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38 Cards in this Set
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- Back
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Obtaining the Correct Medication from Inventory |
After the prescription form has been received and processed, the next step is to obtain the correct medication from inventory. When selecting the medication you must look closely at the manufacturers label. Is the name of the drug, the strength, the form , and the manufacturer of the drug exactly the same as what was ordered? All of the information on the drug label must match the order, with the exception of the dosage strength. If the dosage strength is not appropriate for the order, calculations may be done to determine if the dosage strength can be converted to what is needed. Let’s say that the order asks for a dose of 100 mg po, and the tablet in stock are 200 mg. If the tablets are scored ( a groove runs across the tablet) so that we can accurately break them in half, we can put instructions on the label for the patient tot take one-half tablet per dose (100 mg). This is called dosage conversion and is perfectly acceptable as long as the calculated dose is accurate. |
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What should appear on the Drug Label |
The NDC Number The amount of drug in each tablet or unit of volume The proprietary name and generic name The dosage Form The drug manufacturer The Federal Legend or Rx |
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The NDC Number |
This number contains codes that denote the generic name of the drug, manufacturer, proprietary label, dosage form, strength, and type of packaging. |
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The amount of drug in each tablet or unit of volume ( drug solution or suspension) |
For a drug in solution or suspension, the concentration is either given in mg or mg/mL or may be easily calculated. |
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The proprietary name and generic name |
The generic name always appears on the label, wither alone (generic label) or beneath the trade name ( proprietary label). |
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the Dosage Form |
Tablet, capsule, suspension, solution . etc. |
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The drug manufacturer |
The drug manufacturer |
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The Federal Legend or Rx |
The Federal Legend or Rx |
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Additional information to appear on the Drug label |
Additionally the manufacturer’s label may contain information regarding recommended dosages and safe dosages, instructions on preparation for administration (eg. Rehydration, dilution) and optimum storage conditions.. A lot or control number corresponding to the drug manufacturer should be present, as well as the expiration date for the drug. A code designating the drug, manufacturer, and dosage form ( the NDC number) should also appear, usually at the top of the label |
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The National Drug Code (NDC) Number |
The NDC number is an 11-digit number, containing three distinct segments (separated by hyphens). The use of the NDC numbers allows for rapid and accurate entry of product and labeler information, for use in the national drug quality surveillance program |
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Segment 1 The Manufacturers Identification Code |
The first segment identifies the manufacturer or re-packager of the drug. All manufacturers and repackaging agencies are required to register with the FDA and receive a unique identifier number, which must be present on the labels of their products. This first segment is five digits long. |
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Segment 2 and 3 Drug Product Identification and Manufactures packaging. |
Each drug company is allowed to establish its own codes for identification of its particular drugs, and the various types of packaging in which they are sold (eg. Dose packs, 500 count bottle etc.) These codes are registered with the DEA, and make up the second and third segments of the NDC number. The second segment identifies the drug product and is four digits long. The third segment of numbers identifies the packaging of the product. This segment is two digits long. |
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The NDC Number |
The NDC number will always be 11 digits long. Its format looks like this 12345-6789-01 |
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Alternate Versions of The NDC number |
Sometimes an NDC number may appear to be missing numbers. The manufacturer may only print four digits in the first segment of three digits in the second segment. This NDC number still has 11 digits; they have just excluded the leading zeros on the packaging. Example: A drug has the NDC number 04321-0876-02. The manufacturer has the option of printing it as follows: 04321-0876-02 4321-0876-02 04321-876-02 4321-876-02 All are correct and all represent the manufacturer, drug, and packaging filed with the FDA, and DEA. |
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Measuring the Drug for Dispensing |
Once the amount of drug to be dispensed has been calculated, the drug is measured for dispensing. An order for almost any amount of drug can be filled, as long as the amount dispensed is accurate and appropriate to the route of administration. Solid dosage forms are easily dispensed accurately. We simply count out the tablets or capsules, using a tablet counter, in a sanitary accurate manner. Liquids however must be measured out using properly calibrated equipment and correct procedures. |
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Conversion of Solid Dose Forms |
The solid dosage form that can be most accurately converted is the tablet. A capsule or pulvule cannot be accurately divided, so an order for these dosage forms must be filled as written. In other words if the order is for 250 mg capsules of Cefaclor, and you have 500 mg capsules in stock, the 500 mg capsules cannot accurately be divided, so the order cannot be filled. Tablets may be accurately divided, but only if the are scored tablets ( ie they have a groove dividing the tablet into halves and fourths). These may be broken at the groove, using a tablet splitter, or even by hand. Example: Your order is for 50 mg of phenobarbital, taken orally. You have 100 mg tablets in stock, which are scored in halves. You can fill the order by breaking the tablets at the groove. It is best to break them for the patient to ensure accurate dosing. Otherwise, sending them with a tablet splitter is the next best option. Example: Your order is for 30 mg of phenobarbital taken orally. Since the 100 mg tablets that you have in stock are scored in halves and not thirds, you cannot accurately determine what portion of the tablet is 30 mg, and you cannot fill the order. An option would be to use a liquid dosage form but would require a phone call to the physician by the pharmacist. |
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Dispensing Liquid Dosage Forms |
Unlike solid dosage forms, liquid dosage forms must be accurately measured in an appropriately calibrated measuring device. The concentration of drug in the solution or suspension may be found on the manufacturer’s label. This concentration is used to determine the proper amount of solution or suspension to dispense for the order. An order of almost any amount can be filled as long as the amount dispensed is appropriate. Example: Your order is for 40 mEq of potassium to be administered orally. Your available stock of potassium is a solution of 20 mEq/mL. Upon calculation, you find that the required amount to be drawn up for the order would be 2 mL, which is an appropriate amount to be added to a cup of juice for administration. Example: Your order is for 250,000 units of penicillin to be administered intramuscularly. Your available stock of penicillin is a solution of 25,000 units/mL. Upon calculation, you find that the required amount to be drawn up for the order would be 10 mL, which is too large an amount to be administered as an IM injection. The order cannot be filled with the available stock. |
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Packaging of Liquid Medications |
Drugs in liquid form are usually dispensed in containers specific for the intended use. For example, ophthalmic drugs intended for use in the eye or preparations for use in the ear may be prepackaged in a sterile bottle ( with a dropper in the cap). The majority of liquids, however, are dispensed for either oral use ( by mouth) or parenteral use ( by injection). An institutional pharmacy would dispense liquids for either oral topical or parenteral use, while a retail pharmacy would dispense mainly solutions for oral or topical dosage. An institutional pharmacy might dispense liquids for either oral, topical or parenteral use, whereas a retail pharmacy would dispense mainly oral and topical formulations. |
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Measuring Liquids for Oral Dosage |
Liquids for oral dosage are normally dispensed in plastic dispensing bottles that have markings on the side for milliliters, drams, ounces, or all three. (For a review of dispensing units, see Chapter 10.) The markings on the dispensing bottle or dosage cup are not accurate for measurement! They are a guide for the patient to determine approximately how much is left in the bottle. Never measure a solution or suspension by these markings. Solutions and suspensions must be measured at room temperature, using accurate devices like graduated cylinders. Parenteral drugs are rarely dispensed from a retail pharmacy; however, it is wise to be familiar with them, as questions on parenteral drug dispensing and related calculations will be on the exam. The markings on a liquid dispensing bottle are not to be used for accurate measurement! They are guide for the patient to determine approximate volume. |
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Determining the Amount of Drug to Dispense |
Orders for solid dosage forms are usually straightforward; each tablet or capsule contains a specified amount of drug. Dispensing liquid formulations may be a bit more complicated. Orders for liquid formulations are normally given in milligrams, just as those for solid dosage forms are. To accurately dispense the amount ordered, the concentration of the drug solution must be known. This is normally stated on the manufacturers label. If its is not, it may be calculated from the information that is given on the label. Example: Say that you need to draw up a 15 mg dose of methotrexate. The manufacturers label does not list the concentration of the solution. You, as an astute pharmacy technician, notice that the total amount of drug in the bottle is listed as 250 mg, and the label states that the total volume is 10 mL. A simple division is all that is necessary to obtain concentration: 250 mg divided by 10 mL = 25 mg/mL. |
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Choosing the Proper Container for Dispensing |
Once the drug has been accurately measured, it should be placed into an appropriate container and labeled. The type of container used varies according to the intended use of the drug: • A topical solution may be placed into a bottle with a dropper cap • A cream or ointment is placed in an ointment tube or jar • A liquid for oral dosing should be placed into an appropriate bottle, usually with a small neck that is suitable for slow pouring • Solid dosage forms (eg. Tablets) are placed into a large mouthed dispensing container The type of dispensing container varies according to the form and intended use of the drug. Liquid dosage forms for oral administration are placed into bottle suitable for pouring and creams into jars or tubes, for example. |
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Choosing the size of Dispensing Container |
Care must be taken to ensure that the size of the dispensing container is appropriate for the amount of medication being dispensed. A container that is too large will allow the medication too much freedom to move, which may result in damaged capsules or tablets. In addition the general appearance would be sloppy and the patient may have trouble retrieving the medication from the container. A container that is too small may crush tablets or force a liquid or cream out of the package. The size of the dispensing container should be appropriate to the amount of drug product dispensed. For example, a small volume should be placed into a small bottle. |
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Sealing the Dispensing Container |
All dispensing bottles should be sealed with child-proof caps, according to the Poison Prevention and Packaging Act. An “Easy Open” cap may be placed on the bottle if the patient signs a waiver form indicating that this type of cap is requested. This releases the pharmacy from liability should accidental poisoning occur due to unsecured packaging. In addition to being the proper size and shape, the dispensing container must be appropriate to the drug product being dispensed, as well. For example many drugs are sensitive to light which is why drugs are packaged in caps that seal tightly. Still others (eg. Nitroglycerin) react with most forms of plastic and should be packaged in glass bottles. |
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Properly Labeling the container |
Once the drug has been packaged, it must be labeled appropriately. Information that is required to be on a label ( unless omissions are requested by the prescriber) is as follows: • The name address and phone number of the pharmacy ( usually preprinted on the label) • The name of the patient for whom the drug is prescribed ( or the name of the owner, if the drug is for an animal) • The name of the prescriber • Date of Dispensing • The name of the drug. This means the drug that was actually dispensed. If the prescription was for a proprietary label (brand name) and the generic drug was dispensed, the generic name and manufacturer should appear on the label. If a prescription was filled by generic substitution, the label must contain the name of the generic brand, not the proprietary label originally prescribed! Example: The prescription order is for furosemide, but the patient requests the bran name Lasix. The label must read Lasix, even though the prescription was for furosemide, the generic name may be listed also, but if a brand name is dispensed, it must be on the label. • The Strength of the medication (eg. 40 mg tabs, 5% solution etc.) If the drug is only available in one strength or is a combination drug, this information may be omitted (depending on your state regulations). • The Quantity of Drug Dispensed (number of tablets, number of milliliters etc.) • Directions for Dosage These should be clear, understandable,, and appropriate to the user. For example if the prescription is for a child, the label should read “Give [the drug]”. If the drug is for oral dosage, instructions would be “take ….” For rectal or vaginal use, instructions would be “insert” and so on. Additionally, the label may contain refill information, and usually the initials of the person dispensing the drug will appear by the date of filling. |
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Auxiliary Labels |
Once an outpatient prescription has been filled and labeled, it is helpful to place reminders on the prescription bottle as to how to use the medication (since the medication will be dosed directly by the patient) and to note any activities that should be avoided while using it. These adhesive labels are called auxiliary labels. The auxiliary label reminds the patient of the best way to use the drug fro maximum effect, and emphasizes things to avoid. For example, certain activities may be hazardous, such as drinking alcoholic beverages (which may chemically or physically react with the drug) or operating machinery. Many computer systems will print these directly on the dispensing label. These special labels can be purchased with the self-adhesive auxiliary labels already attached. Once the drug has been dispensed and received by the patient, it now should be entered into the patient profile. |
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Compounding Prescriptions |
Preparing a solution, ointment, or powder from a written procedure is often performed by the technician. Legally, these dosage forms must be prepared by the technician according to a standardized written procedure. The procedure may involve combining the components by weight or by percentage. Extemporaneous Compounding Extemporaneous Compounding is the preparation of a dosage form for drug delivery that is customized for a particular patient. This requires a degree of professional judgement, and therefore must legally be performed by the pharmacist. If the pharmacist generates a written protocol for the preparation of the dosage form, it may be prepared by the technician. Once the protocol for preparation of the drug is in written form, it is considered an extemporaneous compound suitable for technicians to prepare. |
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Preparing Sterile Solutions for Injection Using Aseptic Technique |
If a sterile solution is being prepared, such as a drug for injection or a solution for use in surgical irrigation, the technician must prepare the drug dose or solution using aseptic technique. Drugs that go directly into the blood do not go through the digestive system. Any bacteria present in the parenteral solution can survive and multiply very quickly in the blood stream. Bacteria produce toxins, which “poison” the blood ( hence the name “blood poisoning” ). Cleaning the skin and under the fingernails will not necessarily remove all of these organisms from the skin. Therefore its important to wear glove when preparing these products. Introduction of these organisms directly into the blood can cause sepsis. Sepsis is an extremely serious condition that is fatal to the patient if not treated in the early stages, before excessive bacterial growth has occurred. Because of this potentially serious danger these preparations must be free of viruses, yeast, and particularly bacteria. Thus, when preparing a parenteral dosage form: • Perform all procedures inside a sterile laminar flow hood, with clean, disinfected hands and with hair tide back or covered. • Disinfect the withdrawal site on the drug vial ( the septum or rubber stopper) with alcohol, immediately before withdrawal of the drug. • Both the syringe and needle must be kept sterile. When inside the sterile packaging, the syringe and needle are guaranteed by the manufacturer to be sterile. When the packaging of the syringe is opened, it should be opened from the end that will attach to the needle, and care should be taken not to touch either the syringe or the needle. The protective cap should be left on the needle at all times, unless the needle is being used to withdraw or inject the drug. Note that wearing latex gloves when working in the hood does not guarantee sterility, as they have been exposed to an unsterile environment. The following should be observed when withdrawing a drug for injection • The needle should be placed on the septum, beveled side up, and should pierce the septum at a 45-degree angle, going into the vial. This prevents fragments of the rubber septum from entering the needle and thus the medication (this is known as coring) • When the medication is withdrawn the needle should be at 90 degrees, and care should be taken to avoid touching the plunger with the fingers as it leaves the barrel of the syringe. Any organisms deposited on the plunger from contact with your skin will go directly into the patient when the medication is injected. • Once the medication is withdrawn into the syringe, the protective cap should immediately be placed onto the needle before removal form the hood. This prevents accidental contamination. If the medication is being sent to the nursing floor, the needle should be removed and replaced with a protective plastic or rubber cap. The label should be placed over the plunger end of the syringe barrel as soon as possible to minimize the possibility of dispensing errors. The sterile laminar flow hood is a piece of equipment that surrounds the workspace and forms a barrier between the user/ surroundings and the workspace. It electronically draws filtered room air across the space form the back of the hood to the front (“horizontal flow”) or pushes it from the top of the hood down over the workspace and out the bottom or front of the hood (“vertical flow”). This creates a barrier from the workspace to the ceiling of the hood to keep organisms in the air away from the work space. Passing air currents can still force organisms into the hood, however, so it should be located away from traffic in the pharmacy. In the same way, the technician shoul |
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Working With Hazardous Drugs |
Additional safety measure must be taken if the drug is hazardous. Many injectable drugs, such as cancer chemotherapeutics and steroid drugs, can be harmful to the person handling them. So, in addition to keeping the drug sterile, as described above, the technician must wear protective clothing. |
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Protective Clothing |
Protective clothing includes clothing that completely covers the body: No shorts, short sleeved shirts, or skirts should be worn. In addition, a long protective coat (sterile gown) should be worn to protect the clothing and skin, and safety glasses or goggles may be worn to protect the eyes. The safety glasses should have splash guards on the sides, because when a drug is diluted within a vial the pressure within the vial may build up, causing the drug to splash out if the vial is opened. Vented needles or venting pins may be used to prevent drug splash. |
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Additional Safeguards |
These coverings are for the protection of the technician, not the drug; they do not help to keep the drug sterile. If the drug is hazardous, the technician may also wear additional disposable body coverings such as a hat, head covering or wig, mask, gloves, and shoe covers. This not only helps to prevent accidental spillage of the drug from touching the skin, but also helps prevent contaminating the other parts of the pharmacy with the drug. The coverings can be removed at the door of the IV room and discarded. |
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Accidental Drug Exposure |
Touching the face, eyes, or mouth while preparing a drug product is not only a source of contamination, it may also be hazardous to the health of the technician. Rubbing the eye or mouth can lead to the introduction of comparatively large amounts of drug into the body. When working with a sterile drug, particularly one that is hazardous, care should be taken to keep hands at least six inches inside the hood, away from other parts of the body. Whether the drug is hazardous or not, touching the face or rubbing the eye is a source of contamination. This becomes even worse with a hazardous drug, as any contact with the face, particularly the mucous membranes of the eye and mouth, can introduce concentrated drug into the body in doses much larger than the patient would ever get. This can be extremely toxic. Caution should be observed if the technician is allergic to the drug being prepared. It is best if the task id given to someone who is not allergic to the drug. Touching the face, eyes, or mouth while preparing a drug product is not only a source of contamination, it may also be hazardous to the health of the technician. Rubbing the eye or mouth can lead to larger amounts of the drug being introduced into the body. |
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Intravenous Admixtures and injections |
Various sites may be used for drug injection, and each type of injection must be prepared in a different way. The major routes of parenteral administration are intravenous (IV), intramuscular (IM), and subcutaneous (SC), although intradermal, intrathecal, epidural, intracardiac, and intra-arterial injections are also seen. |
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Intravenous Injections |
Intravenous injections may be of small or large volume, as they go directly into the blood. The largevolume injectables are the intravenous drips (IV Drips). These are large plastic bags or glass bottles of solution, which may be used alone (for a dehydrated patient, for example) or with an admixture. |
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Intramuscular Injections |
Intramuscular injections are designed to be released slowly from the muscle into the blood. This lessens the physiological shock to the body, caused by rapid administration of a drug, and may also increase the length of the drug’s effects. Intramuscular injections have a limited volume (less than 3 mL), as there is not much room within the muscle for the drug to go. They require a large needle (19-21 gauge), as the muscle is tough and hard to inject. |
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Subcutaneous Injections |
Subcutaneous injections are also designed for slow release of drug into the system. Since the space under the skin is limited, these injections are also limited in volume (1 mL or less). |
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Intravenous Admixture |
An IV admixture is a drug that is added to a large-volume parenteral. This is done so that the drug is released slowly into the blood and is less of a shock to the body than a large “all at once” dose ( a bolus injection). Admixtures are don in two ways (eg. D5W or normal saline), or administered using a separate very small IV bag (a piggyback IV) that is designed to release the drug slowly into the tubing with the IV drip. If the drug is mixed in directly with the bulk solution, the resulting drug solution must be labeled appropriately with the name of the solution, the name of the drug, the amount of drug added, and the patient designation. Intravenous admixtures may be mixed directly into a bulk solution or administered using separate “piggy back” IV feeding into the IV line. |
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Proper Labeling of Bulk Intravenous Solutions |
When a sterile product, such as an IV bag or admixture, is labeled, the label should be placed toward the top of the container. This is so that any contamination present in the solution, which will tend to sink to the bottom of the container can easily be seen. The contaminated product can then be discarded before it is administered to the patient. |
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Proper labeling of a Bolus injection |
Labels on a syringe should be as narrow as possible and should be placed at the top of the syringe, crosswise, so as not to cover the markings on the syringe. |
