is recommended that to avoid confusion, micrograms are written out in full.
2. volume: ml or mL
preferred abbreviation for
millilitre
L
preferred abbreviation for
litre
7. Remember to provide with the medicine, where appropriate, a measuring device for the patient for
example a 5mL medicine spoon or an oral syringe.
6. Where appropriate, reference should be made to appropriate patient information leaflet for instructions on
how the product should be used.
Reference number
The prescription reference number generated by the computer is a legal requirement. In dispensing labs, a
unique identifier will be used for each product dispensed.
Date of dispensing
The date of dispensing is a legal requirement and the Society requires that the format is 21 Feb 01 rather than
21/02/01, to avoid confusion with reference numbers.
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Patient’s name
This is a legal requirement. It is preferred that the title, initial(s) or first name and surname be shown. On an
animal’s medication, the owner’s name must appear on the label. The statement “Not for Human Use” or “For
Animal Treatment Only” must appear on the label.
Name and address of the pharmacy
These are legal requirements. The name of the proprietor or the registered trade name of the company and the
address of the pharmacy (not a P.O. Box number) must appear on the label. The telephone number is an ethical
requirement.
Prescriber’s Name or Reference
Optional, but advisable, and preferred by the Society.
Place the label so that it is:
1. Easy to read, with no blemishes.
2. Firmly fixed to the container (which is clean).
3. Straight and visually balanced.
4. Not likely to be damaged, defaced or removed when the container is opened.
5. Not obscured by another label, folder, pamphlet etc.
6. On both the inner and outer container if both are being supplied (always label the primary container).
Please note – there is a new Labelling policy for dispensing labs and this should be followed closely. You
will find this in Appendix A at the end of this manual
6. EXPIRY DATES
There is no collaboration between established formularies and textbooks concerning expiry dates assigned to
extemporaneous preparations. Stability data is unavailable on many formulations. In many cases you must make
a professional judgment on the most appropriate expiry date for a product.
For the purposes of Dispensing classes the following guidelines should be observed:
1. Freshly prepared
As a guide to good pharmaceutical practice it is suggested that mixtures or other medicines recommended to be
“freshly prepared” should be prepared not more than 24hrs before issue to a patient.
2. Recently prepared
Mixtures recommended to be “recently prepared” should be stored in full, air tight, unopened bottles in the
pharmacy for not more than 3 months.
Stock mixtures in use, in opened containers in the pharmacy, should be used within 2 weeks of first opening.
Recommended Expiry Dates for Dispensing classes
Unless otherwise stated in the formula the following guidelines should be observed.
Internal Preparations without a preservative
Internal Preparations with a preservative
7 days
14 days
External Preparations
Diluted from a pre-formulated product
Extemporaneously compounded
14 days
1 month (with a preservative)
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7. CONTAINERS FOR DISPENSED MEDICATIONS
The aim should be to make a clear distinction between preparations that may be taken internally and those
intended for external use.
The container should also be selected which will best protect the life of the preparation.
1. Internal medicines
Preparation
Container
Mixtures
Plain, amber, glass or plastic, medicine
bottle.
Plain, amber, glass or plastic medicine
bottle with wide neck if available.
Plain, amber, glass or plastic medicine
bottle
Plain, amber, glass or plastic medicine
bottle
Plain, amber glass or plastic tablet bottle,
Emulsions (Internal)
Elixirs
Linctuses
Tablets and capsules
Powders
Substances for topical application
Preparation
Eye drops, ear drops, nasal drops
Mouthwashes and gargles
Enemas
Lotions, liniments and antiseptics
Creams, ointments, pastes and gels
Suppositories and pessaries
Individually wrapped in powder papers and
dispensed in a cardboard box.
Container
Dropper bottle
Clear ribbed bottle, glass or plastic, or,
amber if contents sensitive to light
Ribbed poison bottle, amber, glass or
plastic,
Ribbed poison bottle, amber or clear, glass
or plastic
Ointment jars or tubes
Individually wrapped in foil or plastic and
dispensed in a cardboard box.
8. Child resistant closures
A number of oral preparations are required to have child resistant closures and pharmacists are reimbursed for
the extra cost of these. They are listed in the Pharmac schedule. In the Pharmacy Handbook is a list of those
products which should have such closures, it includes those medicines in the Pharmac list as well as some others.
However, pharmacists may feel that there are a number of other drugs and preparations which should have such
closures, and may consider adding a small charge to the patient. For example, all external fluids should have
CRCs, if approved by the patient, or forfeit the extra charge if it is the policy of that pharmacy to supply such
closures.
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9. Abbreviations Used in Prescription writing
abbreviation
ac
alt die
bid or bd
BE
cc
die
EE
Gutt / guttae
nocte or on
mane
mitte
o
d or die
od
on
po
pc
prn
q3h/q4h
qqh
Meaning
before meals / before food
alternate days / every other day
TWICE a day
BOTH eyes
Close control - see note 1
daily
EACH eye
drop
at night
in the morning
send/supply
each
daily
Once daily
at night
by mouth
after meals / after food
as needed / when necessary / if required / when required
every THREE hours/every FOUR hours
every FOUR hours (or “ up to every FOUR hours”) – see
note 2
qid or qds or qd
FOUR times a day - see note 3
qs
quantity sufficient
tid or tds
THREE times a day
cc
with meals / with food
sos
when necessary / if necessary
mdu
as instructed / as directed
caps
capsules
tabs
tablets
mixt
mixture
linct
linctus
ung
ointment
gutt
drops
sig
follow these instructions
Stat or st
immediately (often implies a single dose, though not always)
hss
At bedtime (literally at the hour of bedtime)
“Fractions” are sometimes used to express frequency or duration of treatment.
Example:
1/52
one week
1/7
one day
1/12
one month
Clarification with the prescriber is required if ambiguous.
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Note 1.
Close control is a Pharmac Schedule policy that means dispensing of a prescription in quantities of less than 90
days. It is required to be written and signed in the Doctor’s handwriting with a period of supply attached (e.g. cc
1/12).
Note 2.
The abbreviation q.h. is also understood by some to stand for “quaque hora” or every hour. Care is required in
the interpretation of this abbreviation. Always check with prescriber.
Note 3.
In the USA and some other countries q.d. is usually interpreted as meaning “once daily” rather than “four times
daily”. This is obviously a source of potential confusion.
Note 4.
The word ‘Stat’ can also be used to refer to Pharmac policy with regard to the period of supply of a medicine in
‘one lot’.
Note 5.
Roman numerals are still commonly used in prescribing e.g. IV for 4, iii for 3
More information on abbreviations used in prescription writing is available in:
•
•
Australian Pharmaceutical Formulary and Handbook
http://www.ciap.health.nsw.gov.au/nswtag/publications/guidelines/TERMINOLOGY1206.pdf
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10. SOME USEFUL DEFINITIONS:
Familiarise your self with interpretations and definitions in Section A; General rules of the Pharmaceutical
Schedule
Letters on prescription
• Y = child under 6 year old. No co-payment
• J = 6-17 year old (18 year old only if at school. If they are younger than 18 and have left school they are
considered to be an adult)
¾ J1 = Co-payment of $3.00. Child or parent/guardian has a community services card (C.S.C.)
¾ J3 = Co-payment of $10 (no C.S.C. card)
¾ J4 = Co-payment of $3.00 when prescription is written by a prescriber from the PHO the person/child is
registered with. Does not apply to prescription forms from dentists or private specialists. This applies
to patients aged 6-18 years for prescriptions coming from a PHO practice in which they are enrolled.
• A = adult
¾ A1 = co-payment of $3. Person has a C.S.C card
¾ A3 = co-payment $15 (no C.S.C. card)
¾ A4 = co-payment $3 when prescription is written by a prescriber from the PHO the person is registered
with. Does not apply to prescription forms from other prescribers outside the PHO (e.g. private
specialists, dentists).
¾ Anyone who has left school is considered an adult so a 16 year old school leaver would be A1.
• Z = high user card holder. Prescriber applies for this card on behalf of the person providing they fit the criteria
depending on their medical condition(s). It is valid for one year from date of issue. This code can also apply
to those patients who fit certain criteria defined by a PHO as attracting extra funding for their health services
(GP visits, prescription co-payments). This code MUST be written on the prescription by the prescriber.
¾ Z1 = co-payment $3
¾ Z3 = co-payment $3
¾ ZJ3 = co-payment $3
• O = contraceptive oral or otherwise
¾ $3 co-payment maximum
• X means that a family (1 or 2 adults living together plus or minus children) has paid the co-payment for 20
prescription items in a year, starting February 1st & continuing until January 31st the following year. This
excludes prescriptions for children under 6 as they do not attract a co-payment. A family of separated parents
may only have the children listed at one address (i.e. only on 1 family card, not counted on each parents’
card). Same sex partnerships are regarded as a family, provided that they live at the same address.
¾ X1 = no co-payment
¾ X3 = $2.00 co-payment
¾ XZ3 = $2.00 co-payment
¾ X4 = no co-payment
F270 form = Doctor’s green form or medical practitioner supply form known as an MPSO (Medical practitioner
supply order). This is a special form to allow the supply of medicines to patients for emergency or after hours use.
The medicines allowed are listed in Section E of the Pharmaceutical Schedule. They are also listed in the front of
the MIMs (Section G12)
An H572 prescription form must be used for all controlled drug prescriptions, except for Methadone for Methadone
Maintenance, which must be on an H572M.
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11. PHARMACY SOFTWARE ABBREVIATIONS FOR LABELING
TONIQ
Sig
Expansion
/1
May cause sleepiness: Limit alcohol
/10
Take with a large glass of water
/11
Avoid grapefruit and its juice
/2
Do not drink alcohol
/3
Take each dose on an empty stomach
/4
Don't take with antacids, iron or calcium
/5
Avoid some food & medicines - see card
/5a
Avoid some medicines - ask pharmacist
/6
Keep in fridge - do not freeze
/7
Do not use after ….|….|….
/7a
Do not use ….. days after opening. (Date opened …..|…..|…..)
/8
Protect yourself from too much sunlight
/9
Do not stop taking this medicine
/a
swallow whole, do not crush or chew
/ac
half an hour before food
/b
with food
/d
until finished
1
ONE
10
TEN
1c
Take ONE capsule
1dr
Put ONE drop into
1p
Inhale ONE puff
1t
Take ONE tablet
2
TWO
2c
Take TWO capsules
2dr
Put TWO drops into
2p
Inhale TWO puffs
2t
Take TWO tablets
3
THREE
3c
Take THREE capsules
3t
Take THREE tablets
4
FOUR
4c
Take FOUR capsules
4p
Inhale FOUR puffs
4t
Take FOUR tablets
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5
FIVE
5c
Take FIVE capsules
5t
Take FIVE tablets
6
SIX
7
SEVEN
8
EIGHT
9
NINE
ac
before food
am
in the morning
ap
Apply
B
both
bd
TWICE daily
can
Insert ONE applicatorful high into the vagina at night until finished
can1
Insert ONE pessary high into the vagina at night until finished
cc
with food
d
daily
ea
each
exp
DO NOT USE AFTER
ext
*FOR EXTERNAL USE ONLY*
f
until finished
fev
for pain and fever relief
gle
DO NOT SWALLOW, SPIT OUT
gw
Take with a glass of water
ht
half a tablet
I
Insert
in
in
Inha
Inhale
ins
Insert
l
LEFT
m
in the morning
mane
in the morning
max
(MAXIMUM OF 8 TABLETS IN 24 HOURS)
mdu
as directed
n
at night
nocte
at night
ntbt
NOT TO BE TAKEN
od
ONCE daily
pc
after food
Dispensing Practical Manual 2009
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pd
for pain relief
pdf
for pain or fever
pf
puff
prn
when required
q12h
every TWELVE hours
q4h
every FOUR hours
q6h
every SIX hours
q8h
every EIGHT hours
qd
FOUR times daily
qds
FOUR times daily
qid
FOUR times daily
qqh
every FOUR hours
r
RIGHT
s
suppository
sh
Shake well
sl
under the tongue
sos
when necessary
Spoon1
Take ONE 5ml spoonful
Spoon2
Take TWO 5ml spoonfuls
stat
at once
ster
Rinse mouth out after use.
supp
Unwrap and gently insert ONE suppository into the rectum
ta
Take
td
THREE times daily
tds
THREE times daily
t
tablet
uf
until finished
vag
w
into the vagina
swallowed whole
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12. CHECKLIST FOR CHECKING PROCESS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Patient name
Patient address
Prescriber name
Prescriber address and or NZMC registration number
Patient subsidy code and date of birth (if J or Y)
Prescription date
Pharmacy stamp & correct date
Medicine name – any interactions, what is available (check the most recent schedule).
Medicine strength (if more than 1 available)
Dose instructions or frequency – Safe? Effective?
Quantity to dispense or period of supply – annotate.
Close control (if a stat medicine)
Enter prescription into computer
Check medicine entered is correct brand/strength
Check instructions match exactly those on prescription
Read all C&A labels for that medicine (use dispensing guide) & add to label, if possible.
Read label on screen before printing.( If in doubt, get a tutor to check it).
Put through all labels for all medicines on script
Get medicine from shelf – check strength/dosage form against SCRIPT, not label!
Check expiry date & batch.
Dispense correct amount – check with your annotations on script.
Label container – check correct container – CRC or not? If in doubt, ask a tutor.
Dispense next item on prescription – work from top to bottom of script.
When all items dispensed, check each item against prescription, one at a time – read every
word on label to yourself.(Including patient name, prescribers name & expiry dates). Is the
spelling correct? Does it make sense? Could an 8 year old understand it?
Get someone else to check your work – including the medicine inside container.
Recheck your work yourself.
Would you be happy for that prescription to be given to your child/ mother?
Well done –tidy up and start the next prescription.
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13. INFORMATION ON MARKING PROCESS
Each week the prescriptions that you dispense are handed in for marking. You do not receive any marks
towards your final mark from the weekly marking, it is done to help you improve your skills during the semester
and also prepare for dispensing assessments. Each week you will be sent feedback by email on your work
once it has been marked. The purpose of this is to provide you with evidence of the areas of your practice that
you are performing well in and identify those areas that need improvement. The marking is categorized
according to the type of error (e.g. legal, subsidy or dispensing) so that you can more easily identify specific
areas of your practice that require further work and review your Standard Operating Procedure (SOP)
accordingly.
A guideline to the marking process has been broadly outlined below along with the marking criteria that have
been devised according to their category. In dispensing labs errors are identified individually by category and
are identified as to whether they are a borderline error or if the error is not satisfactory. In dispensing
assessments students that make errors that are ‘not satisfactory’ are eligible to do a re-sit of the assessment.
If you have not made any errors then your work is of a satisfactory standard. If you have performed to a level
above satisfactory and have demonstrated merit then this will be indicated (see below).
Merit (M)
In order to achieve merit, you must at least achieve the standard laid out under ‘satisfactory’ (below) and have
demonstrated skills above this level. Examples of issues that will preclude you from getting merit include poor
container choice, use of child resistant tops where not required, messy and untidy labels will. Bad grammar
and poor spelling where it does not compromise a patient’s safety will also stop you getting a merit. Merit is
also related to the quality of your pre-work and preparation for the dispensing lab and this will be handed in
with your prescriptions and reviewed by the tutor each week.
To achieve merit in an assessment you would be expected to demonstrate this level of practice and also to
have approached the GP (and patient if necessary) in a polite, professional and informed manner. In
assessments you will also be expected to provide thorough written advice, avoiding jargon and including
where necessary WHY the advice is important. Other things which will help towards a merit might include
mentioning appropriate self help card(s), additional advice to patients on where to get further advice, lifestyle
advice etc.
Satisfactory (S)
In order to achieve satisfactory you must have undertaken the assessment in a way that has no errors. For
example, annotation clarifies exactly what has been dispensed.
Borderline (BDL)
If any errors are noted as BDL in your work, these are considered as a borderline error for that item. This
identifies an area of practice that requires improvement.
Not yet satisfactory (NYS)
Some errors may be marked as not yet satisfactory for that item. Any legal error or an action that
compromises the safety of the patient will be marked not yet satisfactory and students that make these types
of errors in an assessment will be eligible for a re-sit. In assessments if the written advice is totally incorrect or
if any advice is likely to harm the patient you will receive no marks relating to the advice component of your
marks for that item.
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Classification of errors
The marking criteria that will be used for dispensing labs and assessments are outlined below. These criteria
are categorised according to key areas of dispensing (e.g. labelling) and errors have been defined as ‘Not yet
satisfactory (NYS)’, ‘Borderline (BDL)’, ‘Satisfactory – not quite merit (S)’. This will allow you to identify areas
where you are making errors (e.g. label) and review your dispensing SOP accordingly. Areas of your practice
where you demonstrate above satisfactory performance will be marked Merit.
Pre-work - preparing for labs
Prework NYS: Medicines grid incomplete
Prework S: Medicines grid has adequate information however could benefit from greater detail
Prework M: Well done you have thoroughly prepared for this dispensing lab and have provided a
complete background for these prescriptions.
Legal - This is related to the legal requirements for prescriptions and dispensing.
Legal NYS: Failure to note a legal error on the prescription.
Legal NYS: No patient name on script.
Legal NYS: No square label on the prescription
Legal NYS: Quantity on script missing or incorrect and student did not clarify with prescriber
Legal NYS: Changes made to script (e.g. date, dose) and not countersigned by prescriber
Legal NYS: No date stamp
Legal NYS: Incorrect date stamp
Legal S: Missing NZMC number (Dr address is there)
Legal S: Missing Dr address (NZMC number is there)
Legal M: Well done you have recognised all relevant legal issues and have made no errors.
Subsidy - This is related to patient code, dispensed medicine and annotation.
Subsidy NYS: Wrong dose form of medicine chosen (non-subsidised dose form chosen)
Subsidy NYS: Wrong pack size of medicine chosen (non-subsidised pack size chosen)
Subsidy NYS: Wrong brand of medicine on label (non-subsidised brand chosen)
Subsidy/scheduling NYS: No annotation.
Subsidy/scheduling NYS: Wrong quantity dispensed.
Subsidy / scheduling NYS: Non-subsidised product chosen (* on sq label)
Subsidy / scheduling NYS: No annotation
Subsidy/scheduling BDL: Incorrect annotation.
Subsidy / scheduling BDL: Incorrect patient code / Patient code not clearly marked on prescription
Subsidy/scheduling BDL: Subsidy level incorrect or not identified.
Subsidy / scheduling BDL: Missing annotation (e.g. number of tablets, repeats if relevant)
Subsidy / scheduling BDL: Incorrect expiry date on repeats (e.g. 60 days for 2/12 script)
Subsidy / scheduling BDL: Subsidy level incorrect or not identified
Subsidy / scheduling M: Well done you have completed this section with merit.
Labelling the medicine
Label NYS: Incorrect Cautionary and Advisory labels - please check dispensing guide
Label NYS: Wrong quantity on label or quantity missing
Label NYS: Wrong instructions on the label or instructions missing
Label BDL: Spelling errors, unclear labels or handwritten.
Label NYS: Instructions on label not same as on the script
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Labelling the medicine
Label NYS: Wrong patient name on label.
Label NYS: Wrong strength on label or strength missing.
Label NYS: Used Generic name on label when Brand written on script
Label NYS: Used brand name on label when generic written on script
Label NYS: Additional instructions on label are confusing and may lead to patient harm.
Label NYS: Missing Cautionary and Advisory labels - please check dispensing guide
Label NYS: Incorrect prescriber on label
Label BDL: Spelling errors, unclear instruction or hand written
Label BDL: Confusing additional instructions on label.
Label BDL: Advice conflicting between label and prescribed instructions
Label BDL: Missing 'best practice' instructions on label (e.g. up to for puffs of Ventolin)
Label BDL: Wrong dosage form used in instructions (e.g. capsule instead of tablet)
Label BDL: Oversticking labels - please remove old incorrect ones first
Label BDL: Used multi-labels when label should have been reprinted
Label S: Better to do multi-labels
Label S: More optimal C&A label available or C&A label incomplete (e.g. Label 7a)
Label S: Instructions adequate but sentence structure could be clearer.
Label M: Well done your label has no errors.
Product - dispensing the medicine
Product NYS: Wrong dosage form dispensed
Product NYS: Wrong brand dispensed (different to that on label or in computer)
Product NYS: Wrong form dispensed.
Product NYS: Wrong strength dispensed
Product NYS: Bottle / container contained mixed tablets (i.e. more than one type of tablet)
Product NYS: Item entered twice in the computer (not edited)
Product NYS: Expired medicine not checked with tutor and signed by tutor.
Product NYS: CRC needed and not used (see Pharmac schedule or Pharmacy Practice Handbook)
Product NYS: Wrong label on container (e.g. mixed labels between products)
Product NYS: Wrong quantity dispensed
Product NYS: Wrong drug dispensed
Product BDL: CRC used when not needed
Product BDL: Not labelling the primary container
Product BDL: Wrong expiry date on repeats.
Product BDL: Product not labelled according to School of Pharmacy Labelling policy
Product BDL: Expiry not checked
Process BDL: Dispenser did not sign. Please sign that you dispensed the medicine.
Process BDL: Not checked or checker did not sign
Process S: Please record your problems and solutions in the space provided in the workbook
Clinical NYS: Drug interaction not noted and the problem left unresolved.
Clinical NYS: Clinical issue not identified and not corrected
Clinical NYS: Clinical issues not recognised or addressed.
Clinical BDL: Relevance of C/I's and warnings.
Clinical BDL: Clinical issue identified and not completely addressed
Clinical S: Dose could be more optimal for this patient
Clinical M: Well done you have dispensed an appropriate medicine to a high standard.
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1. Appendix A: School of Pharmacy - Labelling policy - 2009
The following labelling policy was developed by the Pharmacy Practice team in consultation with
practicing pharmacists. It is deemed to be best practice for dispensing and students are expected to
consult and adhere to this policy during dispensing labs.
When dispensing we have to label the PRIMARY container of the medication. For example we should
label the Inhaler casing for asthma inhalers, the bottle for eye drops, the tube of cream etc. This is
because some patients are likely to throw away the box that the medication came in.
Always remember to label the PRIMARY container. You need to label the PRIMARY container as some
Patients just throw out the box it came in and therefore there will be on directions for them to follow.
If the medication comes in a box eg/ eye drops, inhalers, sprays, creams, and gels you can label the box
but it is optional.
EYE DROPS
There are 2 ways of labelling EYE DROPS. We will accept any of the 2 following ways shown below.
The Box
The PRIMARY Container
Labelling the BOX is optional. You MUST label the PRIMARY container.
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#1
‘Flagging’ the Label. It has one piece of cello tape going across the body of the label. And then an
extra bit of cello tape hanging from the side (see photo above). Ideally, ONE piece of cello tape should
be used on the front of the label. Turn the label over to expose the sticky side. Use only a couple of
pieces of cello tape to cover the sticky side. Be sure not to tape over any parts of the label that you may
require to write on when you put a small amount of cello tape on the front to secure it.
The Label should be ready to be stuck on to the PRIMARY container.
The FINAL product. The label is flagged on to the PRIMARY container.
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#2
The Label.
Cut carefully and straight about the address line. The label should be in 2 pieces.
Turn the label over and stick the address on.
‘Flagging’ the Label. It has one piece of cello tape going across the back of the label to cover up the
sticky part. And then have an extra bit of cello tape hanging from the side (see photo above). Ideally,
ONE piece of cello tape should be used on the back of the label. Be sure not to tape over any parts of
the label that you may require to write on when you put a SMALL amount of tape on the front to secure
it.
The Label should now be ready to be stuck on to the PRIMARY container. The label is flagged on the
PRIMARY container.
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The SMALLER Eye Drop bottle
The BOX and the PRIMARY container.
NOTE: Labelling the BOX is optional.
Carefully cut straight above the Doctors Name. The label should be in 2 pieces. (See label above)
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Turn the label over and stick the address on.
‘Flagging’ the Label. It has one piece of cello tape going across the body of the label. And then an extra
bit of cello tape hanging from the side (see photo above). Ideally, ONE piece of cello tape should be
used on the back of the label to cover up the sticky part. Be sure not to tape over any parts of the label
that you may require to write in when you put a SMALL amount of tape on the front to secure it.
The Label should now be ready to be stuck on to the PRIMARY container.
The label is flagged on the PRIMARY container.
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EYE OINTMENT
The Plastic container and the PRIMARY container.
‘Flagging’ the Label. It has one piece of cello tape going across the body of the label. And then an extra
bit of cello tape is left hanging from the side – as seen in the above picture. Ideally, ONE piece of cello
tape should be used on the front of the label. Turn the label over to expose the sticky side. Use only a
couple of pieces of cello tape to cover the sticky side.
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The FINAL product. The label is flagged on the PRIMARY container.
#2
Carefully cut straight in half. The label should be in 2 equal pieces. Stick one HALF of the label on to
the tube and then the other HALF on the other side of it. No cello tape is required for this label.
The FINAL product should look like this.
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CREAMS, OINTMENTS, GELS (The Larger Tubes)
The Original container and box
Labelling the BOX is optional
The label should be stuck on the ORIGINAL container. The label should not overlap/cover any part of
label when you put this on to the tube. No cello tape or cutting is required.
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SPRAYS
The BOX and the ORIGINAL container. NOTE: Labelling the BOX is optional.
Prepare the LABEL. Cut carefully and straight about the address line. The label should be in 2 pieces.
When typing out the label you should press F8 and SHRINK it.
Turn the label over and stick the address on.
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‘Flagging’ the Label. It has one piece of cello tape going across the back of the label to cover up the
sticky part. And then have an extra bit of cello tape hanging from the side (see photo above). Ideally,
ONE piece of cello tape should be used on the back of the label. Be sure not to tape over any parts of
the label that you may require to write on when you put a SMALL amount of tape on the front to secure
it.
The Label should now be ready to be stuck on the PRIMARY container.
The label is flagged on the PRIMARY container.
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INHALERS
The BOX and the PRIMARY container
NOTE: Labelling the BOX is optional
Cut straight above the address line. The label should be in 2 pieces.
Turn the label over and stick the address on.
‘Flagging’ the Label. It has one piece of cello tape going across the back of the label to cover up the
sticky part. And then have an extra bit of cello tape hanging from the side (see photo above). Ideally,
ONE piece of cello tape should be used on the back of the label. Be sure not to tape over any parts of
the label that you may require to write on when you put a SMALL amount of tape on the front to secure
it.
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The Label should now be ready to be stuck on to the PRIMARY container. The label is flagged on the
PRIMARY container.
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TURBHALERS
The BOX and the PRIMARY container
NOTE: Labelling the BOX is optional
Label the lid of the TURBHALER – (left piece in the photo)
The Label does not require any cello tape or cutting. It should be placed on the Turbhaler like the in the
photos above.
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