GOOD DISPENSING PRACTICES

            The aim of this module is to lay down guidelines for pharmacists to adopt good dispensing practices for a pharmacy.

Objectives To understand the importance of good dispensing practices To understand various components and steps in good dispensing practices To understand common dispensing errors with their consequences To understand how good dispensing practices help in establishing a professional relationship with patients To understand how to maintain Antiretroviral Drug Dispensing Register

Dispensing is a critical part of drug use and is often neglected in training. Patients always benefit from better dispensing. It is vital element in Rational Use of Medicines. Dispensing refers to the process of preparing and giving out medicines to a named person on the basis of a prescription. Dispensing looks to be a simple process and often delegated to anyone, which is irrational and dangerous. Dispensing should be done by a skilled, trained and knowledgeable person. He should have the knowledge about common use, dose, precautions and method of use, side effects besides storage need. It involves the correct interpretation of the wishes of the prescriber and the accurate preparation and labeling of the medicine for use by the patient as advised. A dispenser is usually a pharmacist and should have adequate knowledge to understand and impart medicine and product information; good calculations, arithmetic, communication and counseling including promotional skills and attitude towards patient welfare besides proficiency in store and supply management. Components of good dispensing are dispensing environment comprising of staff, physical surrounding, shelving and storage, surface used during work, equipment and packing materials. The work place should be clean with tidy surroundings, enough place, good condition for storage, a secure area which can be locked, enough lights, protection from too much heat and light, adequate refrigeration facilities with basic reference books and materials. Aim of dispensing is to ensure that the right patient receives the appropriate medicine in the correct dose and correct dosage form. As per the Standard Operating Procedures (SOP) issued by the NACO for the Pharmacists at ART centres, the General guidance while dispensing medicines are:

1.      Dispense drugs as per prescriber’s instructions

2.      Read your medicines containers before and after dispensing

3.      Do not dispense medicines if you doubt prescription

4.      Give proper instructions to patients

5.      Do not dispense medicines from unlabelled containers

6.      The Pharmacist should train one staff nurse on dispensing practices and stock maintenance issues as a backup in case pharmacist is on leave / sick etc.

7.      The Pharmacist should assist Data manager in filling the drugs component of Monthly ART Reporting Format.

8.      The Pharmacist must do the pill count, counsel patients on issues like adherence to drugs and possible side effects of ART drugs.  He should also ensure patient pickups condoms along with drugs while going out from centre.

9.      He should also inform that PLHA has to come back to centre for some major side effects.

The steps in dispensing cycle are receiving and confirming prescription, interpretation and verification (patient, medicines and dose), preparing and labelling, recording and endorsing and supplying medicines with counselling. Major areas of activity are;

1. Receiving Prescription,

2. Interpreting Prescription,

3. Communicate with the prescriber for dubious or unclear instructions, if any

4. Retrieving Medications/Ingredients,

5. Preparing and Processing,

6.  Communicating with Patient,

7. Assuring Patient's Understanding,

8. Monitoring Compliance by Patient, and

9. Keeping Records.

Correct interpretations of the prescription or instructions require checking the name of the drug, checking the dosages, administration, duration and decipher abbreviation, and re-checking drugs and dosages. While filling of prescription always match the labels with the prescription, select the appropriate containers or envelopes, read the label on the drug bottle when selecting the drug, ensure that the drug to be dispensed will not expire within the period of treatment and count out the correct number of the capsules or tablets. Every time check of the container label before taking container from the shelf, check of the container label against the prescription during actual dispensing and check of the container label before putting the container away. On issuing of medicines ask the patient to give his/her name and check his/her name with that on the prescription and check medicines labeling details against the prescription, i. e. correct patient’s name, medicine name, dose, route and frequency. The principle of seven rights, viz. right patient, right drug, right dose, right route, right frequency, right container, and right date shall always constitute the core of the dispensing.   

Newly enrolled patients are usually dispensed ARV medicines for a fortnight to observe/monitor tolerance and once the tolerance is established, medicines are dispensed on monthly basis. On every subsequent visit ARV medicines are dispensed in pre-packed bottles containing doses for 30 days. In order to asses adherence to treatment schedule, it is expected from the pharmacists to check left over pills by pill counting and to ensure how many days treatment is still available with the patient. Accordingly patient should be given the next date of visit in such a way that after additions of 30 days medicines, the patient reports on the date when 4 doses are expected to be still left with the patient. He should not be told to report when 4 doses are left, but should be given the exact date when 4 doses are expected to be left with him. Labeling is simple understandable guidance to patient on appropriate use of medicines and it improves compliance. The bottles supplied by the NACO are already labeled, so there is no need to re-label. However, the pharmacist must explain the relevant instructions, especially if the patient is illiterate or unable to understand directions stated on the label.  

While imparting instructions to the patient, the pharmacist shall give the correct and clear instructions, special instructions, cautions, such as warnings signs, and what to do if certain things happen. He should also ask patient if he is taking any other medicines, so as to avoid possible interactions, not to share their medicines with anybody else and keep the medicines in good conditions. It is better to ensure that patient understands the instructions and therefore, pharmacist should repeat orally the labeled instructions and patient should repeat the instructions back to the pharmacist. Always emphasize the need for compliance. Special Instructions/attention to pregnant woman, those with visual or hearing impairment, illiterates, children and elderly patients and those taking multiple medications shall be given to ensure that the patient complies with the instructions for therapy.  

Treatment Adherence Calculation for Individual Patient by Pill counts

            Apart from counseller, the pharmacists are also required to help in assessing the “Treatment Adherence Calculation” for individual patient by Pill counts. The simplest method to assess adherence percentage is by pill counts. Fractions generated by the following formula when multiplied with 100 would give “Adherence %”.

A = (Number of tablets/ doses actually taken by a patient for a particular time period) ÷   (Number of tablets/ doses the patient should have taken during this same time period)

A = (Number of tablets remaining with the patient during the previous refill/ visit + Number of tablets given to the patient during the previous refill/ visit – Number of tablets remaining with the patient during the present refill/ visit) ÷  (Number of  days between the previous refill/ visit and the present actual visit  ×  Number of doses per day).

This fraction “A”, when multiplied by 100, gives the adherence percentage.

Drug Dispensing Register

This register must be maintained by the pharmacist/drug dispenser in the ART centre. The    purpose of this register is two-fold:

1.      To document and account for every tablet of each drug by obtaining the patient’s signature against the number of tablets given

2.      To calculate the daily consumption of each drug

·           Maintain a separate page for each day. In other words, for a new day, start on a fresh page.

·           After writing the serial number and name of patient, write under corresponding columns, the number of tablets dispensed. (For example, if the patient was given Virolis 30mg and Nevirapine for 1 month, then enter 60 under Virolis 30mg and 60 under Nevirapine. Leave the other cells blank. Ask the patient to sign, or put a thumb impression, if patient is illiterate)

·           At the end of the day, add up the number of tablets for each drug. This represents the daily consumption of each drug. Use this information to compete the drug stock register.

Antiretroviral Drug Dispensing Register

(Maintain a separate page for each day)

Date: ______/______/______

SI No.

Patient Name

Number of Tablets Dispensed

Remarks

Patient Signature

d4T30/3TC/NEV

d4T40/3TC/NEV

ZDV/3TC

d4T30/3TC

d4T40/3TC

Nevipan

Efavirenz

Syrups (specify)

Others: specify

Others: specify

Total tablets Dispensed

Signature of the pharmacist/drug dispenser: ____________________________________

Dispensing Errors:

Error of commission (dispensing the wrong drug or dose) and error of omission (failure to counsel on safe use of medicine) leads to medication errors. Medication errors associated with dispensing can result from misreading prescription leading to dispensing of a wrong drug, retrieval of the wrong drug from stock, a correct drug in wrong strength, dosage form or quantity and dispensing to one patient the drugs intended for another patient.  The well being of the patient is the most important, and mistakes must be immediately acknowledged. If you have dispensed wrong medicine or wrong quantity, call the patient back, apologize and dispense the right drug and right quantity. All incidents must be recorded and reported to the doctor. Usual common causes of mistakes to the reported extent are lack of concentration (90%), similarity in the drug name (51%), inexperience/lack of knowledge (16%), misreading medication order (8%) and wrong assumption (5%).

Promoting Efficient Management in Dispensing:

Overcrowded pharmacies need a good management. Pre-package and label for commonly used medicines can be beneficial in many ways such as, safer, easier and faster distribution can facilitate more time for communication with patient that leads to increased adherence to treatment. It is easier and facilitate more accurate recording of inventory. It improves credibility among users. Techniques to ensure quality in dispensing are maintenance of records, maintenance of daily list of drugs in stock, two prescription system and efficient staff scheduling.

Key Learning Points         •         Dispensing is often neglected in training •         Dispensing is an important activity where pharmacists come in direct contact with the patient •         Interventions exist to improve dispensing •         ENSURE good dispensing procedures at all times •         DISPENSE ACCURATELY •         AVOID dispensing errors •         Patients benefit from better dispensing

Activity 1 : Prepare a list of barriers, noises and distractions in your ART centre dispensing area which affect good dispensing practices and work out possible remedies to overcome these problems.