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The Medication Pathway

Prescribing – Doctors  fails to check prescription against allergy


 associated with around ½ of all avoidable history, existing drugs, possible interactions,
medication errors etc
Dispensing – Pharmacist  dispenses wrong drug
 >10% of all avoidable  wrong patient
Administering – Nurse  wrong instructions
 1/3 of all medication errors  poor communication with the patient &/or
Doctor – Prescribing other members of the health team
1. Make accurate diagnosis Nurse – Administration
2. Decide on medication versus other 9. prepare to administer medication to
treatment patient
3. Choose drug based on efficacy, safety, 10. administered to patient
convenience, cost 11. recorded to patient chart
4. Consider suitability of choice and dose of 12. monitor patient response
individual patient What can go wrong?
5. Write prescription  Wrong patient
What can go wrong?  Wrong drug
 lack of awareness of best practice  Wrong dose (problems with calculations)
recommendations  Wrong route of administration
 failure to alter drug therapy in the face of  Wrong time
altered physiology such as renal/liver  Administration not documented; given twice
impairment  Poor patient communication
 disregard for a patient’s history of allergy to  Inadequate monitoring or follow up
the same medication class The Prescription
 prescription of the wrong drug name, wrong 2 Types of Medication Order:
dose form or abbreviation 1. Prescription
 incorrect dosage or frequency calculations 2. Inpatient Medication Order
 illegible writing Prescription
 inadequate monitoring or follow-up  set of specific directions issued by a medical
 discontinuity of pre-hospital and post-hospital practitioner to a pharmacist for appropriate
medications use of medications in a particular patient
 transcription duplications and omissions in  serves as framework for process involved in
complex hospital medication charts pharmaceutical care running through and
 poor communication with the patient &/or facilitating, all areas of clinical and dispensing
other members of the health team operations
Pharmacist - dispensing  connects the pharmacist with prescribers,
6. review prescription other healthcare professionals, and patient
7. prepare and dispense  Medical Practitioners who can issue
8. deliver medication/s prescriptions:
What can go wrong?  Physicians
 failure to understand doctors prescription  Veterinarians
(especially if handwritten)  Dentists
 fails to ask if medication record is complete  Nurse practitioners
 Physician assistants
 Pharmacists  states the medication/s prescribed
Inpatient medication orders  it is the body or principal part of the
 used in hospitals/other institutions prescription that contains:
 written by physician on forms called Physician  names
Order Sheets/entered directly into the  dose per unit
institution’s computer system  quantities of the prescribed
 orders are sent directly to pharmacy serving medications or ingredients
institution  for compounded prescriptions, they contain
Parts of the Prescription the names and quantities of each ingredient as
1. Prescriber Information part of the inscription
2. Patient Information  dosages or quantities for commercially
3. Date available products or listed ingredients for
4. Superscription compounded prescription may be expressed as
5. Inscription a concentration or unit of measure using the
6. Subscription metric or apothecary system of weights and
7. Signatura measure
8. Refill number  problems concerning inscription:
9. Prescriber’s signature  use of tailing zeros
Prescriber’s Information and Signature  failure to use leading zeros
1. prescriber’s name Subscription
2. address  dispensing direction to pharmacist
3. telephone number  for commercially manufactured products,
4. name of the institutional affiliation/office subscription serves merely to designate the
5. PRC License number dosage form and number of dosage unit to be
6. S-2 license no. dispensed
7. Prescriber’s signature Signatura
Patient Information  directions for patient/transcription
1. Full name
 directions are frequently abbreviated and are
2. Address
interpreted by the pharmacist and conveyed
3. Date of birth
verbally to the patient
4. Allergy information
 it is then transcribed, using layman’s terms,
5. Age
onto the prescription label for patient’s
6. Weight/BSA
continued reference
Date
 problematic abbreviations in the Signa:
 Rx’s are dated at the time when they were
 abbreviation of drug names
written and also when they are received and
 abbreviation of administration
filed in the pharmacy
routes
 Important in establishing the treatment history
 abbreviation of administration
for the patient
frequency
Superscription
 Pharmacists are crucial part of the
 Rx symbol which is the contraction of the Latin
solution to eliminating use of these
verb recipe
error-prone abbreviations through
 Take thou/you take
editorial intervention and provider
 Serves as beginning of the direct order of the
education
prescriber to the pharmacist to fill the order &
dispense the prescription
Inscription
Legal Provisions Affecting Dispensing Practice in the
Philippines

GENERICS ACT OF 1988 A.O. 62. s. 1989: “Rules and


 “Act to promote, require, and ensure the
production of an adequate supply, distribution,
Regulations to Implement
use, and acceptance of drugs and medicines Prescribing Requirements”
identified by their generic names” Guidelines on Prescribing
 To promote, encourage, and require the use of  Validly-registered, medical, dental, and
generic terminology in the importation, veterinary practitioners, are authorized to
manufacture, distribution, marketing, prescribe drugs
advertising and promotion, prescription and  R.A. 5921 (Pharmacy Act): all Rx must contain:
dispensing of drugs  Name of prescriber
 To emphasize the scientific basis for the use of  Office address
drugs, in order that health professionals may  Professional registration
become more aware and cognizant of their  Professional tax receipt number
therapeutic effectiveness  Patient’s/client’s name, age and sex,
 To promote drug safety by minimizing and date of Rx
duplication in medications and/or use of drugs  List A (Annex I): Prohibited and Regulated
with potentially adverse drug interactions. Drugs
Who shall use Generic Terminology?
 Prescriber must have S-2 license
 all government health agencies & their
 Special DDB form must be used
personnel as well as other government
 Recording system following
agencies in transactions related to:
pertinent DDB regulation must be
 purchasing
observed
 prescribing
 GN shall be used in all prescriptions
 dispensing
 GN must be written in full
 administering of drug sand
 Salt/chemical form may be abbreviated
medicines
 GN must be clearly written on the prescription
 all medical , dental and veterinary
after Rx symbol on order chart
practitioners, including private practitioners
 BN may be indicated
 drug outlets, including drugstores hospital and
 If on Rx pad:
non-hospital pharmacies and non-traditional
i. Enclosed in parenthesis
outlets (supermarkets, stores) shall informa
ii. Below GN
any buyer about any and all other drug
 If on patient’s chart:
products having the same generic name,
i. Enclosed in parenthesis
together with their corresponding prices so
ii. After the GN
that the buyer may adequately exercise his
 List B: strict precaution in use
option
 After Rx symbol, before GN, write
(List B)
 Written on Rx:
i. GN, specific salt/chemical
form
ii. Manufacturer
iii. BN
iv. Strength/dose level using  Only GN is written, not legible
units of metric system  GN does not correspond to BN
v. Delivery mode/system  GN and BN are written but not
(quick-dissolve, SR), legible
corresponding appropriate  Drug product is not registered in
dose frequency/interval FDA
Types of Incorrect Guidelines on what to do with incorrect Rx
 Violative & Impossible Rx
Prescription o Shall not be filled
1. Violative Rx o Shall be kept & reported to nearest
 GN not written DOH office
 GN not legible o Pharmacist shall advise the
 BN is indicated, NO SUBSTITION is prescriber about problem
written  Erroneous Rx
2. Erroneous Rx o Shall be filled
 BN precedes GN o Shall be kept & reported to nearest
 GN is in parenthesis DOH
 BN is NOT in parenthesis
3. Impossible Rx
Types of Medicaitons Prescribed and or Dispensed in the
Philippines

 sleep-inducing sedatives
Essential Drugs list/NDF o Secobarbital, Phenobarbital,
 list of drugs prepared and updated by DOG on Barbital, Amobarbital
a basis of health conditions
 Other drugs containing salt/derivative of a salt
 Core list – drugs that meet the care needs of of barbituric acid
majority of population
 Any salt, isomer, or salt of an isomer of
 Complementary list – list of alternative drugs Amphetamine
used when there is no response to core o Benzedrine or Dexedrine
essential drug when there is a hypersensitivity o Any drug which produces a
reaction to the core essential drug or when for pharmacologic action similar to
one reason or another, the core essential drug Amphetamine
cannot be given
 Hypnotic drugs
o Methaqualone or any other
compound producing similar
Classification of Drugs pharmacologic effects
1. Rx/ethical drugs
 Dispensed only upon written order/validly-
registered licensed physician, dentist, or Prohibited Drugs
veterinarian Include:
 Used for management/Tx of a  opium, active components, derivatives:
condition/disease o Heroin & Morphine
2. Non-Rx/OTC drugs  Cocoa leaf, derivatives
 Dispensed even without Rx o Cocaine alpha & beta, Eucaine
 Used by consumers for the  Hallucinogenic drugs
prevention/symptomatic relief of minor or self- o Mescaline, Lysergic Acid
limiting ailments Diethylamide (LSD), other subs.
3. Dangerous drugs producing similar effects
 Either prohibited/regulated drugs  Indian hemp, derivatives
 Special Rx form, use is monitored by DDB  All preparations made from AOTA
 Other drugs (natural/synthetic) with
physiological effects of a narcotic drug

Regulated drugs
Include:
A.O. 63 s. 1989: “Rules and Regulations to Implement Dispensing
Requirements”
o BN
Guidelines on dispensing o Manufacturer
 All Rx dispensed in the drugstores, botica or o Dosage strength
hospital pharmacy shall be o Expiry date
o Kept in file for two years o Directions for use
o Recorded in an Rx book duly- o Name of pharmacist
registered by FDA (open for  In partial filling of Rx, ff. shall be written on the
inspection by FDA inspectors at any face of the Rx:
time during business hours of the o Date of partial filling
outlet) o Quantity served + balance of Rx
o Rx book shall be kept for 2 years unserved
after last entry o Name and address of drugstore
 All drug outlets are required to practice generic  The partially-filled Rx shall be returned to the
dispensing buyer after recording the partial filling in the Rx
 Drug stores, boticas, other drug outlets: book. Drugstore which completes the filling of
o Shall inform Pt/buyer of all available the Rx shall keep the Rx in file.
drug products generically equivalent  Dispensing Drugs in List A and B
to the one prescribed with their o Dispensing must be done by the
corresponding prices pharmacist who shall affix signature
o Shall post in a conspicuous place in on the Rx filled
their establishment a list of drug o Order & instruction of doctor as
products using generic names with written on Rx must be precisely
their brand names, if any, and followed
corresponding prices o Partial filling for List A drugs shall
 Hospital pharmacies not be allowed
o Those operating on the acceptable
formulary system and pricing policy Violations on the Part of the
and using generic terminology in
procurement, prescribing,
Dispenser and Outlet
1. Imposing a particular brand or product on the
dispensing, and recording of drugs
buyer.
shall be exempted from the
2. Inaccurate dispensing.
following:
3. Failure to post or make accessible the required
 Recording of Rx filled in the
up-to-date information on drug product
Rx book, provided such Rx
4. Failure to adequately inform buyer on available
shall be kept in file for 2
product that meets the Rx.
years
5. Failure to indicate the GN/official name
 Individually informing the
designated by FDA & other required information
Pt/buyer on the available
on the drug outlet’s label of the dispensing drug.
generic equivalents and their
6. Failure to record and keep Rx filled.
corresponding prices
7. Failure to report to the nearest DOH office
 For drug products in unit dose or products
incorrect Rx within 3 months after receipt of such
which are not in their original containers the
Rx.
pharmacist shall write legibly on the required
drug outlet’s label the ff.:
o Name of Pt Penalties for Violating A.O.63
o GN of drug
 suspension or revocation of the LTO of the appropriate administrative sanctions by the
drug outlet by the Secretary of Health PRC
 professionals directly involved in the violation
shall be recommended by the Secretary for
R.A. 9165: “The Comprehensive Dangerous Drugs Act of 2002”
 DDB
 PDEA
Records Required for
 Drug resistant & eventually free Philippines Transactions on Dangerous
 2015: 2.3% (1.8M) of population uses
dangerous drugs
Drugs and Precursors and
o 10-69 years old Essential Chemicals
Common drugs of abuse Pharmacist
 Cannabis sativa – Marijuana  shall maintain and keep an original record of
 Methamphetamine HCl sales, purchases, acquisitions, and deliveries of
 Cocaine dangerous drugs, indicating:
National Anti-Drug Program of Action (2014) o License # & address of pharmacist.
Pillars of the Program o Name, address & license of
 Drug Supply Reduction manufacturer, importer, or
 Drug Demand Reduction wholesale.
 Civic Awareness and Response o Quantity and name of the
 Alternative Development dangerous drugs purchase or
 Regional and International Cooperation acquired.
Licenses (Dangerous Drugs) o Date of acquisition or purchase.
 S-1 Retail Distributor or Dispenser (P500) o Name, address, & community tax
 S-2 Prescriber (P500 – P1500 for 3 years) certificate number of the buyer
 S-3 Retail Distributor or Dispenser (P1000) o Serial # of the Rx & name of the
 S-4 Wholesale Distributor (P1000) practitioner
 S-5-I Importer (P3000) o Quantity & name of the dangerous
 S-5-C Manufacturer (P5000) drugs sold/delivered
 S-5-E Exporter (P5000) o Date of sale/delivery
 S-4-D Bulk Depot/Storage (P5000) o Certified true copy of such record
Licenses (Controlled Precursors and Essential covering a period of 6 months, duly
Chemicals) signed by the pharmacist or the
 P-1 Retail Distributor or Dispenser (P500) owner of the drugstore, pharmacy,
 P-3 End User (P2500) or chemical establishment, shall be
 P-4 Wholesaler Distributor (P3000)
forwarded to the Board within 15
 P-5-I Importer (P5000)
days following the last day of June
 P-5-C Manufacturer (P5000)
and December of each year, with a
 P-5-E Exporter (P5000)
copy thereof furnished the city or
 P-5-D Bulk Depot/Storage (P5000)
 P-5-IM Importer/End User (P5000)
municipal health officer concerned
 P-6 Research/Analysis/Instructional Program (P500) o Physician, dentist, veterinarian, or
What to do with Expired Dangerous Drugs practitioner authorized to prescribe
 Surrender to supplier any dangerous drug shall issue 1
original and 2 duplicates
 Surrender to PDEA laboratory
o Original shall be retained by
Dangerous Drugs Pathway in Hospital
pharmacist for 1 year
 Floor stocks
o 1 copy shall be retained by buyer
o Requisition form
o Second copy shall be retained by
 Controlled Drugs Administration Sheet
person issuing the prescription
o Wastage: signed by pharmacist and
o All Rx issued by the medical
nurse as witness
practitioners shall be written on
forms exclusively issued by and
obtainable from the DOH
o Such forms shall be made of a
special kind of paper
o Such forms shall only be issued by
the DOH through its authorized
employees to licensed physicians,
dentists, veterinarians, and
practitioners
o Prescriber shall inform DOH of Rx
within 3 days
o No Rx shall be reused nor refilled

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