The Medication Pathway

Prescribing – Doctors
Prescribing is associated with around half
of all avoidable medication errors.

Dispensing – Pharmacist
Dispensing errors account for over 10%
of all avoidable medication errors.

Administering – Nurse
Administration of medicine is
associated with about 1/3 of all
avoidable medication errors.

The Medication Pathway

DOCTOR - PRESCRIBING WHAT CAN GO WRONG?
The Medication Pathway
• Lack of awareness of best practice recommendations
PHARMACIST - DISPENSING WHAT CAN GO WRONG?
Step 1
Make an accurate • Failure to alter drug therapy in the face of altered Failure to understand doctors prescription
diagnosis physiology such as renal or liver impairment Step 6
(especially if handwritten)
Review prescription
• Disregard for a patient’s history of allergy to the same
Step 2 Fails to ask if medication record is complete
Decide on medication medication class
versus other treatment • Prescription of the wrong drug name, wrong dose form or Fails to check prescription against allergy history,
abbreviation existing drugs, possible interactions, etc
Step 3
• Incorrect dosage or frequency calculations Step 7
Choose drug based on Dispenses wrong drug
Prepare and dispense
efficacy, safety, • Illegible writing
convenience, cost Wrong patient
• Inadequate monitoring or follow-up
Step 4
Consider suitability of • Discontinuity of pre-hospital and post-hospital Wrong instructions
choice and dose of medications
individual patient Step 8 Poor communication with the patient &/or other
• Transcription duplications and omissions in complex Deliver medication/s members of the health team
hospital medication charts
Step 5 • Poor communication with the patient &/or other
Write prescription members of the health team
The Medication Pathway
NURSE - ADMINISTRATION WHAT CAN GO WRONG?

Step 9 Wrong patient

Prepare to administer
medication to patient
Wrong drug

Wrong dose (problem with calculations)

Step 10
Administered to patient Wrong route of administration

Wrong time
Step 11
Administration not documented; given
Recorded to patient twice
chart
Poor patient communication

Step 12 Inadequate monitoring or follow-up

Monitor patient
response

1. Prescription  It is a set of specific directions issued by a medical

practitioner to a pharmacist for the appropriate use
of medications in a particular patient.
2. Inpatient Medication Order
 It serves as the framework for the processes
involved in pharmaceutical care running through,
and facilitating, all areas of clinical and dispensing
operations for medications.

 It connects the pharmacist with prescribers, other

healthcare professionals, and, most importantly,
the patient.
 Medical Practitioners who can issue  Used in hospitals and other institutions.
prescriptions:
◦ Physicians  Written by the physician on forms called the
◦ Veterinarians “Physician Order Sheet” or are entered directly
◦ Dentists
into the institution’s computer system.
◦ Nurse Practitioners
◦ Physician Assistants
◦ Pharmacists  The orders are sent directly to the pharmacy
serving that institution to be screened,
processed and dispensed.

1. Prescriber Information 1. Prescriber’s name

2. Patient Information 2. Address
3. Date 3. Telephone number
4. Superscription 4. Name of the institutional affiliation or
5. Inscription office.
6. Subscription 5. PRC License number
7. Signatura 6. S-2 license no.
8. Refill number 7. Prescriber’s signature
9. Prescriber’s signature
1. Full name  Prescriptions are dated
2. Address at the time they were
3. Date of birth written and also when
4. Allergy information they are received and
filled in the pharmacy.
5. Age
6. Weight or BSA
 This is important in
establishing the
treatment history for
the patient.

 A.k.a. the Rx symbol which is the contraction  States the medication/s prescribed.
of the Latin verb recipe.
 It is the body or principal part of the
 This means ‘take thou or you take.’ prescription that contains:
◦ Names
 It serves as the beginning of the direct order ◦ Dose per unit
◦ Quantities of the prescribed medications or
of the prescriber to the pharmacist to fill the
ingredients.
order and dispense the prescription.
 For compounded prescriptions, they contain
the names and quantities of each ingredient
as part of the inscription.
 Dosages or quantities
for commercially  Dispensing direction to pharmacist.
available products or listed ingredients for
compounded prescription may be expressed  For commercially manufactured products,
as a concentration or unit of measure using subscription serves merely to designate the
the metric or Apothecary system of weights dosage form, and the number of dosage units
and measure. to be dispensed.

 Problems concerning inscription:

◦ Use of Tailing Zeros
◦ Failure to use leading zeros.

 Directions for Patient or Transcription.  Problematic abbreviations in the Signa:

◦ Abbreviation of drug names.
 Directions are frequently abbreviated and are ◦ Abbreviation of administration routes.
◦ Abbreviation of administration frequency.
interpreted by the pharmacist and then
conveyed verbally to the patient.
 Pharmacists are crucial part of the solution to eliminating the
use of these error-prone abbreviations through editorial
 It is then transcribed, using layman’s terms, intervention and provider education

onto the prescription label for patient’s

continued reference.

 To emphasize the scientific basis for the use
of drugs, in order that health professionals
may become more aware and cognizant of
their therapeutic effectiveness.
 To promote drug safety by minimizing
duplication in medications and/or use of
drugs with potentially adverse drug
interactions.
 “An act to promote, require, and ensure the
production of an adequate supply,
distribution, use, and acceptance of drugs
and medicines identified by their generic
names.”
 To promote, encourage and require the use
of generic terminology in the importation,
manufacture, distribution, marketing,
advertising and promotion, prescription and
dispensing of drugs.
 All government health agencies and their personnel as well as
other government agencies shall use generic terminology or
generic names in all transactions related to purchasing,
prescribing, dispensing and administering of drugs and
medicines.
 All medical, dental and veterinary practitioners, including
private practitioners, shall write prescriptions using the
generic name. The brand name may be included if so desired.
 Drug outlets, including drugstores, hospital and non-hospital
pharmacies and non-traditional outlets such as supermarkets
and stores, shall inform any buyer about any and all other
drug products having the same generic name, together with
their corresponding prices so that the buyer may adequately
exercise, his option.
  Only validly‐registered medical, dental and
veterinary practitioners, whether in private
practice or employed in a private institution/
corporation or in the government, are
authorized to prescribe drugs.

 In accordance with R.A. 5921, or the

Pharmacy Act as amended, all prescriptions
must contain the following information: name
of prescriber, office address, professional
registration number, professional tax receipt
number, patient's/ client's name, age and
sex, and date of prescription.

 For drugs in List A (Annex I) containing the  Generic names shall be used in all
list of Prohibited Drugs and Regulated Drugs prescriptions.
as approved by the Dangerous Drugs Board
(DDB), the following are required:  The generic name must be written in full.

◦ The prescriber must have an S‐2 license.

 The salt or chemical form may be
abbreviated.
◦ The special DDB prescription form must be used.

◦ A recording system following pertinent DDB  The generic name of the drug must be clearly
regulations must be observed. written on the prescription immediately after
the Rx symbol, or on the order chart.

 A brand name may also be indicated. In such
cases, the following shall be observed:
◦ If written on a prescription pad:
 Brand name is enclosed in parenthesis.
 Brand name is written below the generic name.
◦ If written on a patient's chart,
 Brand name is enclosed in parenthesis
 Brand name is written after the generic name.
1. Violative Prescription
◦ The generic name is not written.
◦ The generic name is not legible and a brand
name that is legible is written.
◦ The brand name is indicated and
instructions (such as the phrase “NO
SUBSTITUTION”) that tend to obstruct,
hinder, or prevent generic dispensing.
 In prescribing drugs enumerated in List B which
needs strict precaution in their use, the prescriber
must comply with the following:
◦ After the Rx symbol but before the generic name, he must
write clearly "(List B)".
◦ He must ensure that the following information are
accurately written on the prescription:
 The generic name of the active ingredient(s) and the specific
salt or chemical form.
 The manufacturer
 The brand name, if so desired
 The strength or dose level using units of the metric system.
 The delivery mode or delivery system: quick‐dissolve, sustained
release, etc. and the corresponding appropriate dose frequency
or dose interval.
2. Erroneous Prescription
◦ The brand name precedes the generic
name.
◦ The generic name is the one in the
parenthesis.
◦ The brand name is not in the parenthesis.
3. Impossible Prescription  Violative and Impossible Prescriptions

◦ Only the generic name is written but is not
legible.
◦ The generic name does not correspond to
the brand name.
◦ Both generic name and the brand name are
not legible.
◦ The drug product is not registered in FDA
 Shall not be filled.
 Shall be kept & reported by the pharmacist
to the nearest DOH office.
 Pharmacist shall advise the prescriber
about the problem.
 Instruct the customer to get proper Rx.

 Erroneous Prescriptions

 Shall be filled.

 Shall be kept & reported by the

pharmacist to the nearest DOH office.
 list of drugs prepared and periodically updated by 1.
the Department of Health on a basis of health
conditions obtaining in the Philippines as well as
on internationally accepted criteria. It shall consist
of a core list and a complementary list.
◦ Core list- is a list of drugs that meets the care needs of the
majority of the population
2.
◦ Complementary list- is a list of alternative drugs used when
there is no response to the core essential drug or when
there is a hypersensitivity reaction to the core essential
drug or when, for one reason or another, the core essential
drug cannot be given.
Prescription or ethical drugs
◦ Dispensed only upon written order or validly‐
registered licensed physician, dentist or
veterinarian.
◦ Used for the management or treatment of a
condition or disease.
Non‐prescription or over‐the‐counter drugs
◦ Dispensed even without the prescription.
◦ Used by the consumers for the prevention or
symptomatic relief of minor or self‐limiting
ailments.

Include:
3. Dangerous drugs  “opium & its active components & derivatives:
- heroin & morphine

◦ Either prohibited drugs or regulated drugs.  coca leaf & its derivatives
- cocaine alpha & beta Eucaine
◦ Require a special prescription form, the use of  hallucinogenic drugs – mescaline,
which is monitored by the Dangerous Drug Board. lysergic acid diethylamide (LSD) &other substances
producing similar effects

 Indian hemp & its derivatives

 All preparations made from any of the foregoing

 Other drugs, natural or synthetic, with the physiological

effects of a narcotic drug
Include:
 Sleep-inducing sedatives
- secobarbital, phenobarbital, barbital,
amobarbital

 Other drugs containing a salt or derivative of a salt

of barbituric acid

 Any salt, isomer or salt of an isomer of

amphetamine
- benzedrine or dexedrine
- any drug which produces a pharmacologic action
similar to amphetamine

 Hypnotic drugs
- methaqualone or any other compound
producing similar pharmacologic effects.

 All prescriptions dispensed in the drugstores,  All drug outlets are required to practice
botica or hospital pharmacy shall be: generic dispensing.

◦ kept in file for two years
◦ recorded in a prescription book duly‐registered by
BFAD (open for inspection by Food and Drug
Inspectors at any time during business hours of the
outlet.)
◦ The prescription book shall be kept for two years
after the last entry.
 Drug Stores, Boticas, and Other Drug Outlets:
◦ shall inform the patient/buyer of all available drug
products generically equivalent to the one
prescribed with their corresponding prices.
◦ shall post in a conspicuous place in their
establishment a list of drug products using generic
names with their brand names, if any, and their
corresponding current prices
 Hospital Pharmacies  For drug products in unit dose or products
which are not in their original containers the
◦ Those operating on the acceptable formulary pharmacist shall place legibly on the required
system and pricing policy and using generic drug outlet's label the following information:
terminology in procurement, prescribing,
dispensing, and recording of drugs, shall be
1. Name of the patient
exempted from the following:
2. Generic name of the drug
 Recording of prescriptions filled in the prescription 3. Brand name, if any
book, provided such prescriptions shall be kept in file 4. Manufacturer
for two years.
5. Dosage strength
 Individually informing the patient/buyer on the 6. Expiry date
available generic equivalents and their corresponding 7. Directions for use; and
prices. 8. Name of pharmacist

 In partial filling of the prescription, the following  Dispensing Drugs in List A and List B
shall be written on the face of the prescription:
◦ Dispensing must be done by the pharmacist who
1. The date of partial filling. shall affix his/her signature on the prescription
2. The quantity served and balance of the filled.
prescription unserved;
3. Name and address of the drugstore ◦ The order and instruction of the doctor as written
on the prescription, must be precisely followed.
The partially‐filled prescription shall be returned to the buyer
after recording the partial filling in the prescription book. ◦ Partial filling of prescription for drugs belonging to
The drugstore which completes the filling of the List A shall not be allowed.
prescription shall keep the prescription in file.
1. Imposing a particular brand or product on the buyer. Suspension, or revocation of the LTO of the
2. Inaccurate dispensing. drug outlet by the Secretary of Health.
3. Failure to post or make accessible the required up-to-date
information on drug product. Professionals directly involved in the
4. Failure to adequately inform buyer on available product that violation shall be recommended by the
meet the Rx. Secretary for appropriate administrative
5. Failure to indicate the generic name/ official name sanctions by the PRC.
designated by the BFAD & other required information on the
drug outlet’s label of the dispensing drug.

6. Failure to record and keep Rx filled

7. Failure to report to the nearest DOH office incorrect Rx

within 3 months after receipt of such Rx.

PHARMACIST
 Shall maintain and keep an original record of sales, purchases,
acquisitions and deliveries of dangerous drugs, indicating the
following information:

1. License no. & address of pharmacist.

2. Name, address & license of the manufacturer, importer or
wholesale.
3. Quantity and name of the dangerous drugs purchase or
acquired.
4. Date of acquisition or purchase.
5. Name, address & community tax certificate number of the
buyer.
6. Serial number of the Rx & name of the practitioner.
7. Quantity & name of the dangerous drugs sold or delivered.
8. Date of sale or delivery.
 A certified true copy of such record
covering a period of six (6) months, duly
signed by the pharmacist or the owner of
the drugstore, pharmacy or chemical
establishment, shall be forwarded to the
Board within fifteen (15) days following the
last day of June and December of each year,
with a copy thereof furnished the city or
municipal health officer concerned.
 A physician, dentist, veterinarian or
practitioner authorized to prescribe any
dangerous drug shall issue the prescription in
one (1) original and two (2) duplicate copies.
 The original, after the prescription has been
filled, shall be retained by the pharmacist for
a period of one (1) year.
 One (1) copy shall be retained by the buyer.

 The second copy shall be retained by the

person issuing the prescription.

 All prescriptions issued by the medical

practitioners shall be written on forms
exclusively issued by and obtainable from
the DOH.

 Such forms shall be made of a special kind

of paper.

 Such forms shall only be issued by the DOH

through its authorized employees to
licensed physicians, dentists, veterinarians
and practitioners.
 The prescribing physician, dentist, Allen Jr, L.V. (Ed). Remington: The Science and
veterinarian or practitioner shall, within Practice of Pharmacy 22nd ed. London:
three (3) days after issuing such Pharmaceutical Press, 2013.
prescription, inform the DOH of the same in
writing. R.A. 6675: Generics Act of 1988

DOH A.O. 62 s. 1989

 No prescription once served by the DOH A.O. 63 s. 1989
drugstore or pharmacy be reused nor any
prescription once issued be refilled. R.A. 9165: Comprehensive Dangerous drugs Act
of 2002