Webster-pak® Community
Dispensing Procedures Manual
Product Code: s153
™
v 6.0
Webster-pak® Community Dispensing Manual
Webster-pak® Community
Dispensing Manual
Contents
Introduction to Webster-pak ____________________________________2
Essential Components for Webster-pak Community __________________3
Getting Started ______________________________________________6
Patient Profile _______________________________________________7
Medication ‘Not Suitable for Packing’ _____________________________7
Complying With PBS Requirements _______________________________8
Complying with other Guidelines _________________________________8
Packing and Sealing Webster-pak Community _______________________8
The Final Check _____________________________________________11
Having the Prescriptions When Needed ___________________________12
Re-Ordering Medication _______________________________________12
What About Dosage Changes? __________________________________12
What If The Patient Needs More Than One Pack? ___________________13
For More Information _________________________________________13
References _________________________________________________13
© (07/2013) Manrex Pty Ltd t/as Webstercare 2014. Webstercare, Webster-pak, Webstersystem and MedsPro are
Registered Trade Marks of Manrex Pty Ltd t/as Webstercare. Blu-Lok, QA Sig Box device and Virtual Pill Count (VPC)
are Trade Marks of Manrex Pty Ltd t/as Webstercare.
________________________________________________________________
© (07.2013) Manrex Pty/Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014
17-19 Moore St, Leichhardt NSW 2040
Tel: (02) 9563 4900 Fax: (02) 9563 4955 Free Call: 1800 244 358
Page 1
Webster-pak® Community Dispensing Manual
Introduction to Webster-pak
Studies in Australia have shown that more than half of people on three or more
medications do not take them as prescribed. The cost to the community as a result of a
person’s unnecessary admission to a residential aged care facility or to hospital due to
adherance errors is enormous and preventable.
Webster-pak is a multi dose, dose administration aid designed to assist people to
correctly take their medication as prescribed.
An independent clinical trial 1 has shown Webster-pak to more than double the rate of
adherance with elderly patients. Widespread usage in other areas also supports this
improvement. It is suitable for anyone, who is taking routine medication (irrespective
of age).
Webstercare aims to;
• Encourage a safe and responsible attitude towards use of medication
• Minimise the likelihood of under and over use of medication
• Optimise the possible health outcome through appropriate use of medication
• Allow easy monitoring of medication use by a relative or carer
Supply of Webster-pak is consistent with the concept of quality use of medicines, for
both residential care and home care patients. The Webster-pak makes medication
monitoring and medication review a practical and cost effective option for community
patients.
With Webster-pak Community the medication profile is printed onto the specially
designed header card for laser and Ink Jet printers. A unique low temperature foil, or
low-temp foil is used which makes the sealing process effortless and inexpensive.
Once the pack is complete, the pack itself will serve as an effective complete
medication profile as well as a dose administration aid. In the event of an emergency all
the information is on hand for the doctor, ambulance officer or hospital staff.
1 Ware Gail J et al. New Zealand Medical Journal 27 November 1991, Vol 104, No 924: Pages 495-7 Unit Dose
Calendar Packaging and Elderly Patient Compliance.
© (07.2013) Manrex Pty/Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014
17-19 Moore St, Leichhardt NSW 2040
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Webster-pak® Community Dispensing Manual
Essential Components for Webster-pak Community
The following materials will be needed prior to starting. Some purchases for example
Blisters, Foils and Header cards will be ongoing while other items are generally a oneoff purchase.
Folders
The side of the re-usable plastic folder is labelled with the days of the week: Monday
at the top of the pack, following through to Sunday at the bottom.
The folders are used in a colour coded system according the completed packs use or
what type of medication is contained in the pack.
Colour Coding System
Blue
Regular Weekly medication: Breakfast,
Lunch, Dinner, Bedtime
Black
Regular Weekly medication Low Vision
White
When Necessary medication (PRN)
Green
Antibiotic & Short Term medication
Mustard Warfarin medication
Burgundy Special Dose Times & Before Meals
medication
Purple
Special Alert, Accountable drugs,
Cytotoxic and special precautions
Blisters
Through experience we have found that 60-80% of patient medication will fit into the
small sized blister. If the dose or tablet size is too large, the next sized blister may be
used.
Small Concertina
Blister
(product code:
780 pack of 500)
Medium Concertina
Blister
(product code:
787 pack of 500)
Large Concertina
Blister
(product code:
782 pack of 500)
King Concertina
Blister
(product code:
790 pack of 250)
© (07.2013) Manrex Pty/Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014
17-19 Moore St, Leichhardt NSW 2040
Tel: (02) 9563 4900 Fax: (02) 9563 4955 Free Call: 1800 244 358
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Webster-pak® Community Dispensing Manual
Webster-pak Community Header Cards
The Header Card contains the patient information and colour photograph, medication
information, the dosage times as well as your pharmacy name and telephone number.
All this information can be printed on the Header Card using a laser or ink jet printer
together with Webstercare’ Medication Management Software (MMS).
The Community Header Cards are available with pre-printed dosage times for
Breakfast, Lunch, Dinner and Bedtime.
Blank Header Cards are also available to allow you to tailor dosage times according to
individual patient’s medication regimes.
Laser Community Header Card
(product code: 406 sold in pack of 250)
Laser Blank Community Header Card
(product code: 587 sold in pack of 250)
Foil
Due to the fact that printing is not required on the back of the pack, a pre-cut sheet of
LoTemp foil (Product Code 366-S) is all you need for sealing a Community Webster-pak.
Pre-cut sheets come in packs of 500 sheets and are packaged between thick pieces of
cardboard to prevent the sheets from curling.
Webstercare LoTemp foil is designed to seal at a low temperature. This ensures
minimal heat, pressure and waiting time required to form an effective seal.
Platen
The Blu-Lok™ Platen is a silicon-moulded frame which is used to hold the blister whilst
packing the medication. It has cut-out holes matching the Webster-pak blisters. The
© (07.2013) Manrex Pty/Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014
17-19 Moore St, Leichhardt NSW 2040
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Webster-pak® Community Dispensing Manual
Blu-lok Platen also has an interlocking feature allowing two or more platens to be
secured together for packing more than one Webster-pak.
Blu-Lok Platen
(product code: 660 sold individually)
Sealing Mouse
The Sealing Mouse has been designed specifally for sealing LoTemp foil on the back of
Webster-paks. Its ergonomic and compact design offers a flat sealing surface ensuring
an even seal for each pack.
Sealing Mouse
(product code: 795 sold individually)
Sealing Iron
The Sealing Iron is a ‘dry’ or non-steam iron which can be used as an alternative to the
Sealing Mouse to seal LoTemp foil on the back of Webster-paks.
© (07.2013) Manrex Pty/Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014
17-19 Moore St, Leichhardt NSW 2040
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Webster-pak® Community Dispensing Manual
Sealing Iron
(product code: 320 sold individually)
Webstercare Medication Management Software
The Communty Webster-pak is available in all versions of the Webstercare Medication
Management Software.
Webster-pak is now available in 20 different languages, designed to cater for people
whose first language is not English. This enables people from certain non-English
speaking backgrounds to read the days of the week and the time of day in their own
language to take their medication as prescribed. There are 2 parts: a tailored header
card (Community style) for each language and tailored Monday to Sunday labels for
each language. Please refer to your Webstercare order form for individual product
codes.
Getting Started
It is most important that before you start to pack medication into a Webster-pak you
have complete and accurate information. To record this, use the Doctor Order/Patient
Medication Profile Form (Product Code 284 – pad of 100 sheets). Exact dosage times
and complete profiles of all medication must be recorded and maintained.
It is essential to check this information with the doctor or carer from written
documentation supplied by the doctor. It is essential to cross check this information
against the prescriptions. You may find discrepancies that will need to be discussed and
resolved before commencing. At this time it is opportune to check for any potential
drug/drug or drug/disease allergies, interactions or dosage discrepancies and take
appropriate action.
© (07.2013) Manrex Pty/Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014
17-19 Moore St, Leichhardt NSW 2040
Tel: (02) 9563 4900 Fax: (02) 9563 4955 Free Call: 1800 244 358
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Webster-pak® Community Dispensing Manual
Patient Profile
All Webstercare systems including Webster-pak Community have been designed with
specific steps to follow in order to minimise the risk of human error. It is important that
ALL steps are followed EVERY time a Webster-pak is filled AND before it leaves the
pharmacy. It is the pharmacist’s responsibility to ensure that the medication packed is
correct against the very latest instructions from the doctor. To support this process,
Webstercare advises that a hard copy profile be generated and maintained.
For a new patient, confirm and enter the data from all original documentation which
may include prescriptions etc. into Webstercare Medication Management Software
(MMS).
Once the data entry is completed in MMS print a hard copy profile by selecting ‘Patient
Medication Record With Pill Images’.
The hard copy profile is confirmed by the pharmacist against the original
documentation. This is to check the accuracy of the data entry and that the correct
medication profile has been entered. If possible request the prescriber to ‘sign off’ the
completed profile.
This becomes the hard copy profile which is used to check the Webster-pak system
after packing is completed. The hard copy profile should be stored in a plastic sleeve in
a folder with a copy of the prescriber’s original documentation, along with any previous
versions of the hard copy profile to confirm its validity.
As changes occur to the patient’s medication profile, they are hand-written on the hard
copy profile. These are confirmed by a pharmacist and the client profile is updated in
MMS. An updated copy is printed from MMS as needed.
Store the previous version with all documentation behind the latest copy.
All printed copies of the hard copy profile need to be checked by the pharmacist.
For more information on patient profiles, please refer to the ‘Hard Copy Profile’
document in the back of this manual.
Medication ‘Not Suitable for Packing’
Solid dose medication unsuitable for repackaging can be dispensed in their original
containers. The header card, where “Also On” or “Non-packed” medication is printed,
is a reference for when non-packed medication should be administered. This gives a
complete record of all the medicines a person is taking. Some examples of medicines
that may be unsuitable for repackaging include: effervescent tablets, dispersible
tablets, buccal tablets, hygroscopic preparations and solid dose cytotoxic preparations.
For more information, please refer to the Webstercare advice on ‘Medications not
suitable for packing in a dose administration aid’ document in the back of this manual.
© (07.2013) Manrex Pty/Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014
17-19 Moore St, Leichhardt NSW 2040
Tel: (02) 9563 4900 Fax: (02) 9563 4955 Free Call: 1800 244 358
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Webster-pak® Community Dispensing Manual
Complying With PBS Requirements
Medications are dispensed via the PBS in the usual way. Once the dispensing is
complete, a record of the dispensed medication for each patient must be maintained.
This can be done through the use of the MedsPro® – Virtual Pill Count (VPC)™ system.
A record of your patient’s medications is retained in the software. If at any time a
patient requests their medications, you have a record of their balance held on their
behalf and you can supply at short notice. Alternatively, Integrity bags can be used to
store each patient’s medications with the identification similar to “this medication is
the property of.............”
Non-packed medication will be dispensed and labelled as normal and supplied as
normal eg. Liquids, eye drops, ointments, PRNs.
Complying with other Guidelines
Pharmacists should also refer to the “guidelines for medication management in
residential aged care facilities” released by the Australian Pharmaceutical Advisory
Council (APAC). Other professional guidelines such as QCPP and PSA should also be
taken into consideration.
Packing and Sealing Webster-pak Community
The Webster-pak Community is a quick and simple way for pharmacies to prepare a
medication management system for community customers.
For a quick reference guide on how to pack Webster-pak Community please refer to
the ‘Packing Procedure’ document in the back of this manual.
Preparation
The Packing Technician:
• Thoroughly washes hands prior to packing or uses gloves
• Collects the first client’s medication
• Ensures there are plenty of blisters for packing
• Places the medication for the first client on their left. Once they have used the
medication, it is placed on their right hand side until packing is complete to
assist with workflow.
STEP 1.
Using the Webstercare Medication Managment Software (MMS) print the Community
Header Cards.
© (07.2013) Manrex Pty/Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014
17-19 Moore St, Leichhardt NSW 2040
Tel: (02) 9563 4900 Fax: (02) 9563 4955 Free Call: 1800 244 358
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Webster-pak® Community Dispensing Manual
The bottom panel of the header card
On the front of the card you can print the
patient’s name and photograph (Client
Photo) as well as any other non-packed
medication to be administered. You can
also print your pharmacy name, logo and
contact details.
The centre panel of the header card
You can print the complete patient profile
onto the the Community Header card.
Including: Patient’s Name, Doctor, Date
and a reference to the profile number.
The information on the centre panel of the
header card is printed upside down. This is
because the header card will be folded on
the completed pack, so this information
will appear the correct way up.
The bedtime medications are also printed
on the left hand side as this will be viewed
from the back of the pack. The drug name,
strength, dosage and description is also
printed.
STEP 2.
Place an empty blister sheet in the Blu-Lok
platen.
Fold the header card along the
perforations so the profile faces you and
place it under the lip of the blister sheet.
© (07.2013) Manrex Pty/Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014
17-19 Moore St, Leichhardt NSW 2040
Tel: (02) 9563 4900 Fax: (02) 9563 4955 Free Call: 1800 244 358
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Webster-pak® Community Dispensing Manual
STEP 3.
Pack the medications from right to left into
the blister sheet as per the medication
profile printed on the header card.
IMPORTANT: As you are viewing the
blister sheet back to front, Breakfast
is on the right, bedtime on the left.
STEP 4.
IMPORTANT: DOUBLE CHECK the filled blister against the header card, confirming
packing accuracy before sealing the pack.
Place a sheet of low-temp pre-cut foil over
the back of the blister sheet. Making sure
the shiny silver side of the foil is face
down.
Align the bottom corners of the foil with
the bottom corners of the blister sheet.
Note: the foil should overlap the header
card towards the top of the pack by
approximately 1cm.
A Sealing Mouse or a dry (non-steam) iron
on a low or “wool” temperature setting
can be used to seal the foil.
Make sure you run the Sealing Mouse or iron over the entire back surface of the foil.
Particularly around the foil edges and where the foil overlaps onto the header card.
The heat from the Sealing Mouse or Iron will activate the adhesive on the low-temp
foil. As the adhesive cools, it will adhere to the blister sheet and header card making a
single complete pack.
For this reason applying slight pressure using
the palm of your hand or a white board duster
to the back of the foil as it cools will maximise
the foil to blister seal.
After sealing the pack, sign the ‘TECH’ box on
the front of the header card to confirm
packing accuracy.
© (07.2013) Manrex Pty/Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014
17-19 Moore St, Leichhardt NSW 2040
Tel: (02) 9563 4900 Fax: (02) 9563 4955 Free Call: 1800 244 358
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Webster-pak® Community Dispensing Manual
Finally, place the sealed pack into the appropriate coloured folder and put aside for a
pharmacist to check.
For more information on sealing a Webster-pak, please refer to the ‘Webstercare
Sealing Techniques’ document in the back of this manual.
The Final Check
STEP 5.
The pharmacist arranges the packs to be checked on the left side of the checking area
in a folder tray, with an empty folder tray on the right side of the checking area.
Confirm the following are correct against the hard copy profile;
•
Information on the header card and the start date are accurate.
•
The pack is in the correct colour folder.
•
Confirm drug names and strengths in each blister from Mon-Sun for each meal
time (column by column).
Handy Hint: Check in reverse i.e. start from Bedtime working towards Breakfast.
Working backwards breaks expected patterns and makes errors easier to detect.
•
Alternate-day doses schedule is correct as printed on the front of the header
card. It is important to check the start date on the pack to confirm the correct
week sequence.
•
The correct number of pieces are in each blister from top to bottom, this time
from Breakfast to Bedtime. Again confirm the alternate dose schedule.
STEP 6.
After checking the pack the pharmacist initials
the ‘PHARM’ box printed on the header card.
Place this pack backwards in the empty folder
tray to your right to indicate the pack has
been checked while maintaining the order of
the packs.
For a quick reference guide on how to check a
pack please refer to the ‘Multi Dose Websterpak Checking Guide’ document in the back of
this manual.
© (07.2013) Manrex Pty/Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014
17-19 Moore St, Leichhardt NSW 2040
Tel: (02) 9563 4900 Fax: (02) 9563 4955 Free Call: 1800 244 358
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Webster-pak® Community Dispensing Manual
Having the Prescriptions When Needed
To comply with the PBS regulations you must ensure that prescriptions are available at
the time of dispensing. It is unacceptable and illegal for there to be owing prescriptions
unless in the case of an emergency order from the doctor. The Webster-pak makes it
far easier for you to get prescriptions when you need them because you know exactly
how much medication is on hand at any time.
Depending on the normal response time and visiting patterns of the doctors, you need
to order prescriptions in advance of them being required. This is very simple with the
Webster-pak. You can tell at any time how much of any medication is left in any original
pack or bottle. Once this gets down say for example between 1 and 2 weeks supply,
you may need a new prescription.
Re-Ordering Medication
Re-Ordering medication is simple using the blue Pharmacy Order Sheet (Product Code
477) and Thermal Re-Order Labels. During the packing process, if less than one-week’s
supply of a medication remains, remove the label’s lift-off tab and apply to the Order
Sheet. Alternatively, orders can be handwritten onto the Order Sheet.
The Pharmacy Order Sheet can then be actioned by either dispensing medication from
an existing prescription, or sending a letter to the doctor informing them of the need
for a new prescription.
What About Dosage Changes?
In a community setting a complete new pack may be supplied each time there is a
change. The previous pack used must be returned to the pharmacy.
© (07.2013) Manrex Pty/Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014
17-19 Moore St, Leichhardt NSW 2040
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Webster-pak® Community Dispensing Manual
What If The Patient Needs More Than One Pack?
There are a few occasions where a second pack may be required;
• A patient may have too many medications to fit into one
blister compartment
• There are too many medications in the one compartment
making it hard to check the pack
• A patient may have more than four dosage times per day
Once a second pack is prepared, attach them together with a split
ring eg. shower curtain ring or similar device.
For More Information
Your success with Webster-pak depends on you understanding the procedures
involved. Please feel free to contact us at any time if you need further assistance or
advice on Free Call 1800 244 358.
References
PSA standard 7:
http://www.psa.org.au/download/community-pharmacy-agreements/doseadministration-aids/professional-practice-standard-7.pdf
APRAH guidelines on specialised supply of medicines:
http://www.pharmacyboard.gov.au/Codes-Guidelines.aspx
QCPP guidelines:
http://www.guild.org.au/
Safe use of oral cytotoxic medicines:
http://www.australianprescriber.com/magazine/36/1/article/1377.pdf
© (07.2013) Manrex Pty/Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014
17-19 Moore St, Leichhardt NSW 2040
Tel: (02) 9563 4900 Fax: (02) 9563 4955 Free Call: 1800 244 358
Page 13
Medications not suitable for packing
in Webstercare® Systems
Packing Cautions
Pharmacy Board of Australia guidelines recommend pharmacies maintain a list of medicines or medicine types
that should not be removed from the original manufacturer’s packaging for packing in a Dose Administration
Aid1.
A pharmacist must make an informal judgment as to the suitability of packing a medicine in a Webstercare
system. It is recommended that the pharmacist use a ‘risk assessment’ approach utilising all available
information.
Included medicines may vary depending on the local prescribing preferences and climate. Consideration may
also be given to the formulation used and the length of time the medicine is to be stored in the Webstercare
system. If unsure, please contact the manufacturer for more information.
Examples to consider include:
Ÿ
Ÿ
Ÿ
Ÿ
Moisture sensitive or hygroscopic formulations
Dispersible tablets
A Webstercare system packed more than a week in advance
Medicines packed in a PRN (when required medicine) Webstercare system
Webstercare® recommends medication removed from a manufacturer’s original packaging should be:
Ÿ Placed immediately in the Webstercare system using tweezers or Pil-Kot™ packing accessory
Ÿ Sealed immediately after filling using the correct sealing technique*
Medicines which must NOT be removed from the manufacturer’s packaging and packed in a Webstercare
system include:
Pradaxa: dabigatran etexilate capsules
Anginine: glyceryl trinitrate tablets
Wafer formulations: packed as a PRN pack
The following medicines are not to be packed in this pharmacy unless the pharmacist has specified otherwise:
T (02) 9563 4900 I FREE CALL 1800 244 358 I F (02) 9563 4955 I FREE FAX 1800 626 739
[email protected] I www.webstercare.com.au
© (06/06) Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014. Webstercare and W-Device are Registered Trade Marks of Manrex Pty Ltd t/as Webstercare.
Pil-Kot is a Trade Mark of Manrex Pty Ltd t/as Webstercare.
v 4.0
1
Pharmacy Board Australia Guidelines on Specialised Supply Arrangements: March 2012
*Sealing technique information is available from Webstercare.
Webster-pak Community
®
PACKING PROCEDURES
4
1
Align a sheet of lowtemp pre-cut foil over
the back of the blister
sheet. The foil should
overlap the header card
by approximately 1cm.
Seal the foil to the
blister sheet.
Using the Webstercare®
Medication Management
Software (MMS), print
the Webster-pak®
Community header
cards.
5
Place an empty blister
sheet into a Blu-Lok™
platen. Fold the header
card so the profile faces
you and place it under
the lip of the blister
sheet.
3
The packing technician
checks the sealed pack
and signs the square
‘TECH’ box to confirm
packing accuracy.
6
Product Code: s165
Pack the medications
into the blister sheet as
per the medication
profile printed on the
header card as a guide.
Check for accuracy
before sealing.
The pharmacist checks
the pack against the
hard copy medication
profile. After placing
the sealed pack into a
Webster-pak folder,
the pharmacist signs
the ‘PHARM’ box on
the completed pack to
confirm that it has
been audited.
T (02) 9563 4900 I FREE CALL 1800 244 358 I F (02) 9563 4955 I FREE FAX 1800 626 739
[email protected] I www.webstercare.com.au
© (02/08) Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2013. Webstercare, Webster-pak and W-Device are Registered Trade Marks of Manrex Pty Ltd t/as Webstercare.
Blu-Lok and the QA Sig Box device are Trade Marks of Manrex Pty Ltd t/as Webstercare.
V 2.0
2
®
Webstercare Sealing Techniques
Some simple tips to ensure a great
seal everytime
Webstercare® low temp foil is specifically designed to seal at a low temperature.
This ensures minimal heat, pressure and waiting time is required
to form an effective seal.
1
2
3
4
5
6
7
Turn the iron on and adjust temperature to a mid range setting. The Webstercare Sealing Mouse™
is recommended for use or a ‘Dry Iron’ (non-steam iron).
Place the blister sheet in the Blu-Lok™ platen and pack medication.
Align the foil (shiny side down) against the back of the filled blister sheet, holding it in position.
Press the Sealing Mouse or iron against the top right corner to secure the foil in position.
Run the Sealing Mouse or iron in a sweeping motion across the foil backing making contact with all
areas of the foil.
Immediately after the foil has been
warmed, apply light pressure to the foil by
rubbing with a white board duster.
If rubbing by hand, wait a few seconds for
foil to cool to the touch.
Remove the sealed pack from the platen
and lay the pack blister face down.
int
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T (02) 9563 4900 I FREE CALL 1800 244 358 I F (02) 9563 4955 I FREE FAX 1800 626 739
[email protected] I www.webstercare.com.au
© (06/10) Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014. Webstercare and the W Device are Registered Trade Marks of Manrex Pty Ltd t/as Webstercare.
Blu-Lok and Sealing Mouse is a Trade Mark of Manrex Pty Ltd t/as Webstercare.
V 2.0
Product Code: s189
If you have any questions please call our Customer Service Team
Ph: 1800 244 358
Multi Dose Webster-pak
®
CHECKING GUIDE
All Webstercare® systems including Multi Dose Webster-pak have been designed with specific steps to follow in order to
minimise the risk of human error. It is important that ALL steps are followed EVERY time a Webster-pak® is filled AND before it
leaves the pharmacy. It is the pharmacist's responsibility to ensure that the medication packed is correct against the very latest
instructions from the doctor. To support this process, Webstercare advises that a hard copy profile be generated and
maintained.*
1
If printing for the first time, print a
hard copy profile using MMS. Select
‘Patient Medication Record With Pill
Images’. This is stored in a plastic
sleeve in a folder with a copy of the
prescriber’s original order to confirm
its validity.
2
3c
Confirm drug names and strengths
in each blister from Mon-Sun for
each meal time (column by
column).
Handy Hint: Check in reverse i.e.
start from Bedtime working towards
Breakfast. Working backwards
breaks expected patterns and makes
errors easier to detect.
3d
Arrange Multi Dose packs to be
checked on the left side of the
checking area in a folder tray, with
an empty folder tray on the right
side of the checking area.
3a
Confirm the following (3a-3e) are
correct against the hard copy
profile:
Alternate-day doses schedule is
correct as printed on the front of
the header card. It is important to
check the start date on the pack to
confirm the correct week sequence.
3e
Information on the header card and
the start date are accurate.
3b
4
PRN Medication
Regular 7 Day Medication
Antibiotic & Short Term
Warfarin Medication
Special Dose Times &
Before Meals Medication
The pack is in the correct colour
folder.
Special Alert
e.g. Accountable drugs, Cytotoxic
The correct number of pieces are in
each blister from top to bottom, this
time from Breakfast to Bedtime.
Again confirm the alternate dose
schedule.
After checking the pack the
pharmacist initials the PHARM box
printed on the header card. Place
this pack backwards in the empty
folder tray to your right to indicate
the pack has been checked while
maintaining the order of the packs.
Regular 7 day Low Vision
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© (07/14) Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2015. Webstercare, Webster-pak and W-Device are Registered Trade Marks of Manrex Pty Ltd t/as Webstercare.
The QA Sig Box Device is a Trade Mark of Manrex Pty Ltd t/as Webstercare.
v 2.0
*See over page
Hard Copy Profile
HOW TO CREATE AND MAINTAIN A HARD COPY PROFILE
For a new patient, confirm and enter
the data from all original
documentation which may include
prescriptions etc. into Webstercare®
Medication Management Software
(MMS).
Once the data entry is completed in
MMS print a hard copy of the profile
by selecting ‘Patient Medication
Record With Pill Images’.
The hard copy profile is confirmed by
the pharmacist against the original
documentation. This is to check the
accuracy of the data entry and that the correct medication profile has been entered. If possible
request the prescriber to ‘sign off’ the completed profile.
This becomes the hard copy profile which is used to check the Webster-pak® system after packing is
completed. The hard copy profile should be stored in a plastic sleeve in a folder with a copy of the
prescriber’s original documentation, along with any previous versions of the hard copy profile to
confirm its validity.
As changes occur to the patient’s medication profile, they are hand-written on the hard copy profile.
These are confirmed by a pharmacist and the client profile is updated in MMS. An updated copy is
printed from MMS as needed.
Store the previous version with all original documentation behind the latest copy.
All printed copies of the hard copy profile need to be checked by the pharmacist.
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v 1.0
If you require any further assistance with creating or maintaining a hard copy
profile, please call Customer Service on free call 1800 244 358.
Managing oral cytotoxic medicines in
Webstercare® systems
Cytotoxic medicines management guide
Methotrexate and other oral chemotherapy medicines are “high risk” medicines1. Serious toxicities and fatal
outcomes have occurred as a result of incorrect prescribing, dispensing and misinterpretation of instructions2.
Cytotoxic medicines should be administered in a safe environment where all healthcare professionals follow
principles of the same medication practice.
The Guiding principles for medication management in residential aged care facilities3 recommends that
residential aged care facility (RACF) organisations develop a specific policy for the safe management of
cytotoxic medicines and contaminated waste.
The following suggested precautions are for consideration when developing a cytotoxic policy.
When cytotoxic medicines are prescribed
·
Verify dose regime. If there is any doubt about the prescribed dose seek clarification from the
prescriber.
·
Do not use “as directed” instructions, even if the instructions are recorded elsewhere.
Pharmacy and packing cytotoxic medicines
·
Specify the cytotoxic drug name, dose and frequency of administration to print on Webster-pak®,
medication chart and signing sheet.
·
The Webstercare Medication Management Software(MMS) will alert pharmacy staff when
methotrexate and cytotoxic medicines are entered into a patient’s profile: “ALERT: Special
conditions apply. Check with pharmacist.”
·
Specify the day of the week and include the term “once a week” instructions for methotrexate and
other once a week cytotoxic medicines.
·
For cyclic doses of cytotoxic medicines include start and stop dates.
·
Ensure pharmacy staff are not exposed to skin contact or dust inhalation from the cytotoxic
medication when packing a Webster-pak.
·
Pack methotrexate and other cytotoxic medicines in a separate purple Webster-pak folder.
·
Add CYTOTOXIC alert label to the Webster-pak, medication chart
and signing sheet to identify the medicine as cytotoxic.
·
Seal the Webster-pak containing cytotoxic medicine into the cytotoxic
delivery bag. This is a precaution in case the packaging is damaged in
transit.
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v 1.0
Please see over for references.
Managing oral cytotoxic medicines in
Webstercare® systems
Cytotoxic medicines management guide
Administration of a cytotoxic from a Webster-pak
·
Train and assess RACF staff as competent in administration of cytotoxic medicines.
·
Use disposable protective gloves to avoid direct contact with cytotoxic medicines and avoid
contamination with other medicines. Use a mask if there is a risk of inhaling cytotoxic aerosol or dust.
·
Remove medicine from the Webster-pak using a dedicated purple cytotoxic Pil-Bob®.
·
Transfer cytotoxic medicine to disposable medicine cups for administration to
resident – do not re-use medicine cups for other residents.
·
If a tablet is damaged do not open the blister - contact the pharmacy for advice.
·
DO NOT CRUSH cytotoxic medicines.
·
If a medicine is spilt or dropped, do not pick it up with your hands. Use a cytotoxic spill kit if
available.
·
All staff should be alerted that the medicine is cytotoxic. Women who are pregnant or of
childbearing age and who might come into contact with cytotoxic medicines should contact their
own GP for further advice.
·
Unused tablets must be returned to the supply pharmacy and not disposed of at the RACF.
·
Refer to your relevant state and territory Work, Health Safety legislation for further information.
Contact Customer Service to request the cytotoxic support products brochure or place an order on
Freecall 1800 244 358 or [email protected]
References:
Pharmacy Board of Australia Guidelines for dispensing medicines
2
Safe use of oral cytotoxic medicines; Australian Prescriber; Vol 36; Feb 13
3
Guiding principles for medication management in residential aged care facilities; Dept Health and Aging; Oct 12
T (02) 9563 4900 I FREE CALL 1800 244 358 I F (02) 9563 4955 I FREE FAX 1800 626 739
[email protected] I www.webstercare.com.au
© (06/06) Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2014. Webstercare, Webster-pak, Webstersystem and W-Device are
Registered Trade Marks of Manrex Pty Ltd t/as Webstercare.
v 1.0
1
VOLUME 36 : NUMBER 1 : february 2013
article
Safe use of oral cytotoxic medicines
SUMMARY
All health professionals involved should:
••
The oral route is increasingly used to
administer cytotoxic therapy for cancer and
non-cancer conditions.
have appropriate training and skills in the use of
cytotoxic chemotherapy and cancer care, when
therapy is being used in this context7
••
Oral cytotoxic therapy carries the same risk
of medication errors as parenteral therapy.
seek advice from a practitioner experienced in
cytotoxic chemotherapy when required
••
follow the principles of safe medication practices
for oral cytotoxic medicines.
It is essential that health professionals
involved in providing oral cytotoxic therapies
understand how they are used, what adverse
effects can occur and how to minimise
medication errors.
Introduction
Oral administration of cytotoxic therapy has
increased over the past decade as newer drugs and
formulations have become available (see Table).
Cytotoxic chemotherapy is not restricted to cancer.
Conditions including rheumatoid arthritis, psoriasis
and other autoimmune diseases may be managed
using oral medicines such as methotrexate.
The pros and cons of oral cytotoxic
therapy
The oral route offers many advantages over the
parenteral route of administration. Medicines can be
administered in the community, without the need for
venous access, and fewer visits to the hospital are
needed.
While self-administration at home is convenient for
both patients and carers, it can present a risk for the
patient. Adverse effects can go undetected unless
appropriate steps are in place to monitor the patient.
Cytotoxic chemotherapy has a narrow therapeutic
index and a small increase in dose can result in toxic
effects, while under-dosing can lead to failure of
therapy. Serious toxicities and fatal outcomes have
occurred as a result of incorrect prescribing and
dispensing as well as patient misinterpretation of
dosing instructions.1-6
Responsibilities of the healthcare
team
The safe delivery of oral cytotoxic therapy requires a
multidisciplinary approach. Patients may be managed
under shared-care arrangements between hospital
specialists, general practitioners and community
pharmacies.
All patients should have a treatment plan. This
is completed by the specialist who initiates the
treatment7 and should be given to the patient and
all the healthcare professionals involved in their
treatment. It is important that the patient has the plan
with them if they see a different doctor, for instance in
an emergency.
Christine Carrington
Senior consultant
pharmacist
Princess Alexandra Hospital
Assistant pharmacy
director
Cancer Services
Royal Brisbane and
Women’s Hospital
Brisbane
Key words
capecitabine, methotrexate
Aust Prescr 2013;36:9–12
For the treatment plan to be useful, it should be
explicit about:
••
••
the patient’s diagnosis
••
the expected number of cycles and the intended
duration of treatment
••
other adjuvant or concurrent treatments the
patient is receiving (for example radiation therapy
or surgery for cancer patients)
••
expected adverse effects and their management.
the name of the chemotherapy protocol or specific
cytotoxic medicine
Prescribing
Prescriptions for oral cytotoxic therapy should be
clear and unambiguous. The term ‘as directed’ must
not be used regardless of how long the patient has
been on the therapy.
Table Oral cytotoxic medicines
Drug class
Drugs
Alkylating agents
busulfan, chlorambucil, cyclophosphamide*, lomustine, melphalan,
procarbazine, temozolomide
Anthracyclines
idarubicin
Antimetabolites
capecitabine, fludarabine, hydroxyurea*, mercaptopurine*,
methotrexate*, thioguanine
Podophyllotoxins
etoposide
Vinca alkaloids
vinorelbine
* currently used for both cancer and non-cancer indications
Full text free online at www.australianprescriber.com
9
VOLUME 36 : NUMBER 1 : february 2013
article
Oral cytotoxic medicines
••
the generic drug name, number of tablets to be
taken7 and frequency and duration of therapy
(written in full)
issued within the Pharmaceutical Benefits Scheme
regulations, the patient should be directed to destroy
any repeats or return them to the prescriber if
treatment is changed or stopped.
••
whether the medicine is given on a cyclical or
continuous basis. For example, capecitabine is
frequently administered for 14 days of a 21-day
cycle while temozolomide may be administered for
5 days of a 28-day cycle. The start and stop dates
for a cycle should be clear.
Patients should always be advised on the action to
take should they experience an adverse event – for
example severe diarrhoea with capecitabine requires
immediate cessation of therapy. Patients should be
given the name of an accessible healthcare contact
they can speak to regarding any concerns.
••
the day on which tablets should be taken. For
example, methotrexate is most commonly given
as a once-weekly dose (Box).8 Fatal errors have
occurred when methotrexate has been prescribed
to be taken daily or when the incorrect strength of
tablets has been prescribed.9
Dispensing and supplying oral
cytotoxic treatment
Prescriptions should specify:
Wherever possible the quantity prescribed should
be the quantity needed for one cycle (cancer
chemotherapy) or one month (for example
methotrexate for rheumatoid arthritis). Preferably,
repeat prescriptions should not be issued as doses
may change according to adverse effects and
therapeutic response. If a repeat prescription is
Box Safe prescribing of weekly
methotrexate 8
Provide the patient with verbal and written information
on the intended schedule of therapy including the dose
as a quantity of tablets and the frequency of dosing
Ensure handwritten prescriptions are complete and
legible and include in full the form, strength, dose and
directions
Nominate on the prescription the day on which the
dose should be taken
Do not write ‘as directed’ on the prescription
Consider limiting the prescribed quantity of
methotrexate to four weeks
Do not override warnings and flags for methotrexate in
prescribing software
Keep the strength of tablet supplied to the patient
consistent to avoid confusion for the patient over the
number of tablets they need to take
Be aware of signs of methotrexate toxicity or
intolerance, for example dry persistent cough,
vomiting and diarrhoea
Patients should be advised to contact their doctor or
pharmacist straight away if a dose is missed, or they
develop an infection such as gastroenteritis or fever
If a patient is admitted to hospital, strike out the
six days of the week when methotrexate is NOT
required in the administration section of the inpatient
medication chart
10
Full text free online at www.australianprescriber.com
The dispensing of oral cytotoxic therapy includes
verification of the prescription for the patient and
their condition, and appropriate supply in a safe
and timely manner.7 For cancer chemotherapy the
pharmacist should have access to the treatment plan,
the chemotherapy protocol and relevant patient
parameters including height and weight and recent
laboratory results.10 The pharmacist should ensure
that the relevant supportive medicine has been
prescribed or is available to the patient.
Interactions between chemotherapy, other prescribed
drugs, and over-the-counter and complementary
medicines can cause changes in the efficacy and
safety of oral chemotherapy.11 For example, analgesic
doses of aspirin and non-steroidal anti-inflammatory
drugs can increase the toxicity of methotrexate when
they are used with cancer therapy. Low-dose aspirin
can be used with weekly methotrexate. The risk
associated with lower doses of methotrexate used in
rheumatoid arthritis therapy is much less.
Conversely cytotoxic chemotherapy can alter
the effectiveness of other drugs. For example,
capecitabine significantly reduces the metabolism
of warfarin, increasing its anticoagulant effect. A
complete medication history should be taken from the
patient or carer before dispensing a prescription and
potential interactions should be discussed.
If a dose administration aid (for example a Websterpak) is required by the patient, then oral cytotoxics
must be packed separately from the patient’s noncytotoxic medicines.
Medicine labelling
The labelling of oral cytotoxic therapy should clearly
state the dose and the number of tablets to be taken.
The label for weekly dosing for medicines such as
methotrexate and vinorelbine should include the term
‘once a week’ and specify the day the dose should be
taken. Cytotoxic chemotherapy can be carcinogenic,
mutagenic and teratogenic. A warning sticker should
be placed on all containers of cytotoxic chemotherapy
tablets and capsules, in accordance with local health
VOLUME 36 : NUMBER 1 : february 2013
article
and safety policy. An adhesive purple sticker with the
wording ‘cytotoxic, handle with care’ is recommended.
A warning label must be placed on administration
aid packs that identify the contents as cytotoxic. Oral
cytotoxic tablets and capsules should not be broken
or crushed as this can increase the risk of exposure
and alter the bioavailability of the medicine.
Information for the patient
Patient information is paramount to support the safe
use of oral cytotoxic therapy. Patients should be given
verbal and written information that includes dose
instructions (when the medicine should be taken
and if it is required to be taken before or after food),
adverse effects and safe storage instructions.7,12 Some
oral cytotoxic medicines need to be stored securely
in a refrigerator, for example chlorambucil and
melphalan.
Patients should be advised that oral cytotoxic
medicine should only be taken out of the dispensed
packaging immediately before a dose. To minimise
exposure of carers and family members to cytotoxic
medicines, patients should be advised that selfadministration is preferable. If administration by a
carer is required then disposable gloves should be
worn. Unused tablets must be returned to the local
pharmacy or original supplier and not disposed of at
home.
The intermittent, cyclical treatment that is
characteristic of many cancer chemotherapy protocols
is difficult for some patients to understand and they
may misinterpret instructions. Medication guides,
patient calendars and dose administration aids are
often useful to help patients follow complex dose
regimens, particularly those on multiple medicines.
Adherence to oral therapy is important to maximise
the benefits and reduce the risks of treatment. This
should be discussed with the patient.
If appropriate, Consumer Medicine Information
leaflets should be given to patients, however the
context in which cytotoxic chemotherapy is used
often limits their suitability. Patient information
leaflets on many of the commonly used cancer
chemotherapy protocols can be found on the eviQ
Cancer Treatments Online website.13 This website
also provides information about how to safely
take oral chemotherapy treatments at home.* The
Australian Rheumatology Association provides patient
information on drugs such as methotrexate and
cyclophosphamide.8
* www.eviq.org.au/Protocol/tabid/66/
categoryid/449/id/492/Patient+Information++Oral+Chemotherapy.aspx
Patients should be advised of the importance of
notifying dentists, doctors and other healthcare
professionals who may be involved in their care about
their cytotoxic therapy.
Identifying and managing adverse
effects
Cytotoxic chemotherapy causes many adverse
effects such as nausea, vomiting, bone marrow
suppression, stomatitis, diarrhoea, hand-foot
syndrome, peripheral and central neurotoxicity,
renal and liver dysfunction and hair
loss. The effects require careful
monitoring, and supportive therapies
Patient information is
may be needed to minimise them.
paramount to support
Antiemetics should be prescribed
the safe use of oral
according to the emetogenic potential
14
of the chemotherapy. Nausea and
cytotoxic therapy
vomiting can continue for several days
after a dose of chemotherapy and
the duration of antiemetic therapy should take this
into consideration. Guidelines exist for prescribing
antiemetics with cancer chemotherapy.15,16
Blood counts need to be frequently checked with
cytotoxic therapy. Patient monitoring, including
laboratory tests and the parameters for initiating the
next cycle of chemotherapy, should be clearly defined
in the protocol or treatment plan. For example, a
neutrophil count of greater than 1 x 109 is usually
required for a cycle of cancer chemotherapy to
proceed.
Particular care should be taken with patients when
the cytotoxic therapy is taken continuously, for
example cyclophosphamide or chlorambucil, as
severe myelosuppression can develop. Cytotoxic
chemotherapy can adversely affect liver and renal
function and these should be monitored before each
course of therapy.
Live vaccines are contraindicated in patients with
impaired immune function which includes those
receiving oral cytotoxic therapy. These vaccinations
should usually be delayed until at least six months
after the completion of any chemotherapy. Inactivated
vaccines are generally safe, but patients may have
a diminished immune response to the vaccine. The
influenza vaccine should be administered before each
influenza season and pneumococcal vaccine should
be considered before starting therapy.
Recommendations
Despite the convenience that oral cytotoxic therapy
offers, it carries the same risk of medication errors
and adverse effects as parenteral therapy. Oral
Full text free online at www.australianprescriber.com
11
VOLUME 36 : NUMBER 1 : february 2013
Oral cytotoxic medicines
article
cytotoxic medicines have a narrow therapeutic index
and monitoring the patient for safety and efficacy
is essential. Written and verbal communication
with patients and carers is critical for the safe and
appropriate use of cytotoxic therapy.
If a patient unknown to the prescriber, pharmacist or
healthcare professional presents for oral cytotoxic
therapy, the risk of continuing therapy should be
balanced against the risk of stopping therapy until
a full history and safety checks are done. In many
cases delaying therapy for a short time while a full
patient review is conducted and laboratory counts are
obtained is safer than continuing therapy.
Dr Carrington served on advisory boards for Amgen
and Merck Sharp & Dohme and has received honoraria
from Roche and Merck Sharp & Dohme for educational
presentations.
References
1.
2.
3.
4.
5.
6.
7.
8.
The Institute for Safe Medication Practices. Lowdown on
lomustine: we’d hate CeeNU make this mistake. ISMP Safety
Alert; 2004 Jul 15.
www.ismp.org/Newsletters/acutecare/articles/20040715.
asp [cited 2013 Jan 7]
Holquist C, Phillips J. FDA Safety Page: fatal medication
errors associated with Temodar. Drug Topics 2003;7:42.
http://drugtopics.modernmedicine.com/drugtopics/
DrugInformation/ArticleStandard/article/detail/110864
[cited 2013 Jan 7]
NHS National Patient Safety Agency UK. Rapid Response
Report: risks of incorrect dosing of oral anti-cancer
medicines. 2008 Jan 22:NPSA/2008/RRR001.
www.nrls.npsa.nhs.uk/resources/?entryid45=59880 [cited
2013 Jan 7]
Weingart SN, Spencer J, Buia S, Duncombe D, Singh P,
Gadkari M, et al. Medication safety of five oral
chemotherapies: a proactive risk assessment. J Oncol Pract
2011;7:2-6.
Arnet I, Bernhardt V, Hersberger KE. Methotrexate
intoxication: the Pharmaceutical Care process reveals a
critical error. J Clin Pharm Ther 2012;37:242-4.
Department of Health Victoria. Quality use of medicines
notice: Caution with oral chemotherapy for cancer. 2010.
www.safetyandquality.gov.au/wp-content/
uploads/2012/02/Oral-for-health-services-VictorianDepartment-of-Health.pdf [cited 2013 Jan 8]
Carrington C, Stone L, Koczwara B, Searle C, Siderov J,
Stevenson B, et al. The Clinical Oncological Society of
Australia (COSA) guidelines for the safe prescribing,
dispensing and administration of cancer chemotherapy.
Asia Pac J Clin Oncol 2010;6:220-37.
Australian Rheumatology Association. Patient Information.
2012.
www.rheumatology.org.au/community/
PatientMedicineInformation.asp [cited 2013 Jan 7]
9. NHS National Patient Safety Agency UK. Improving
compliance with oral methotrexate guidelines. 2006.
NPSA/2006/13.
www.nrls.npsa.nhs.uk/resources/healthcare-setting/
community-hospital/?entryid45=59800&cord=ASC [cited
2013 Jan 7]
10. Carrington C, Gilbar P, Wintraeken J; The Society of Hospital
Pharmacists of Australia Committee of Specialty Practice in
Cancer Services. Standards of practice for the provision of
pharmaceutical care of patients receiving oral chemotherapy
for the treatment of cancer. J Pharm Pract Res 2007;37:149-52.
11. Goodin S. Oral chemotherapeutic agents: understanding
mechanisms of action and drug interactions.
Am J Health Syst Pharm 2007;64 Suppl 5:S15-24.
12. Viele CS. Managing oral chemotherapy: the healthcare
practitioner’s role. Am J Health Syst Pharm 2007;64 Suppl
5:S25-32.
13. Cancer Institute NSW. EviQ Cancer Treatments Online
[website].
www.eviq.org.au [cited 2013 Jan 7]
14. Grunberg SM, Osoba D, Hesketh PJ, Gralla RJ, Borjeson S,
Rapoport BL, et al. Evaluation of new antiemetic agents and
definition of antineoplastic agent emetogenicity–an update.
Support Care Cancer 2005;13:80-4.
15. Roila F, Herrstedt J, Gralla RJ, Tonato M. Prevention of
chemotherapy- and radiotherapy-induced nausea and
vomiting: guideline update and results of the Perugia
consensus conference.
Support Care Cancer 2011;19 Suppl 1:S63-5.
16. Basch E, Prestrud AA, Hesketh PJ, Kris MG, Feyer PC,
Somerfield MR, et al. Antiemetics: American Society of
Clinical Oncology clinical practice guideline update.
J Clin Oncol 2011;29:4189-98.
FURTHER READING
Risks associated with prescribing oral methotrexate [media
release]. NPS MedicineWise. 2011 Dec 20.
www.nps.org.au/media-centre/media-releases/repository/
health-professionals-alert-to-the-risks-associated-with-oralmethotrexate [cited 2013 Jan 7]
Dental note
Safe use of oral cytotoxic drugs
Michael McCullough
Chair
Therapeutics Committee
Australian Dental
Association
12
The increasing use of oral cytotoxic drugs for
non-oncological diseases has resulted in an increased
likelihood that dental patients will be taking them.
The oral mucosa has a very high cell turnover rate
and these drugs will invariably result in thinning of the
mucosa, and often, concurrent salivary hypofunction.
Full text free online at www.australianprescriber.com
These patients are likely to require increased care and,
if they have complex dental treatment needs, may
require specialist management. Good communication
with the treating doctors and appropriate referral
where necessary will significantly help these patients.