Frequently Asked Questions

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1 Frequently Asked Questions What are the requirements for license renewal? Licenses Expire Contact Hours Required A technician registration must be renewed yearly on 12/31. 5 How do I complete this course and receive my certificate of completion? Online Fax Mail Go to and follow the prompts. Print your certificate immediately. (386) Be sure to include your credit card information. Your certificate will be ed to you. Use the envelope provided or mail to Elite, PO Box 37, Ormond Beach, FL Your certificate will be ed to you. How much will it cost? Cost of Courses Course Title CE Hours Price Critical Measurement Tools for the Competent Pharmacy Technician 2 $10.00 A Dose of Professionalism for the Pharmacy Technician 3 $12.00 BEST VALUE SAVE $ Entire 5-hour Course 5 $20.00 Are you a Virginia board approved provider? State boards rule/statutes state that any course approved by the Accreditation Council for Pharmaceutical Education (ACPE) is accepted. All of our courses are accredited by ACPE. Will you report my hours? Yes. We report your hours electronically to CPE Monitor within 2 business days. You will find more information on CPE Monitor on the inside back cover. Is my information secure? Yes! Our website is secured by Thawte, we use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at you will see our robust FAQ section that answers many of your questions, simply click FAQ in the upper right hand corner or us at office@elitecme.com or call us toll free at , Monday - Friday 9:00 am - 6:00 pm, EST. Important information for licensees: Always check your states board website to determine the number of hours required for renewal, and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Virginia Board of Pharmacy Contact Information Perimeter Center 9960 Mayland Drive, Suite 300 Henrico, VA Phone: (804) Fax: (804) Website: Page i

2 Table of Contents CE for Virginia Pharmacy Professionals CHAPTER 1: CRITICAL MEASUREMENT TOOLS FOR THE COMPETENT PHARMACY TECHNICIAN Page 1 When you have concluded this knowledge-based activity you will be able to, summarize the many advantages of using the metric system as the mainline approach to conducting pharmacy measurements and express the importance of the International System and how it works to consolidate a number of different concepts into a comprehensive, scientific measuring system. Critical Measurement Tools for the Competent Pharmacy Technician Final Exam Page 7 CHAPTER 2: A DOSE OF PROFESSIONALISM FOR THE PHARMACY TECHNICIAN Page 8 After completing this continuing education program you will be able to describe how to report medication errors and prevention strategies used to prevent errors and describe the technician s role in customer satisfaction surveys and internal audits of processes. All 5 Hrs ONLY $ What if I Still Have Questions? No problem, we have several options for you to choose from! Online at PharmacyTech. EliteCME.com you will see our robust FAQ section that answers many of your questions, simply click FAQ in the upper right hand corner or us at office@ elitecme.com or call us toll free at , Monday - Friday 9:00 am - 6:00 pm, EST. A Dose of Professionalism for the Pharmacy Technician Final Exam Page 19 Visit PharmacyTech.EliteCME. com to view our entire course library and get your CE today! PLUS... Lowest Price Guaranteed A+ Rating from BBB Serving Professionals Since 1999 Elite Continuing Education All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Elite Professional Education, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials. Page ii

3 Chapter 1: Critical Measurement Tools for the Competent Pharmacy Technician 2 Contact Hours By Bradley Gillespie, PharmD, who has practiced in an industrial setting for the past 20+ years. Currently, he has special interests in rare diseases and developing continuing education programs for health care professionals. Author Disclosure: Bradley Gillespie and Elite Professional Education, LLC do not have any actual or potential conflicts of interest in relation to this lesson. Universal Activity Number (UAN): H04-T Activity Type: Knowledge-based Initial Release Date: June 1, 2015 Expiration Date: June 1, 2017 Target Audience: Pharmacy Technicians in a community-based setting. To Obtain Credit: A minimum test score of 70 percent is needed to obtain a credit. Please submit your answers either by mail, fax, or online at. Learning objectives After the pharmacy technician has concluded this knowledge-based activity, he or she will be able to: Examine the historical significance of the apothecary and avoirdupois methods of measure, and critique the pros and cons of using these methods in contemporary pharmacy practice. Summarize the many advantages of using the metric system as the mainline approach to conducting pharmacy measurements. Introduction The metric system may be the most commonly observed system of measurement encountered by the pharmacy technician, and thus, should be thoroughly understood and appreciated. Even so, the apothecary, avoirdupois and household measurement systems also appear in contemporary practice. As a result, pharmacy technicians also must understand these approaches and be able to readily make conversions. In addition to these systems of measurement, it is also critical that pharmacy technicians have a thorough understanding of SI units, Weighing instruments Before the development of mass-manufactured dosage forms, perhaps the most critical of instruments in an apothecary shop was an accurate instrument for measuring medicines. The historical problem, though, was that across the world, leaders could rarely agree on a universal standard of measurement. However, in 1497, England resolved that the tory weight would be the official unit of mass to be used by both spice merchants and apothecaries. By the advent of the 18th century, traditional standard iron and lead weights were replaced with brass. Even when the avoirdupois system came into vogue in 1855, the majority of apothecaries stuck with their tory weights. The earliest scales were made by suspending two pans on opposite ends of a beam. These devices were known as equal-arm scales. The medicinal substance would be poured into one pan, and it could be balanced by the placement of known counterweights in the other. Questions regarding statements of credit and other customer service issues should be directed to This lesson is $ Educational Review Systems is accredited by the Accreditation Council of Pharmacy Education (ACPE) as a provider of continuing pharmaceutical education. This program is approved for 2 hours (0.2 CEUs) of continuing pharmacy education credit. Proof of participation will be posted to your NABP CPE profile within 4 to 6 weeks to participants who have successfully completed the post-test. Participants must participate in the entire presentation and complete the course evaluation to receive continuing pharmacy education credit. Recognize the simplicity with which metric units can be easily manipulated and interconverted, owing to their simple decimal notation. Express the importance of the International System, and how it works to consolidate a number of different concepts into a comprehensive, scientific measuring system. milliequivalents, millimoles and temperature as each relates to pharmacy practice. Each of the common measuring systems will be described as well as how they relate to the preferred pharmacy measurement approach: the metric system. To best understand the relatedness of the various measurement systems, a variety of examples will be provided to further illustrate the relationship between them and the metric system. When the pans were filled with equal weight, they would be even, with the beam parallel to the ground. The sum of the counterweights would then be equal to the weight of the measured medicine. The beam would be suspended by its center, sometimes held by hand or at other times hung from a solid object above. One variation was a pillar scale that was similar in appearance but featured a freestanding pillar or support in the middle. 1 Although the principles of weight measurement remain the same, the available technology has evolved over time. While modern pharmacies may use a variety of analytical balances, all pharmacies are required by law to have a Class A prescription balance in their facility. A Class A prescription balance is a double-pan, torsion-type balance that uses both internal weights for measurements up to 1 gram and external weights for measurements exceeding 1 gram. Page 1

4 The Class A balance is required to have a sensitivity of no less than 6 mg, with most balances having a maximum capacity of 120 grams. The Class A balance is required to be able to weigh 120 mg with an error of no greater than 5 percent. The National Bureau of Standards dictates that the Class A balance must have the following features: A metal identification plate indicating the serial number, model, sensitivity and capacity of the instrument. Liquid measurement When pharmacy technicians are measuring liquids, there are two main thoughts to keep in mind: First, they need to be mindful of their ability to accurately measure the components of a prescription preparation; and at the same time, should give serious consideration to how well the patient will be able to measure his or her own individual dose of medication. With that said, while the techniques used to measure liquids are likely the simplest measurements made in the pharmacy, they are, at the same time, the most susceptible to error, sometimes caused by selecting the wrong instrument and sometimes by an unprofessional technique. A few things should be kept in mind to ensure the highest-quality measurement of liquids: The apothecary system The apothecaries weight, evolved from an earlier Roman system, was used in Europe for measuring pharmaceutical ingredients as early as the year The measuring system was refined and modified based on direction from the British royal family. 4 The apothecary system arrived in the United States from England during the colonial period as a method for measuring, weighing drugs, and solutions of medications. The main units used in the apothecary system include the grain, scruple, dram, ounce and troy pound. In cases where less than a full unit were used, fractions were employed to describe the partial measure. For example one-fourth of a grain would be written as gr. ¼, while the fraction ½ is written as ss. One major drawback of the apothecary system is the ease with which at least two symbols can be easily confused, and thus they must always be written clearly: drams (ʒ) and ounces ( ). Lowercase Roman numerals are used after the symbols for these units of measure. For example, ʒiiss reads two and one-half drams while iv reads four ounces. 5 The base unit of the apothecary weight system is the grain. The relationship between the different units is described below: 20 grains = one scruple. 3 scruples = one dram. 8 drams = one ounce. 12 ounces = one troy pound. The conversion from apothecary weights to metric weight units is not so orderly: Interesting apothecary facts The grain. A grain weight found its origin as the weight of a dried grain of wheat (France); more specifically, in England, a dried grain of barleycorn. The troy pound. In medieval times, it was common for merchants to come to the people instead of the people coming to them. To accomplish this, merchants would travel the countryside, spending a day or more at regional fairs before returning home to restock their wares. Some cities were large enough to support great fairs, which drew merchants and traders from many countries. Removable pans of equal weight that are free of dirt and corrosion. A leveling device (usually leveling screws). A lid to protect the balance from dirt and draft that could interfere with its accuracy. A device to arrest the oscillation of the balance when adding or removing weights. A graduated beam with a readable dial capable of measuring up to 1 gram, in 0.01 gram increments, with a stop at the zero point. 2 It is critical to use precision volumetric glassware to measure exact quantities of liquids. The capacity is always inscribed on the vessel, as well as the inscription TD (to deliver) or TC (to contain). This distinction is critical because it signifies whether the labeled volume is the amount contained in the vessel (TC), or the amount of liquid delivered upon emptying the vessel (TD). Typically, pipettes, burettes, syringes and droppers are TD vessels, while volumetric flasks and graduated cylinders are TC. One last key thought to keep in mind is that Erlenmeyer flasks, beakers and prescription bottles, regardless of markings, are not volumetric glassware, and should never be relied upon for accurate measuring. 3 1 grain = 64.8 milligrams. 1 scruple = grams. 1 dram = 3.89 grams. 1 ounce = 31.1 grams. 1 pound = 373 grams. While these units are used to measure weights, the measure of liquids are similar, using liquid pints, fluid ounces, fluid drams and fluid scruples, with the units breaking down as follows: 1 liquid pint = 16 fluid ounces = 473 milliliters. 1 fluid ounce = 8 fluid drams = 29.6 milliliters. 1 fluid dram = 3 fluid scruples = 3.7 milliliters. 1 fluid scruple = 20 minim = 1.23 milliliters. 6 Because in the apothecary system, ingredient quantities are usually written using Roman instead of the more commonly known and understood Arabic numerals, it is critical that pharmacy technicians familiarize themselves with the following notations and their meanings: ss = ½. I or i = 1. V or v = 5. X or x = 10. L or l = 50. C or c = 100. D or d = 500. M or m = 1, One such city was a city in the Champagne region of France called Troye. It seems quite likely that the apothecary troy pound originated in this city, where a standard weight of coinage used for the measuring of metals, jewels and medicines was developed. In time, this approach was adopted throughout Europe and is still used in the jewelry trade. Scruples. The apothecary term of scruples likely conjures up images of moral principles. Nonetheless, this connection is not obvious and likely has made many people wonder about its origin. According to history, in medieval times, the apothecary apprentices were supposed to use weights to carefully measure out the correct amount Page 2

5 of medication for each prescription. But because the scruple was such a small amount (about the same as a one-quarter teaspoon of salt), an unwilling apprentice could instead just add a pinch of the ground substance in place of a measured scruple to a drug mixture instead going through the pain of carefully weighing out the required scruple of medicine. If the apothecary did not see the scruple weight laid out on the table, he might ask the apprentice, Have you no scruples? The avoirdupois system The avoirdupois (which is pronounced ave-waar-do-puwah) is a system of weights used regularly, for most purposes, in the United States. Although not an official weighing system, it also is used to some extent by people in The United Kingdom and Canada. This odd-sounding word stems from old French and loosely translates to the goods of weight. Like the apothecary system, the smallest weight is the grain, which also like in the apothecary system, is said to represent the weight of a grain of wheat. The next largest unit of weight is the dram, which is represented by grains. Neither of these two units is frequently encountered when using the avoirdupois approach to measurement. The next units are commonly used and are the ounce, which is composed of 16 drams, and the pound, which is made up of 16 ounces. When this is all combined, it can be calculated that in the avoirdupois system, a pound is equal to 7,000 grains. When this is contrasted to the apothecary system, where a pound is equal to 5,760 grains, it quickly becomes evident that a large medication error could occur if these two systems of weights were confused and somehow interchanged. This Household measurements Household measurements, often a mixture of other measuring approaches, are often used in homes, particularly in kitchens. Some common household volume measurement units include the teaspoon, tablespoon, cup, pint, quart and gallon. Weights are typically counted as ounces and pounds. As might be expected, these measuring approaches lack the precision and accuracy afforded by more standardized, scientific methods. Nonetheless, household measurements are common in pharmacy practice because patients lack familiarity with other approaches. In fact, prescription directions often use household measures, such as teaspoons. As such, pharmacy technicians must have a working knowledge of these methods and be able to interconvert. Common household measurements and their equivalents are listed below: 3 teaspoons = 1 tablespoon. 2 tablespoons = 1 fluid ounce. 8 fluid ounces = 1 cup. 2 cups = 1 pint. 2 pints = 1 quart. 4 quarts = 1 gallon. 16 ounces = 1 pound. The metric system Multiple systems of measurement were common in traditional pharmacy practice. In 1799, a new system was adopted in France, designed to avoid many of the problems inherent to traditional systems. This new method of measurement was called the metric system. The metric system quickly gained popularity and was adopted by a number of countries. Currently, only two countries in the world do not use the metric system as their official method of measurement. The United States is one of those two. As such, this phrase then became associated with carelessness or lack of concern for accuracy. Over time, it evolved to mean a lack of moral integrity or principles, so came the word unscrupulous. 8 Although the apothecary system has fallen from favor, pharmacy technicians must be intimately familiar with this ancient system of measurement and be able to make ready conversions to the metric system to properly dispense medications. potential problem led to the abolishment of the apothecary system in the U.S. in the 1970s. Although not legally mandated, it is rare that units less than 1 ounce from the avoirdupois system are used in contemporary pharmacy practice. Further, when we think of pounds, we typically follow the avoirdupois approach and consider it to contain 16 ounces. The avoirdupois system relates only to weights and does not contain units used for the measurement of liquids. The conversions from avoirdupois to metric are: 1 pound = grams. 1 ounce = grams. An interesting fact about the avoirdupois system of weights It might be puzzling to some why the standard English measurement system has a French name. The reason for this is simple: At the time this approach was adopted, the language spoken by the English court was French, and because this was an official weighing system governing legal commerce, it followed that French was appropriate. 9 Because of the inaccuracy of household measuring systems, it may make sense to convert household measurements to the metric system. This is especially important when entering information into a pharmacy computer system. Household/metric conversions are described below: 1 teaspoon = 5 milliliters. 1 tablespoon = 15 milliliters. 1 fluid ounce = 30 milliliters. 1 cup = 240 milliliters. 1 pint = 480 milliliters. 1 quart = 960 milliliters. 1 gallon = 3,840 milliliters. 1 ounce = 30 grams. 1 pound = 454 grams. 2.2 pounds = 1 kilogram. It is critical to note that the fluid ounce used in household measurement is the same fluid ounce used to measure volume in the apothecary system. Nonetheless, care should be taken when dealing with weights because there are 12 ounces in the apothecary pound and 16 ounces in a household pound. Typically, when people think of pounds, they are thinking of the 16-ounce household or avoirdupois pound. The metric system is composed of seven base units designed to describe various units of measurement. These base units and what they describe are: Meter (m) length. Kilogram (kg) mass (commonly used to describe weight). Kelvin (K) temperature. Second (s) Time. Ampere (A) electrical current. Candela (cd) luminous intensity. Mole (mol.) amount of a substance. Page 3

6 A number of metric units can be easily defined in terms of the meter or kilogram, and these are the most common units of measurement that will be encountered by the pharmacy technician. Multiples of metric units are all related by the power of 10, which allows a conversion between units by simply shifting the decimal point. For example, while a kilogram is equal to 1,000 grams, a gram is equal to one-thousandth of a kilogram, or kg. 11 A series of prefixes are used to describe numbers larger or smaller than the base unit. These prefixes are: Tera (T) trillion. Giga (G) billion. Mega (M) million Kilo (k) ,000. Hecto (h) Deka (da) Deci (d) 10-1 one-tenth. Centi (c) 10-2 one-hundredth. Milli (m) 10-3 one-thousandth. Micro (µ) 10-6 one-millionth. Nano (n) 10-9 one-billionth. Pico (p) one-trillionth. The British Pharmacopeia has pushed for the pharmaceutical and medical professions to exclusively use the metric system since In 1944, a British physician publicly advocated a shift to the use of the metric system in medicine and pharmacy. This concept was wellembraced, and subsequent to this, all articles published in the British Medical Journal made use of metric equivalents for measurements. In a 1953 article, Nixon and Whittet suggested that the mixture of measurement systems then in place could lead to cases of confusion and serious errors. As a result of this, they concluded that there is little excuse for practicing pharmacies to use traditional units of measurement. 13 When first steps were made to implement the use of the metric system, the main objection to its use was the fear of a misplaced decimal point, which could lead to a massive over- or under-dosage of medication. Proponents of the metric system countered that this could be avoided simply by using the proper prefixes, e.g., milli, kilo, and so on. 13 Much of current pharmacy practice in the U.S. is guided by the United States Pharmacopeia (USP). USP 33-NF 28 states that in general, weights and measures are expressed in the International System of Units (SI: the metric system). USP also states that prescriptions shall be written to state the quantity and/or strength desired, using metric units, unless another approach is specified in the product monograph. Even in cases where a non-metric amount is prescribed, a metric-equivalent of that amount should be dispensed. Metric units are the only designations that should be used on product labels and labeling. 14 From a practical perspective, there are a few guidelines to keep in mind when using the metric system for pharmacy measurements: In cases where less than a full unit is being described, it is critical to use a leading zero (0.5 milligrams, versus.5 milligrams). This helps to avoid overlooking the placement of the decimal point, which could lead to a ten-fold error (5 milligrams rather than the intended 0.5 milligrams). Conversely, trailing zeroes should also be avoided because 10.0 milliliters could easily be misinterpreted as 100 milliliters. Before any computations can be performed, all units must be converted to the same denomination. For example, to add 0.2 grams to 250 milligrams, the former quantity, 0.2 grams, should be converted to 200 milligrams. 15 International System of Units (abbreviated SI from the French Le Système International d Unités ) At the time of the French Revolution, the decimal-based metric system was created. Subsequent to that, platinum standards representing the meter and the kilogram were deposited on June 22, 1799, in the Archives de la République in Paris. This was recognized as the initial step in the development of what is now known as the international System of Units (SI). By 1832, Carl Friedrich Gauss, a German mathematician and physicist, began to strongly promote the application of SI units as a comprehensive and clear system of units and a set of prefixes to describe the physical sciences. Gauss was the first scientist to make absolute measurements of the earth s magnetic force in a decimal system based on three basic units: millimeter, gram and second, representing the quantities of length, mass and time, respectively. A kilogram had been defined as the mass of a cubic decimetre (one liter) of water. As described above, the international prototype of the kilogram was made of platinum and declared to be, from that time forward, the official unit of mass. It should be noted that although in common parlance, kilograms are used to refer to weight, in 1901, it was clarified that the kilogram is a unit of mass. (Mass measures the amount of a substance, while weight measures the gravitational pull of that substance). It is critical to have a unit of measure that can be used to specify the amounts present of chemical elements or compounds. In 1971, the term mole was defined as the amount of any substance that contains the same number of particles as there are atoms of carbon in kilograms (12 grams) of carbon. In the same declaration, it was determined that when the term mole is used, the particles being defined must be stated: atoms, molecules, ions, electrons or another sort of particle. Photograph of an international kilogram prototype made of platinum 17 The SI unit for temperature was adopted in 1990, and is kelvin (K), which, by definition, is the point in degrees Celsius when all atomic motion ceases. To put this number into perspective, note that the freezing point of water, 0 degrees Celsius, is K. The magnitude of degrees K and Celsius are identical. 20 Page 4

7 Milliequivalents and millimoles Millimoles: While the SI unit for quantities of a substance is mole, this is a very large amount of material (remember, equivalent to the number of atoms in a 12-gram sample of carbon), and not really relevant to the quantities of substances used in the pharmacy. As a result, the term millimole, which is 1/1,000 of a mole (0.001 mole) is a more reasonable descriptor. To describe the concentration of a substance in solution, the term millimolar (mm) is often used. A 1 mm solution is, by definition, a solution containing 1 millimole of a substance dissolved in a liter of liquid. Milliequivalents: While the millimole is used to describe the number of particles present in a sample, the situation can be complicated when electrolytes in solution require description. The actual chemical activity of an electrolyte solution is a feature of the type of electrolyte present. To make this determination, it is necessary to know the valence of the electrolyte. Temperature The U.S. Food and Drug Administration has issued a number of regulations, and several professional organizations have developed guidelines designed to ensure that temperature-controlled prescription drug products are properly maintained from the manufacturer to the wholesaler, to the pharmacy, to the patients. This is an ideal opportunity for pharmacy technicians to help ensure that temperature-sensitive drug products are properly maintained and subsequently dispensed to their patients. 21 While the details of temperature control may vary from jurisdiction to jurisdiction, all drug products have some guidelines for storage temperature, whether it is storage at ambient temperature, refrigerated or frozen. In addition to describing drug product storage conditions, critical patient data could also include their body temperature. Depending on the practice setting, pharmacy technicians may find themselves in a position of needing to interpret this information. Target temperature ranges may be stated in degrees Fahrenheit and also in degrees Celsius. As such, it is critical that the practicing pharmacy technician is familiar with both measurement approaches and is easily able to convert back and forth, as warranted by the situation. The following formula can be used to convert from degrees Fahrenheit to degrees Celsius: Degrees Celsius = 5/9 x (Degrees Fahrenheit - 32) To convert degrees Celsius to degrees Fahrenheit, the following formula can be used: Degrees Fahrenheit = Degrees Celsius x 5/ To use SI terminology (degrees kelvin K), simply add to the temperature in degrees Celsius: Degrees Kelvin = degrees Celsius NOTE: LOWERCASE kelvin. cm Practical examples 1. A prescription is written for ss gr of morphine sulphate powder sachets. As an astute pharmacy technician, you realize that while this is likely not the best way to describe a prescription, it can easily be converted to the metric system to be consistent with your pharmacy record-keeping system. To make this conversion, you know that ss denotes one-half, and a grain of morphine sulphate is the same as 64.8 milligrams, so ½ of a grain must be 32.4 milligrams of morphine sulphate: 1 grain 1/2 grain = = 32.4 milligrams 64.8 milligrams Some common electrolytes used in pharmacy practice and their valences are listed below: Sodium (Na+) 1 Potassium (K+) 1 Calcium (Ca++) 2 Magnesium (Mg++) 2 The valence of the electrolyte determines the ionic charge, and thus the relative activity of the molecule. For example, a millimolar solution of sodium (valence/ionic charge of 1), would have one-half the activity of a millimolar solution of magnesium (valence/ionic charge of 2). 2. You receive a prescription calling for the patient to receive i, per dose, of a cough suppressant. Although it is likely best to express this dosage using the metric system for your pharmacy s database, you are a practical pharmacy technician, and realize that the patient will be measuring the dosage at home. As such, patient directions using the household measuring system may be most appropriate. This will require a series of multiple conversions: 1 ounce = about 30 milliliters = 1 teaspoon = 6 teaspoons = ounce 5 milliliter 1 tablespoon = 2 tablespoons 3 teaspoons 3. One day while putting together the monthly order for compounding excipients, you come across a note from the pharmacist in charge requesting that you order a pound of magnesium sulphate for use in improving powder flow properties. Because the catalog you are using lists quantities using the metric system, you realize that you will need to convert the mass of magnesium sulphate to grams. You have just finished reviewing the apothecary as well as the avoirdupois systems of measurement though, and you are puzzled. Which system was the pharmacist thinking about when she made the order? Apothecary: 1 troy pound = 373 grams. Avoirdupois: 1 pound = grams. You write a note to the pharmacist to clarify her intentions. 4. The pharmacist on duty has asked you to help put together a traditional herbal remedy for the treatment of cirrhosis of the liver that requires one scruple of Bupleurus species (a traditional Chinese herb used to treat inflammatory diseases). The only instrument that you have to weigh the powder substance is a metric, Class A prescription balance. Sadly, you are not up to date on all of your apothecary/metric conversions. Fortunately, one of your pharmacy technician colleagues has just finished studying for her pharmacy technician certification exam, and tells you what you need to know to make the conversion: 1 scruple = grams. 5. A patient comes to the pharmacy counter and states that he has just returned from the doctor, who told him he should take a grain of aspirin per day to prevent cardiovascular incidents. Needless to say, the patient has no idea what a grain of aspirin is and does not know what to purchase. You know that a grain is almost 65 mg. Although you are not aware of a dosage form of aspirin that contains exactly that dose, you do know that an 81 mg dose of aspirin would be close to what the doctor ordered. Page 5

8 6. A patient presents a prescription for 100 milliliters of cough syrup. The product is stored in a 500 milliliter stock bottle, so you will need to procure an amber prescription bottle into which the prescribed amount of syrup can be measured. Looking through the supply cabinet, you encounter bottles labelled iv, iii and ii. You are puzzled by these notations, and have no idea which bottle to select. These symbols look familiar, but you are confused with a similar symbol. After you go back and look at your notes describing apothecary measurement symbols (and the use of them with Roman numerals), you realize that these bottles have a capacity of 4, 3 and 2 ounces, respectively. A quick conversion to the metric system: 1 fluid ounce = 29.6 milliliters tells you that if you use the iv bottle, it will hold nearly 120 ml, ample to contain all of the medication called for in the prescription. 7. When working through a stack of prescriptions, you encounter an order calling for ʒii of cholestyramine to be taken orally three times per day before meals. Although you have filled prescriptions for cholestyramine previously, you have never seen the dose described in this way. While the apothecary symbol looks familiar, you ask the pharmacist on duty for help confirming the prescription. She looks puzzled as well, but upon checking a reference book is able to determine the proper quantity. The symbol ʒ denotes drams using the apothecary method of measurement. The Roman numeral ii describes the fact that two drams should be dispensed. An apothecary/metric conversion table tells you that: 1 dram = 3.89 grams. With this knowledge, it is with confidence that you develop a prescription label directing the patient to take 8 grams of cholestyramine (2 scoops), three times daily, before meals (7.78 grams can be rounded to 8 grams for ease of measurement). 8. A mother has presented to you a prescription for amoxicillin suspension for her young child, who has an ear infection. The prescription is written to provide a two-teaspoon dose, twice daily for a total of 10 days. While you realize that it is likely good that the volume is stated in terms of teaspoons for the benefit of the mother measuring the dose, you will need to convert to the metric system for entering into the pharmacy computer system. Your keen knowledge of household measures makes this an easy task: 1 teaspoon = 5 milliliters, so 2 teaspoons = 10 milliliters. Since the medication will be taken twice daily, 20 milliliters per day will be required for 10 days, dictating a total quantity dispensed of 200 milliliters. 9. When reviewing a patient chart before dispensing a chemotherapeutic agent, you note that the patient has recorded an oral temperature of 99.0 degrees F. Pharmacy standard operating procedures require that before dispensing the medication, the pharmacy technician document the patient s temperature and confirm that it is less than 38 degrees C. A quick conversion, using the formula: Degrees Celsius = 5/9 x (Degrees Fahrenheit - 32) tells you that this patient has an oral temperature of 37.2 degrees C, which is an acceptable temperature for receiving his scheduled round of chemotherapy. You document this temperature and begin preparing the chemotherapy admixture. 10. An elderly patient comes to the pharmacy counter with a prescription for Colyte to be used in preparation for a colonoscopy. The directions on the label say to dissolve the entire contents of the container in 3.84 liters of drinking water. The patient is confused because he never learned about the metric system in school. You quickly respond that he needs to dissolve the contents of the medication in a gallon of water. You know this because of the simple relationship: 1 gallon = 3,840 milliliters = 3.84 liters. 11. One evening while working in the main hospital pharmacy, you receive a call from the pediatric unit stating that it needs a bag of unfractionated heparin prepared, designed to deliver 25 international units (IU)/kg/hour for an eight-hour period. The patient weighs 44 pounds. How many units of heparin should be injected into the IV bag? This question has two parts: a. 44 pounds must be converted to kilograms: 44 pounds = 1 kilogram = 20 kilograms 2.2 pounds b. The total IU to be injected = 25 IU x 20 kilograms x 8 hours = 4,000 IU 12. When reviewing clinical laboratory values in a liver disease patient, you note that the patient s most recent ALT level was recorded as 110 international units (IU)/liter. Although this is the SI units for this laboratory value, your pharmacy standard operating procedure requires that you record the lab value using IU/deciliter. This conversion is easy for you to make because you are fully aware that a deciliter is equal to 100 milliliter, or 0.1 liter, making this value equal to 11 IU/deciliter. 13. When processing prescriptions, you run across an order for.5 milligrams of clonazepam, to be taken orally, as needed for anxiety. Based on your knowledge of the use of decimal notation in preparing prescriptions, a warning alarm goes off in your head, prompting you to contact the prescriber to verify the strength of the medication being filled. The problem here is the lack of a leading zero in the prescription strength. When written as.5, rather than 0.5, it is not totally clear, and could be confused with a 5 mg dose. You were correct to verify the dosage with the prescriber. 14. In a patient being treated for hypomagnesemia, you are required to review the patient s serum magnesium levels before dispensing the medication. Upon observation, you see that the patient s most recent magnesium level was 2 meq/l. Out of curiosity, you decide that you would like to determine the milimolarity of magnesium in that patient. The first step is to determine that the valence of magnesium is 2. This means that for every millimole of magnesium, a total of 2 milliequivalents will be appreciated. Since the patient has a magnesium level of 2 meq/l, it can be ascertained that their serum s concentration of magnesium is 1 millimoles/liter, or 1 millimolar (mm). 15. Your pharmacy standard operating procedure states that the refrigerator must be constantly maintained in a temperature range of 5-10 degrees C. Here is the problem: The only properly calibrated thermometer in your pharmacy reads the temperature in degrees Fahrenheit. What can you do to remedy this problem? The easiest approach is to simply convert the acceptable temperature range to Fahrenheit using the formula: Degrees Fahrenheit - Degrees Celsius x 5/ Using this formula, you can determine that the acceptable temperature range is 34.8 degrees F degrees F, which can easily be monitored using the available thermometer. Page 6

9 References 1. Collector s Weekly (2013). Pharmacy antiques. Retrieved online 29 October 2013 at 2. University of North Carolina School of Pharmacy (2013). Class A prescription balance. Retrieved online 29 October 2013 at balancea.htm 3. University of North Carolina School of Pharmacy (2013). Liquid measurement. Retrieved online 29 October at liquid.htm 4. Royal Pharmaceutical Society of Great Britain (2013). Balances, weights and measures. Retrieved online 27 October 2013 at TechnologyCentre/balances-history.pdf 5. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition by Saunders, an imprint of Elsevier, Inc. 6. Pharmacy-Tech-Resources.com (2013). Apothecaries system of weights and measures for pharmacy technicians. Retrieved online 26 October 2013 at 7. University of North Carolina School of Pharmacy (2013). The Pharmaceutics and Compounding Laboratory: Accuracy in Measurements. Retrieved online 27 October 2013 at 8. Pharmacist.com (2013). Things you ll use every day: Measurement systems. Retrieved online 27 October 2013 at Calc2dCh01_bookSample.pdf 9. Georgia Pharmacy Technician (2011). Avoirdupois system. Retrieved online 27 October 2013 at EMCP.com (2013). Using household measure in pharmacy calculations. Retrieved online 27 October 2013 at The Metric System (2013). Retrieved online 26 October 2013 at wichita.edu/history/topics/metric.html 12. The University of North Carolina at Chapel Hill. How Many? A Dictionary of Units of Measurement. Retrieved online 26 October 2013 at prefixes.html 13. Nixon NCW, Whittet TD. The metric system in medicine and pharmacy. BMJ. 1953; 1: USP 33-NF 28 Reissue Section 9.10 Use of metric units. Retrieved online 26 October 2013 at NF28-ReissueGeneralNotices.pdf 15. Pharmaceutical calculations. Joel L. Zatz and Maria Glaucia Teixeira. Fourth Edition, John Wiley & Sons, Hoboken New Jersey 16. National Institute of Standards and Technology (2013). Brief history of the SI. Retrieved online 27 October 2013 at National Institute of Standards and Technology (2013). Unit of mass (kilogram). Retrieved online 27 October 2013 at New York University (2013). Mass versus weight. Retrieved online 29 October 2013 at National Institute of Standards and Technology (2013). Unit of amount of substance (mole). Retrieved online 27 October 2013 at National Institute of Standards and Technology (2013). Unit of thermodynamic temperature (kelvin). Retrieved online 27 October 2013 at Units/kelvin.html 21. Ziance R, Chandler C, Bishara RH. Integration of temperature-controlled requirements into pharmacy practice. J Am Pharm Assoc. 2009; 49:e61-e69 CRITICAL MEASUREMENT TOOLS FOR THE COMPETENT PHARMACY TECHNICIAN Final Examination Questions Choose the best answer for questions 1 through 5 and mark your answers on the Final Examination Sheet found on page 21 or complete your test online at 1. The most commonly observed system of measurement encountered by pharmacy technicians is. a. The avoirdupois system. b. The household measurement system. c. The metric system. d. The apothecary system. 2. Which of the following statements about a Class A prescription balance is FALSE? a. All pharmacies are required by law to have one in their facility. b. Its sensitivity must be no less than 6 mg. c. It must have a leveling device. d. Most have a maximum capacity of no less than 250 grams. 3. Which of the following statements about liquid measurements is TRUE? a. Erlenmeyer flasks are ideal for measuring liquid prescription volumes. b. They are likely the simplest measurements made in the pharmacy and are, at the same time, the most susceptible to error. c. The inscription TD means to to document. d. Measuring liquids is the most difficult measurement for pharmacy technicians. 4. Which of the following statements about household measurements is TRUE? a. Household measurements are the best way to document drug usage in most pharmacy computer systems. b. Household measuring systems are some of the most scientifically rigorous approaches available to pharmacy technicians. c. The most common household measurement unit is the kilogram. d. Household measurements are common in pharmacy practice because patients lack familiarity with other approaches. 5. When thinking about temperature and how it relates to pharmacy practice, which of the following is FALSE? a. Most drug products can be stored at whatever temperature is convenient. b. The U.S. Food and Drug Administration has issued a number of regulations designed to ensure that temperature-controlled prescription drug products are properly maintained. c. Target temperature ranges may be stated in degrees Fahrenheit and also in degrees Celsius. d. Temperature control standards may vary from jurisdiction to jurisdiction. RPTVA02CME15 Page 7

10 Chapter 2: A Dose of Professionalism for the Pharmacy Technician 3 Contact Hours By Katie Ingersoll, RPh, PharmD, and Staff Pharmacist for a national chain. Author Disclosure: Katie Ingersoll and Elite Professional Education, LLC do not have any actual or potential conflicts of interest in relation to this lesson. Universal Activity Number (UAN): H04-T Activity Type: Knowledge-based Initial Release Date: June 1, 2015 Expiration Date: June 1, 2017 Target Audience: Pharmacy Technicians in a community-based setting. To Obtain Credit: A minimum test score of 70 percent is needed to obtain a credit. Please submit your answers either by mail, fax, or online at. Questions regarding statements of credit and other customer service issues should be directed to This lesson is $ Educational Review Systems is accredited by the Accreditation Council of Pharmacy Education (ACPE) as a provider of continuing pharmaceutical education. This program is approved for 3 hours (0.3 CEUs) of continuing pharmacy education credit. Proof of participation will be posted to your NABP CPE profile within 4 to 6 weeks to participants who have successfully completed the post-test. Participants must participate in the entire presentation and complete the course evaluation to receive continuing pharmacy education credit. Learning objectives After completing this continuing education program, the pharmacy technician should be able to: List the demographic and insurance information necessary for a patient s profile as well as information necessary to complete a prescriber s profile. Discuss the Health Insurance Portability and Accountability Act (HIPAA), including protected health information, disclosures that may be made, and patient rights under HIPAA. Discuss medication error prevention, including common points of error and strategies used to prevent errors. Describe how to report medication errors and prevention strategies to reduce the occurrence of errors. Describe the technician s role in customer satisfaction surveys and internal audits of processes. Introduction The responsibilities of pharmacy technicians are continuously changing, but the professional status of the technician remains the same. Technicians are perfectly poised to encourage the safe and efficient delivery of medications to patients, and many professional standards and regulations exist to guide the technician in this regard. Applying the knowledge of these guidelines to daily practice will help Creating and maintaining patient profiles Each patient must have his or her own medication profile that contains demographic information, insurance information, and medication records. A complete patient profile ensures the pharmacist has all of Demographics Basic patient identifiers need to be collected for all new patients to allow the pharmacy to contact the patient if needed and ensure the correct patient is selected when filling future prescriptions. If a patient has never had a prescription filled at a particular pharmacy, the following information should be collected to complete the patient s profile: Full name. Date of birth. Gender. Address. Page 8 the technician remain in compliance with the law and serve patients in the safest and most effective manner possible. In addition, actively participating in quality assurance activities will help the technician assume a more integral role in the pharmacy team. Assuming a central role on the pharmacy team will allow the technician to grow both personally and professionally. the information necessary to accurately assess the appropriateness of medications used for treatment and minimize adverse events. Phone number. Allergies, to medications, foods, and any other pertinent stimuli. Chronic medical conditions. Other medications the person is taking. It is important for the pharmacy technician to obtain basic medical information about patients, including medical conditions, other medications they are taking, and allergies. Because certain medications can have adverse reactions or are contraindicated in specific disease states, it is important for pharmacy technicians to enter chronic medical conditions in patient profiles to ensure pharmacists have the

11 information they need to properly assess medication therapy. Some state boards of pharmacy have regulations requiring pharmacies to enter chronic disease states in patient profiles, so this information should be collected on each patient to ensure compliance with state laws, if applicable. Medications that patients obtain elsewhere and over-the-counter products the patient is taking should be entered into the patient s profile to ensure the pharmacist can appropriately check for drug interactions and contraindications. Allergy information is critical to ensuring a patient does not receive a drug that could potentially cause a life-threatening allergic reaction. Insurance information Collecting insurance information from patients will allow the pharmacy to bill their insurance for the services rendered. The patient should be asked for a prescription insurance card to obtain the information necessary to bill a claim to an insurance company. Pharmacies generally need the following information to bill prescription insurance for pharmacy services: BIN number identifies the company with whom the patient has insurance. Identification number identifies the patient within the insurance company. Group number identifies the patient s employer or group the insurance is purchased through. PCN number processor control number, identifies the processing necessary within the insurance company. Provider information Prescriber profiles need to be created and maintained for each prescriber who has written prescriptions filled at each pharmacy. Each prescriber s profile should include: The prescriber s first and last name. Office address of the prescriber, with a separate listing for each office if the person practices at multiple locations. Drug Enforcement Agency (DEA) number if the person ever prescribes controlled substances. Tech alert! Serious allergies to stimuli other than medications should be recorded as well. A few medications are processed in ways that can cause allergic reactions in patients with allergies to eggs, peanuts, shellfish, and other severe allergies, so this information should be recorded for the pharmacist to accurately assess medication therapy. All patient information must be collected in a manner that ensures the confidentiality of the information. Any information written down before entering it into the computer system should be destroyed in a way that maintains confidentiality of written information, such as shredding or incineration. All information collected orally should be spoken in soft tones to prevent others from hearing. Person code number indicating where the patient falls in order of people covered on the plan, such as cardholder, spouse, or child. If a patient does not bring an insurance card but has active coverage, either the patient or technician can collect the pharmacy billing information from the insurance company. Medicare Part D information can often be looked up through a government-run search engine. This requires the patient s Social Security number, which should be communicated and disposed of in a confidential manner. Pharmacy technicians should ensure the patient s prescription insurance information is collected appropriately before the patient leaves the pharmacy to ensure billing can be completed in a timely fashion. National provider identifier (NPI). State license number, if required by state law. Updates to prescriber profiles should occur as requested by the prescriber. Prescriber files may be closed without notification from the prescriber if it is discovered that the person has retired, had his or her license revoked, or otherwise stopped practicing medication. Laws governing patient information Federal laws have been created to respect the basic rights of all patients and to ensure health care professionals explain those rights to patients. These help ensure a patient s welfare is protected. HIPAA The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996, and has far-reaching effects for all health care professionals. There are many implications of this act, which is divided into two major sections: Title I: Health Care Access, Portability, and Renewability Increasing the portability and continuity of health insurance, such as when a patient changes or loses a job. Reducing health insurance fraud, waste, and abuse. Encouraging the use of health savings accounts. Title II: Administrative Simplification Ensuring the confidentiality of protected health information (PHI). Disclosing and using only the minimum amount of PHI necessary. Giving patients the right to see who has accessed their PHI. HIPAA established that health care workers are responsible for the protection of a patient s PHI, which is any patient information that identifies a patient, relates to a past, present or future health condition, and is created or used by a covered entity under HIPAA. Examples of PHI include: Name, address, and other demographic information. Date of birth. Social Security number. Payment history. Account, license, and record numbers. Prescription and medical history. address. Device identifiers, such as IP addresses. Genetic information. Covered entities under HIPAA include any person or group that provides health care to a patient, bills for health care services, or is paid for health care services. This includes pharmacists and pharmacy technicians as well as doctors, nurses, and other health care providers. Page 9

12 Protecting PHI in various communication formats HIPAA protects health information in any communication format. Written PHI must be handled and stored appropriately and guarded against potential unauthorized releases of information. Pharmacies should have a plan for dealing with written PHI to ensure that all PHI they receive or produce is guarded against potential unauthorized disclosures. All trash that has patient information on it should be disposed of in a confidential manner, by shredding or storing in an opaque bag until an outside HIPAA-compliant company can pick it up for shredding. Prescription vials containing patient information should have labels removed before disposal. Electronically transmitted health information must be communicated through HIPAA-compliant channels, and computerized patient information must be protected. This includes billing claims for prescriptions and prescriptions received through electronic transmission as well as computerized patient records and medication information. This information must be securely stored and protected from unauthorized access. Users of electronic medical record systems should be given individual usernames and passwords to access the computer system. Training requirements All pharmacy staff and any other facility employees who have access to PHI must receive formal training on HIPAA. Employees should Notice of privacy practices HIPAA requires patients to be provided with a written notice of a covered entity s privacy practices. The notice should include information about the privacy practices of the pharmacy or health care provider, including how they intend to use or disclose a patient s PHI and how they will protect this information. The patient should be given the privacy notice in person or by mail, and a copy of the privacy Minimum necessary PHI After verifying the identity of the person seeking to obtain PHI, disclosures must include only the minimum necessary amount of information on the patient. Minimizing the amount of PHI disclosed will decrease the amount of PHI available for potential unauthorized disclosures. Pharmacy technicians should apply this concept when discussing patient information with others and also when requesting PHI themselves from other health care providers. There are exceptions to the minimum necessary disclosure rule. When having a discussion with a patient, providers should not limit themselves to obtaining only the information necessary to treat PHI disclosures Protected health information may be disclosed to other health professionals who are involved in a patient s treatment as long as the health care professional has his or her own privacy policy that the patient has acknowledged. The minimum necessary rule does not apply to two providers exchanging PHI on the same patient, except if dealing with sensitive issues such as HIV status, psychotherapy, or substance abuse treatment. Disclosures may be made to relatives and caregivers within reason and at the discretion of the health care professional. There are limitations disclosures should remain applicable to the health condition being discussed, and should not be made if the patient explicitly requests PHI not be disclosed to relatives or caregivers. Disclosures made to parents of Page 10 Tech alert! Usernames and passwords for systems containing protected health information should never be given out to unauthorized users! People who do not have access to the computer system but require access to complete their job should set up their own access through the appropriate channels. Orally communicated PHI must be protected from potential disclosures as well, and therefore should be discussed at low volumes to prevent other people from hearing this information. Patients may request a more private area for discussion of PHI if they are uncomfortable having a discussion where others could potentially hear, and should be directed to a private area, such as a consultation room, away from earshot of other people. Pharmacy technicians should use discretion when discussing PHI with a patient s family member, friend, or other representative. Confidential patient information should not be discussed with anyone other than the patient, the patient s caregiver who has medical power of attorney over the patient, or the parent of a child less than 18 years of age. If a patient s spouse or other family member is representing the patient at the pharmacy, technicians should use caution when disclosing patient information, and only disclose the minimum necessary information if the patient s representative introduces it into the conversation. be made aware of the general principles of HIPAA as well as their employer s privacy practices. notice should be posted in an easy-to-view area of the pharmacy. Each patient should sign an acknowledgment on the first day of their treatment stating they have received the health care provider s notice of privacy practices, and signatures should be maintained for at least six years from the date of last service to the patient, depending on state law. one specific thing. Obtaining as much information as possible for the purpose of treatment is necessary to provide proper care. Other exceptions can be made to follow other laws or if PHI is used by the patient or an authorized representative. The minimum necessary rule also applies to the health care employees who have access to PHI. If it is not necessary for employees to use PHI to perform their jobs, they should not be given access, such as the cleaning staff in a hospital. Minimizing the number of people who have access to PHI will decrease the amount of PHI available for potential unauthorized disclosures. a minor should be made at the discretion of the pharmacist and according to state law. Tech alert! Disclosing health care information on minors to parents can be a sensitive subject, such as when a minor is taking birth control pills or emergency contraception. If you are unsure whether a disclosure should be made, consult the pharmacist. PHI can also be released to companies that work on behalf of the patient, such as insurance companies. This information may only be disclosed for treatment, payment, or normal health care operations, and the minimum necessary rule applies to these disclosures. Other disclosures can be made under certain circumstances, such as: Law enforcement reasons.

13 Drug Enforcement Administration (DEA) investigations. Board of Pharmacy investigations. Adverse event reporting. Workers Compensation. Certain public health reasons. Accidental disclosures HIPAA does have allowances for accidental disclosures of PHI, such as when another patient hears a pharmacist counseling someone else or a patient finds another patient s medication leaflet in the parking lot. If these disclosures could not be reasonably prevented, are a result of a permitted disclosure, and only include a limited amount of information, they are acceptable. De-identified PHI PHI that has been de-identified may be disclosed if it cannot be used to identify a patient. This requires the removal of all potentially identifying information, including a patient s name, demographics, ID and account numbers, and date of birth or death. Patient rights under HIPAA Patients have the following rights under HIPAA: The right to receive a list of all non-routine disclosures of their PHI within the past six years. The right to receive a copy of their medical records. Violations of HIPAA Periodic audits are conducted by the Department of Health and Human Services. Violations can result in fines and imprisonment, depending Other implications of HIPAA NPI numbers The enactment of HIPAA also initiated the use of national provider identifier (NPI) numbers for all health care professionals who use electronic communications and prescribe medication or vaccines to patients. After registration with the National Plan and Provider State Board of Pharmacy regulations Pharmacy technicians should make sure they are familiar with regulations enacted by their state s Board of Pharmacy that govern their practice of pharmacy. They may need to register for a pharmacy technician license if required by their state. If required, this license must be obtained after receiving adequate technician training, and the applicant may need to pass the Pharmacy Technician Certification Board (PTCB) exam to obtain licensure. If required, licensure must be obtained before beginning work as a pharmacy technician. A state s board of pharmacy regulations may be more stringent than federal laws, including HIPAA. For example, states have varying Use of a patient s health information outside of these permitted disclosures requires approval from the patient through a written and signed authorization letter stating the proposed use of disclosed information. Pharmacy technicians should always use caution to prevent these accidental disclosures by keeping their voice low when discussing patient information and storing and disposing of written patient information appropriately. De-identified patient information can be used for research purposes, public health purposes, case studies, or quality improvement. Those that use de-identified health information for research may need to sign a data use agreement that fulfills the requirements of HIPAA. The right to request changes to their medical records, such as an error on a prescription on their record. Pharmacy technicians should ensure requests pertaining to these rights are handled in a timely fashion to accommodate the patient s needs. on the severity of the disclosures and whether they were accidental or due to willful neglect. Enumeration System, providers are issued a unique 11-digit NPI number that will remain with them as long as they continue to practice medicine. Health care professionals are required by HIPAA to use their NPI number for all transactions involving PHI. standpoints on the confidentiality of a minor on the subject of contraception. If state laws are more restrictive than federal law, the state law should be followed, and technicians should make sure to familiarize themselves with pertinent state laws. Board of pharmacy regulations govern the length of time records need to be maintained. Each state has a different time frame for record storage, including patient profiles. Pharmacy technicians should consult their state board of pharmacy to determine how long patient profiles should be maintained. Participate in quality assurance activities Medication error prevention Michelle is a pharmacy technician at the local branch of a large chain retail pharmacy. Her store is undergoing a remodel, and there is construction going on throughout the store during her workday. In the early afternoon, she is trying to get a few more prescriptions typed for patients waiting in the store before she can finally go on her lunch break, when a customer looking for toilet paper interrupts her. Michelle directs her to the paper products aisle, and when she goes back to typing her prescriptions, she accidentally types a prescription for Mr. Smith for the incorrect strength of morphine. The product she selected is four times as strong as the one the doctor ordered. The pharmacist does not catch this mistake on the quality assurance check, and Mr. Smith receives the medication that he needs for pain associated with a recent back surgery. He takes the medication, and luckily, his wife was home when he took it because it resulted in severe respiratory depression that sent him back to the hospital. Page 11

14 What is considered an error? Errors are preventable occurrences that can lead to inappropriate use of a medication while the health care professional or patient is in control of the medication. They can be caused by systems and procedures related to prescribing and dispensing the medication within the health care system, and can also be associated with use by the patient. When do errors occur? Medication errors can occur in the pharmacy at any part of the prescription dispensing process. Common points of error include data entry, production/counting, pharmacist quality assurance check, and point of sale. Pharmacy technicians should be aware of potential Data entry Many types of medication errors can occur when entering prescriptions into the pharmacy s computer system. Data entry is the point where the pharmacy technician pulls up the patient s file or creates a new file for new patients, and types the prescription into the file. The patient s demographics should be entered to create the patient s file, including name, address, date of birth, and phone number. Any allergies, medical conditions, and insurance information should be added at this point as well, and confirmed with the patient at each visit. Missing or inaccurate information in the patient s file can increase the chance of an error occurring; missing demographics can result in confusion between multiple customers with similar names, and Difficult to read handwriting Pharmacy technicians should use caution when deciphering medication orders handwritten by prescribers. Since prescribers are often in a rush when writing out prescriptions, their handwriting can be difficult to decipher and occasionally illegible. Knowing the reason why a patient is taking a particular medication can help clarify questionable handwriting, and looking at a patient s medication history can also provide insight into what is being prescribed. Pharmacy technicians should never guess what they cannot decipher if the medication order is questionable because of poor handwriting, Verbal orders All orders received over the phone, whether a refill or new prescription, should be read back after it is recorded. This allows the pharmacy to verify that the prescription that was recorded matches the order the doctor prescribed. Reading back prescription information after the entire order is recorded to ensure it is transcribed correctly The five rights of data entry There are several ways that medication errors can occur during data entry. Errors are commonly related to five common points in the data entry process. The pharmacy technician should ensure that the right Right patient Ensuring the right patient is chosen when entering a prescription into the patient profile is the first step in correctly filling a prescription. Using two patient identifiers, such as name and date of birth, to verify a patient s identity will help ensure the right patient is chosen. If two patients have the same name and date of birth, their address or another identifier should be used to distinguish between the two. Medication errors are a common occurrence that can affect as many as 1.5 million American patients per year, according to the Institute of Medicine s error report, Preventing Medication Errors. This report brought to light the sheer number of medication errors that occur in the U.S. annually, and inspired many health care facilities to refocus on patient safety. 13 causes of error at all points in the dispensing process to prevent errors from occurring and maximize patient safety. Procedures for dispensing medications should be evaluated regularly to address potential causes of error. missing allergies and medical conditions can result in inappropriate medications being dispensed. Developing a checklist of information that should be obtained from the patient at each visit will help prevent errors from occurring because of missing information. Once the file has been created or found, the technician should read the entire prescription and assess it for completeness and accuracy before typing it into the patient s file. The prescription should then be typed into the computer system by following the pharmacy s designated data entry process for every prescription. Any automatic safety alerts that arise when entering data into the computer system should be addressed immediately and not bypassed. it should be clarified with the prescriber to prevent medication errors. Suggesting typewritten orders to prescribers who have handwriting issues is also appropriate. Tech alert! If technicians are unsure what a prescriber wrote on a prescription, they should never guess! Clarification of illegible handwriting should always be made with the pharmacist or prescriber to minimize the risk of error. is good practice and will help prevent medication errors with verbal orders. Because state laws on pharmacy technicians taking verbal orders vary, technicians should consult their state board of pharmacy to find out what prescription information they may take over the phone and what must be received by a pharmacist. patient, drug, dosage, route, and timing are entered into the computer system and printed on the patient s medication label to prevent medication errors from occurring. Common reasons for errors when selecting patient names include similar sounding names, similar spelling of names, and patients in the same family with the same names and different titles, such as Sr., Jr., or III. Pharmacy technicians should ensure they are familiar with these common reasons for errors and take the steps necessary to prevent them from occurring. Page 12

15 Right drug There are many factors that contribute to errors from the selection of incorrect medication. Pharmacy technicians should be aware of medications that look and sound alike, as well as high-alert medications and those that have multiple release formulations, such as extended and regular release tablets, to prevent medication errors from selecting the wrong drug. Look-alike and sound-alike medications The Institute for Safe Medication Practices (ISMP) maintains a list of easily confused medications, including look-alike and sound-alike medications. The medications on this list are commonly confused for one another, either because they look similar to one another or sound similar to each other when spoken. The ISMP also includes other pairs of medications on their list that do not necessarily look or sound alike but are easily confused for one another and have been associated with errors in the past. The medications on this list have been associated with errors that were reported to the ISMP through its National Medication Errors Reporting Program (ISMP MERP). Pharmacy technicians should familiarize themselves with the medications on this list that are commonly used in their pharmacy to understand when potential errors may occur and attempt to prevent errors. When medications are going through the approval process for sale in the U.S., the Food and Drug Administration (FDA) reviews the names of medications to assess for similarities among other available products. Drug names that are similar to another medication already on the market are rejected, but some do make it to the market and are changed after errors are reported. Reporting errors involving similar drug names to the FDA through its MedWatch system will help the FDA assess the risk of error and require the names to be changed or other safeguards put in place, if necessary. The FDA also collaborates with the ISMP to share error reports to obtain the most information possible on errors occurring in the U.S. Therefore, errors involving drug name similarities can be reported to the ISMP or FDA so the information can be used to develop programs to prevent future errors from occurring. Examples of look-alike and sound-alike medications include: Hydroxyzine and hydralazine. Leukeran and leucovorin. Mucinex and Mucomyst. Prilosec and Prozac. Retrovir and ritonavir. Zantac and Xanax. Tech alert! The ISMP s complete list of look-alike and soundalike medications can be found at confuseddrugnames.pdf. 9 As you can see, in a busy pharmacy setting, these medications can be easily confused for one another, especially when written in poor handwriting or spoken with an accent. The FDA has approved the use of tall man lettering on the labeling of some of these commonly confused medications to help distinguish between similar names. This type of labeling uses capital letters in the word to highlight the portion of the word that is different. For example, hydroxyzine and hydralazine are listed on stock bottles of these medications to help prevent confusion between the two products. Using tall man lettering to highlight differences between drug names has been shown to decrease the risk of confusion between similar drug names, decreasing error potential.10 A complete list of medications that have been FDA-approved to use tall man lettering as well as additional medications suggested by the ISMP can be found at High-alert medications Certain medications are associated with a greater risk of harm to patients if they are used incorrectly. These high-alert medications are associated with a higher risk of harmful side effects that can increase as the dosage of medication increases. This means that dosing errors with these medications are particularly dangerous errors involving dosing that is one decimal place off can be potentially fatal. Examples of high alert medications and the risks associated with them include: Opiates, such as oxycodone, fentanyl, and morphine, because of the risk of respiratory depression. Anticoagulants, such as warfarin and heparin, because of the risk of excessive bleeding. Insulin, because of the risk of hyper- or hypoglycemia. Chemotherapy medications, such as methotrexate and cisplatin, because of the risk of toxicity. These high alert medications may have special precautions in place to prevent errors associated with them, depending on the institution. These precautions may include separation of these medications from others in the pharmacy s stock or alerts that arise in the computer system when the pharmacist is checking the prescription of a high-alert medication for accuracy. Pharmacy technicians should familiarize themselves with the risks associated with high-alert medications and the precautions in place at their institution to prevent errors associated with these potentially dangerous drugs. Different formulations of the same medications Technicians should also be aware of varying forms of the same medications. Medications that are available in instant and extended release formulations are often confused for one another. Technicians should look for abbreviations after medication names for drugs with several formulations and ensure they are entered into the computer system properly. They should also look for any abbreviations that do not correlate with products on the marketplace. For example, a patient brings in a prescription for bupropion LA. There is no LA formulation of bupropion, but there is a regular release as well as sustained release (SR) and extended release (XL) versions. Checking the formulation the patient was on previously can help to decipher any discrepancies, and if the pharmacist cannot discern the correct formulation, the doctor should be called for verification. Other formulation errors that commonly occur involve differing concentrations of the same medications. An example of a medication with various concentrations is heparin. Heparin is commonly available in 1,000 units/ml, 5,000 units/ml, and 10,000 units/ml. Heparin is also a high-alert medication because it is an anticoagulant and can increase the risk of bleeding if given in doses higher than necessary and increase the risk of blood clots if given in doses lower than necessary. Using the incorrect concentration of heparin has the potential to result in fatal consequences, especially when used in children and infants. Pharmacists and pharmacy technicians should check the concentration of heparin several times before filling a medication order or refilling an automated dispensing machine. There are many other medications with several concentrations available, including: Morphine. Lorazepam. Amoxicillin suspension. Epinephrine. Insulin. Page 13

16 Pharmacy technicians can help pharmacists and the pharmacy team prevent medication errors by being aware of the different Right dose Being diligent about calculating and selecting the correct dosage of medication in the data entry process is critical to ensuring the correct dosage is dispensed to the patient. Dosages are often incorrectly interpreted when excessive zeros are used, and pharmacy technicians should be aware of this common error to make sure they do not interpret zeros incorrectly, potentially resulting in a significantly higher or lower dose. Trailing zeros should not be used after a decimal point. For example, a common dosage of warfarin is 1 mg.; it should never be written as 1.0 mg. because it is easy to miss the decimal and confuse it for 10 mg. This could result in a potentially fatal error with this high-alert medication. Being aware of common dosages of medications can help the pharmacy technician prevent these errors, because, for example, it is less common to see a prescription written for 10 mg. tablets of warfarin than it is to see a prescription for 1 mg. tablets. Leading zeros should always be used before a decimal point. For example, haloperidol that is dosed at 0.5 mg. should never be written as.5 mg, as it can easily be confused for 5 mg., another dosage that is available for haloperidol. This would result in a 10-fold increase in dose that could be harmful to a patient. Pharmacy technicians should become familiar with common dosages of medications and think about what is available when they are entering medications into the computer system. Any questions should be clarified with the pharmacist or prescriber before entering Right time and route Ensuring the correct directions are entered into the computer system from a prescription will help the patient take the medication at the right time and through the correct route of administration. Pharmacy technicians should take the time to read the directions on the prescription before typing them into the computer system to make Abbreviations 6 Incorrect use of abbreviations is a major contributing factor to errors in the timing and route of administration. The Joint Commission (JCAHO) issues an official Do Not Use list of abbreviations that are commonly associated with medication errors, and hospitals are required to have their own Do Not Use list with these abbreviations included on their list. Abbreviations on the Do Not Use list should never be used, and prescribers who use these abbreviations should be contacted to prevent the further use of these error-prone shortcuts. This list includes the following abbreviations that should not be used: U for unit The word unit should be written out to avoid mistaking it for a zero or part of another word. IU for international unit The words international unit should be written out to avoid confusing this abbreviation for IV or the number 10. QD for daily and QOD for every other day These abbreviations should always be written out as daily or every other day to avoid confusion between the two terms as well as to prevent misinterpreting either of these for QID, which stands for four times daily. MSO4 for morphine sulfate and MgSO4 for magnesium sulfate, as well as MS, which could be interpreted as either these concentrations available for each medication and using caution when handling these medications. the information into the computer system to avoid significant and potentially fatal errors. Calculation of dosages also occurs during data entry, and is another contributing factor to incorrect dosage errors. For example, if a prescriber writes a prescription to have a patient take 0.5 mg. of liquid lorazepam every eight hours, the pharmacy technician must calculate how many milliliters of liquid to give in each dose, based on the concentration of liquid lorazepam stocked at the pharmacy. Because the amount of liquid given in each dose is incredibly important in ensuring the patient receives the correct amount of medication in each dose, the technician should ensure this is done carefully and accurately. Pharmacy technicians should take the time to calculate dosages appropriately and consult the pharmacist if any questions or concerns arise. Calculating the number of days a given supply of medication should last is another important part of the data entry process. If an incorrect days supply is calculated, this can lead to the patient receiving too much or too little medication for a set period of time, which can lead to the patient taking the incorrect amount of medication. Calculating the correct days supply is also important from an insurance standpoint, because an incorrect days supply can result in rejected insurance claims and even prompt insurance audits. Technicians should take their time when calculating days supply and discuss any questions or concerns with the pharmacist. sure they make sense and do not need further clarification from the doctor or pharmacist. Any questionable instructions or handwriting issues should be discussed with the pharmacist before entering the information into the patient s file. words should all be written out to prevent misinterpreting one for the other, resulting in a potentially fatal error. Trailing zeros and lack of leading zeros the Joint Commission also encourages the use of leading zeros and recommends against using trailing zeros to prevent dosage errors. The Institute of Safe Medication Practices has compiled a more thorough list of abbreviations and symbols that are associated with errors reported to it. Pharmacy technicians should familiarize themselves with this list to prevent common errors associated with these abbreviations and shortcuts. This list can be accessed at Avoiding abbreviations altogether can prevent many errors associated with difficult-to-interpret abbreviations. Writing out the medication name and directions can eliminate those easily confused abbreviations, reducing the risk of errors. But because many prescribers will continue to use these abbreviations despite the risk associated with them, pharmacy technicians should be on the lookout for potential errors and clarify any questionable information with the pharmacist or prescriber. The use of technology can also prevent abbreviation-related errors. Prescriptions that are typed out instead of handwritten can prevent errors caused by poor handwriting. Prescriptions can also be ed or electronically transmitted directly to the pharmacy s computer Page 14

17 system to start the data entry process, eliminating some of the data entry a technician has to do and the errors associated with it. Prescribers with poor handwriting should be encouraged to use electronic systems for writing and sending in prescriptions to reduce Production/counting The production part of the dispensing process occurs after medication orders are entered into the computer system. Production consists of printing a label for the prescription vial, counting out the number of tablets or pouring liquid medication for the prescription, and preparing the order for the pharmacist s final check. Even if there are no errors in the data entry phase, errors can still occur in the production phase, and pharmacy technicians should be aware of the potential for errors at this point of the dispensing process. Pulling medication off the pharmacy s shelves for use in dispensing can be associated with medication errors. Stock bottles often have similar packaging to other medications, and different strengths of the same medication are often located next to one another. Error Barcode technology Barcode technology is available to ensure the correct medication is used to fill prescriptions. After a prescription is typed into the computer system, the barcode of the stock bottle is scanned to create a label for the patient s prescription vial. This allows the computer to check that the bottle picked off the shelf matches the product that was selected in typing the prescription, and thus ensure the correct medication is used to fill a Counting errors Errors can also occur when counting out the amount of medication needed to fill a prescription order. Orders in the outpatient pharmacy setting are often filled in increments of 30 because many insurance companies pay for a 30- or 90-day supply of medication at a time. Pharmacy technicians should make sure to pay attention to the number of tablets or units a prescription requires, especially when they are written for odd quantities or more than the standard number of units. Quantities should be double-counted for controlled substances and any time a technician for any reason is unsure how many tablets were counted out to ensure the proper quantity is dispensed to the patient. Pharmacist quality assurance check During the quality assurance check, the pharmacist reviews all prescriptions to ensure they are filled according to the prescriber s directions and are appropriate for each patient. Errors can occur when this check is performed inaccurately, which can occur when the pharmacist is very busy or distracted. Drug interaction errors Drug interaction errors commonly occur when information is overlooked during the pharmacist s quality assurance check, and are more common in patients who take many medications, such as elderly and critically ill patients. These patients are also prone to changes in metabolism that can alter the effects of their medications and their interaction with other medications, increasing the risk of adverse effects. Point of sale Errors can also occur when selling medications to patients. In a busy pharmacy environment, errors can occur when a medication is sold to someone it was not intended for. This can result in a patient taking error potential. Ensuring all error-reducing technology is used appropriately and not bypassed will help prevent potentially harmful errors from occurring. prevention strategies, such as physically separating similar looking bottles and different dosages of the same medication with dividers, will help prevent technicians and pharmacists from pulling the wrong medication off the shelf to fill an order. Stickers or signs can also be used for high alert medications, or those that are prone to more dangerous errors. When filling prescriptions, the National Drug Code number should be checked three times for accuracy when the medication is pulled off of the shelf, when the medication is counted out, and when the stock bottle is put back on the shelf or disposed of. Pharmacy technicians should be aware of the similarities in packaging of products in their pharmacy and use all available technology to prevent errors when pulling medications off of the shelves for use in dispensing. patient s prescription. Technicians should make sure barcodes are scanned for each medication filled to prevent errors. Tech alert! Barcode technology is an error-prevention strategy that should not be bypassed unless absolutely necessary. Regularly overriding barcode scans is associated with an increased risk of errors! If the medication s barcode was not scanned to print the medication label or if medications and labels were shuffled around after the labels were printed, there is potential for the wrong medication to be counted and put into a prescription vial. Pharmacy technicians should count out the required amount of units for a prescription right after printing the label to minimize the risk of medications being mixed up and incorrectly dispensed. Always using barcode technology and not bypassing this error-prevention tool will also help the pharmacy to dispense the correct product. Errors are also common if the same pharmacist completes the data entry and filling process and also checks the prescription for accuracy. Ideally, different people should complete the dispensing process and quality assurance checks to decrease the risk of overlooking erroneous information. While it is generally the responsibility of the pharmacist to determine whether medications will interact with one another, knowing common drug interactions will allow the technician to help the pharmacy team prevent common medication errors. Pharmacy technicians should discuss common interactions with their pharmacist and learn from drug interaction errors that occur to prevent their recurrence. a completely different medication than what their doctor ordered, and is also a violation of HIPAA when a patient receives another patient s protected health information. Page 15

18 It is important for technicians to verify that the medication is going to the correct patient by asking the person picking up a prescription for two patient identifiers, such as the name and date of birth of the patient. The technician should ask for this information in the form of an open-ended question, such as What is your birthdate? instead of Is your birthdate May 4, 1972? Counseling All patients should receive counseling on all new prescriptions and be offered counseling on refills, depending on state law. Counseling is an opportunity for the pharmacist to discuss the medication with the patient and includes a review of the medication name, dose, and directions. Reviewing this information with the patient gives the pharmacist a chance to ensure the information on the prescription bottle is what the patient expected to receive, and allows the pharmacist to discuss the potential for side effects and adverse reactions as well as any questions the patient has. And counseling is often a time when errors are prevented because the pharmacist is given a chance to look at the order again with the patient Patient responsibility Even if prescriptions are filled with 100 percent accuracy, there is still a level of responsibility that lies with patients and their caregivers to ensure their own safety when taking prescription medications. Patients should understand that they are responsible for several things with their medication treatment, including: Using their medications as their doctor prescribed them. Looking for side effects and reporting them to medical professionals as necessary. Identifying when their medications look or smell differently than normal, and discussing the differences with a pharmacist before using the different medication. Keeping an accurate record of the medications they are taking, including over-the-counter products and supplements, and After an error occurs If an error occurs, the pharmacist should be notified immediately. The first step in dealing with an error is ensuring the patient is safe. The pharmacist should then assess what happened and how it happened. Performing a root-cause analysis will help the pharmacy staff assess what happened and what needs to be done to prevent it from happening again. Root-cause analysis 12 Conducting a root-cause analysis after an error occurs is essential to help staffers learn from their mistakes and assess what steps need to be taken to prevent similar errors from occurring in the future. The analysis is a written plan set up to analyze an error and is an opportunity to discover what must to be done to prevent recurrence. There are several methods for conducting a root-cause analysis. The Joint Commission publishes a checklist with questions to guide the process of analysis, available at Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_ Plan/. This plan requires the user to complete a thorough description of the event, including the date and time it occurred, what happened, the patient s diagnosis, medication list, and medical history. A series of 24 questions assesses the process that should normally occur and the process that did occur, including human factors, equipment factors, environmental factors, communication factors, staffing issues, and external factors that contributed to the error. They also assess the systems in place to decrease risks of errors, the barriers to appropriate Page 16 Some pharmacies have automatic safeguards at the point of sale that require the patient s date of birth to be entered into the computer system to prevent errors at this point. Automatic safeguards should not be bypassed without approval from the pharmacist. present to ensure the prescription information is consistent with the information the patient received from his or her doctor. It also allows the pharmacist to ensure the patient knows how to properly take the medication and what to do if side effects occur; many medication errors are associated with patients taking their medication incorrectly, causing side effects and adverse reactions. Pharmacy technicians should make sure all patients are given an opportunity to receive counseling, not only to minimize the risk of errors and maximize patient comprehension of medications dispensed, but to remain compliant with state board of pharmacy laws as well. ensuring their entire health care team is kept up-to-date on their current medications. Involving themselves in designing their own medical treatment regimen. Ensuring their entire health care team is kept up-to-date on their medical status, especially with new allergies and medical conditions. When a pharmacy technician notices patients are not following these guidelines, they should be referred to the pharmacist for further consultation. Patients should always be taught that they can raise concerns about their treatment with their pharmacist, and should be encouraged to call or come by the pharmacy to resolve even the smallest medication questions. Tech alert! It is important to avoid blaming one person for the occurrence of an error. Analyzing the error and how it occurred to prevent future errors is more important than focusing on who caused the error. use of these systems, and what additional training or systems are necessary to prevent future errors. After answering the error assessment questions, the next step is to develop a written action plan for dealing with the error. The action plan should include measurable risk reduction strategies, such as, Verify two patient identifiers at the pick-up window before selling a medication to a patient. The plan should list who will be responsible for implementing the plan for each action item, as well as when it will be implemented and when it will be assessed for effectiveness. Once the action plan is developed and implementation has begun, it is important to have a discuss ion about the incident with the people involved in its occurrence. Those involved in the error can feel guilt and even suffer physical and mental effects, especially if the error caused harm to a patient. The involved parties should focus on preventing future occurrences of the error and improving patient safety, and refrain from blaming each other.

19 Reporting errors Errors should be reported to both internal and external agencies that monitor medication errors. The error reporting process will help both the pharmacy and the health care system develop procedures to prevent similar errors from occurring in the future. Errors should be reported without fear of punishment; this process is designed to improve the system for the future, not to blame one person for the error. Pharmacies should have a written plan in place for internal error reporting. Reporting medication errors to external agencies will also help improve patient safety on a broader scale. External agencies that track medication errors include: The Food and Drug Administration (FDA) MedWatch Receives reports of not only medication errors, but also adverse events related to medications, product use errors, quality issues, and therapeutic differences between manufacturers. Vaccine adverse event reporting system (VAERS) Surveillance program for collecting adverse event information related to administration of vaccines. Institute for Safe Medication Practices National Medication Errors Reporting Program (ISMP MERP) For practitioners and pharmacies to report errors. Errors can be reported by going to or by calling FAIL-SAF(E). ISMP also has an error reporting system for consumers at Preventing errors Pharmacy technicians play a key role in the prevention of medication errors. Technicians should follow safe practices for filling each and every prescription, encourage a safe workplace, and recognize gaps in Safe practices Pharmacy technicians can decrease the risk of creating errors by ensuring safe practices and procedures are followed when entering prescriptions into the computer system. Following the pharmacy s designated process for data entry for each and every prescription will help the technician develop a routine to follow when entering prescriptions, making it easier to ensure all steps are followed for each prescription. Communication is also incredibly important throughout the dispensing process. Any questions the technician has about a prescription should Safe workplace As in the example with Michelle, pharmacy staff members often have an incredibly high workload, and can be pushed to complete several tasks at once. Trying to focus on many tasks at one time and interrupting one task to complete another are common root causes for errors. Working in a stressful or noisy environment can also contribute to errors. Patient education Because consultation is a point where many medication errors are prevented, pharmacy technicians should do everything they can to ensure patients receive proper consultation on their medications. State pharmacy laws often require consultations at the point of sale, but consultations can also be appropriate when a patient is dropping off a prescription or calling about a refill. Any time a pharmacy technician Training pharmacy staff The staff should receive adequate training on the pharmacy s systems before beginning work in the pharmacy. Orientation to the pharmacy s policies and procedures is essential to preparing technicians to conduct their work accurately and efficiently. They should be tested on the information to assess their proficiency before starting work and encouraged to ask questions and seek assistance with problems that arise when they begin to work in the pharmacy. Continuing education 11 Another strategy for preventing medication errors is continuing education for both pharmacists and pharmacy technicians. Continually both their own education as well as their patients to help decrease the risk of errors occurring. be communicated to the pharmacist or patient as appropriate; answers to these questions should never be assumed. All tools available to the technician for error prevention should be used and not bypassed. Alerts that the computer system detects should be assessed thoroughly, and not ignored. If errors occur, technicians should ensure they understand how the error occurred and what they should do to prevent it from happening again in the future. Technicians should ensure they follow the steps needed to improve their dispensing skills to prevent future errors. Pharmacies should minimize distractions in the workplace and encourage technicians to complete one task before starting another to decrease the risk of medication errors. Employees should also be encouraged to take breaks when appropriate to allow them to step away from a busy situation and regain focus on the tasks at hand. talks to a patient and determines there is a need for additional information, the patient should be directed to the pharmacist for education. Ensuring patients receive all the information they need to properly take their medications decreases the risk of incorrect medication administration, decreasing medication errors. Training also should occur for all employees when new policies and procedures are introduced or when there is an immediate need for further training, such as after an error occurs. This should be done to update both pharmacists and technicians so the entire pharmacy staff can continue to perform their jobs appropriately and continue to maintain patient safety. learning more about medications and their side effects, interactions and contraindications will help pharmacy technicians to spot potential Page 17

20 errors before they occur. Pharmacy technicians should also stay up to date on current safety issues and recalls on pharmaceutical products to minimize the risk of errors related to these issues. Pharmacy technician certification is also associated with a decrease in medication errors. Certified pharmacy technicians have learned the knowledge necessary to pass the Pharmacy Technician Board Exam, and have a broader pharmacy knowledge base than their uncertified Customer satisfaction surveys Many retail pharmacies have surveys available to patients to assess customer satisfaction with the pharmacy s services. These surveys assess the patient s experience at the pharmacy and allow the pharmacy to improve on the areas that patients feel need improvement. They are often Web-based or available over the phone, and must be completed within a set timeframe after services are rendered, often within 14 days of the pharmacy visit, depending on the pharmacy. Some pharmacies offer incentives for patients to complete the surveys, such as drawings for cash prizes or coupons for future purchases. The customer satisfaction surveys often ask a range of questions to assess the patient s feelings on their pharmacy experience. The questions cover both pharmacy and general customer service topics, such as: Was the pharmacist available for consultation? On a scale of 1 to 5, how satisfied are you with the service you received today? Based on your last experience at our store, how likely are you to recommend this store to others? Internal audits of processes Pharmacists and technicians must continuously assess the daily processes for dispensing medications and maintaining the pharmacy to ensure patient safety and compliance with the law. Managers often review the pharmacy s operations on a monthly basis, but the technician is perfectly poised to monitor operations more frequently. Each pharmacy generally has a checklist that is assessed monthly to ensure the pharmacy is operating smoothly and efficiently. Assessing the items on this checklist before the manager completes it will help the pharmacy technician understand what steps need to take place to optimize efficiency and patient safety. Technicians should discuss the References The American Pharmacist s Association. The Pharmacy Technician, 4th Edition. Englewood, CO: Morton Publishing Company U.S. Department of Health and Human Services Office for Civil Rights. A health care provider s guide to the HIPAA Privacy rule: Communicating with a patient s family, friends, or others involved in the patient s care. Accessed October 27, 2013 at www. hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/provider_ffg.pdf Department of Health and Human Services. HIPAA Administrative Simplification: Standards for Privacy of Individually Identifiable Health Information. 45 CFR Parts 160 & : October. Accessed October 27, 2013 at hipaa/understanding/special/genetic/ginanprm.pdf. Mizner J. Mosby s Review for the Pharmacy Technician Certification Examination, 2nd Edition. St. Louis: Elsevier Hopper T. Mosby s Pharmacy Technician Principles and Practice, 3rd Edition. St. Louis: Elsevier The Joint Commission. Facts about the Official Do Not Use list. 6/2013. Accessed November 4, 2013 at pdf. The Institute for Safe Medication Practices. ISMP s List of Error-Prone Abbreviations, Symbols and Dose Designations Accessed November 4, 2013 at ismp.org/tools/errorproneabbreviations.pdf. The Institute for Safe Medication Practices. FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man Letters Accessed November 6, 2013 at counterparts. The use of certified technicians allows the pharmacist to spend more time counseling patients and focusing on patient care, ensuring patients understand how to take their medications and preventing errors in the process. Tech alert! Pharmacy technicians should contact their state s board of pharmacy to determine the continuing education requirements in their state. There is often an area for customers to leave comments and concerns in an anonymous format to protect patient confidentiality while allowing the customer s voice to be heard. Pharmacy staff should remind patients to leave out any identifying health information to protect their anonymity. The results of these surveys are then compiled into reports to help the pharmacy team assess the satisfaction level of their service. Reports can often be compiled for various timeframes, such as weekly, monthly, or annual reports, to assess service at a particular point of the year. The results of these survey reports should be discussed with the pharmacy team to examine strengths and weaknesses of the pharmacy s service. Pharmacy technicians should take the time to point out these survey opportunities to customers and ask them to complete them within the allotted time frame. The more customers complete these surveys, the more the overall scores are reflective of the services provided by the pharmacy. And because customer satisfaction is important to conducting business, the pharmacy technician should take a leading role in helping the pharmacy achieve its customer service goals. monthly review process with their managers and take an active role in improving the dispensing process. The state board of pharmacy also conducts regular reviews of pharmacies to ensure they remain in compliance with the law. Many states have a guideline of the information board that inspectors look for during an inspection. Reviewing this information on a regular basis before inspections occur will help the pharmacy maintain compliance and allow the staff to actively participate in the maintenance of the pharmacy. Guidelines for board of pharmacy inspections can be found on the state s board of pharmacy website. The Institute for Safe Medication Practices. ISMP s List of Confused Drug Names. 6/2011. Accessed November 6, 2013 at confuseddrugnames.pdf. Filik R, Purdy K, Gale A, Gerrett D. Drug name confusion: evaluating the effectiveness of capital ( Tall Man ) letters using eye movement data. Soc Sci Med Dec;59(12): Accessed November 6, 2013 at com/science/article/pii/s x. Medscape. Certified Pharmacy Technicians: Innovation and Medication Error Prevention. Accessed November 6, 2013 at viewarticle/ The Joint Commission. Framework for Conducting a Root Cause Analysis and Action Plan. March Accessed November 6, 2013 at Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_Plan/. Institute of Medicine (IOM). Preventing Medication Errors. Report Brief Accessed November 7, 2013 at preventing-medication-errors-quality-chasm-series/medicationerrorsnew.pdf Page 18

21 A Dose of Professionalism for the Pharmacy Technician Final Examination Questions Choose the best answer for questions 6 through11 and mark your answers on the Final Examination Sheet found on Page 21 ot take your test online at. 6. Which of the following is NOT an example of protected health information? a. Genetic information. b. Date of birth. c. De-identified patient cases for research purposes. d. Payment history. 7. Protected health information can be disclosed under certain circumstances for all of the following EXCEPT: a. DEA investigations. b. Board of Pharmacy investigations. c. Law enforcement reasons. d. A patient s divorce hearing. 8. Under HIPAA, patients have the right to receive a list of all nonroutine disclosures of their PHI within the past years. a. 3. b. 5. c. 6. d Which of the following high-alert medications is correctly matched with the risk associated with them? a. Opiates risk of respiratory depression. b. Anticoagulants risk of hyper- or hypoglycemia. c. Insulin risk of excessive bleeding. d. Chemotherapy medications risk of excessive bleeding. 10. The is a written plan set up to analyze an error and is an opportunity to discover what must to be done to prevent recurrence. a. Root-cause analysis. b. Joint Commission. c. Institute for Safe Medication Practices. d. Error reporting. RPTVA03DPE15 Page 19

22 2015 CE Course for Virginia Pharmacy Professionals All 5 Hrs ONLY $ Customer Information Three Easy Steps to Completing Your License Renewal Step 1: Complete your Elite continuing education courses: What if I Still Have Questions? No problem, we have several options for you to choose from! Online at PharmacyTech. EliteCME.com you will see our robust FAQ section that answers many of your questions, simply click FAQ in the upper right hand corner or us at office@ elitecme.com or call us toll free at , Monday - Friday 9:00 am - 6:00 pm, EST. 99 Read the course materials and answer the test questions. 99 Complete the course evaluation. To receive credit for your courses completion of the evaluation is mandatory. 99 Submit your final exams and course evaluations along with your payment to Elite online, by fax, or by mail. Step 2: Receive your certificate of completion. 99 If submitting your course online you will be able to print your certificate immediately. 99 If submitting your course by fax or mail a certificate will be ed to you. Step 3: Once you have received your certificate of completion you can renew your license online at gov/mylicense/renewalintro.asp, or mail in your renewal. You should receive your renewal notice within 60 days of the expiration date. In order to avoid late fees, your CE and license renewal must be completed before renewal. Board Contact Information: Virginia Board of Pharmacy Perimeter Center 9960 Maryland Drive, Suite 300 Henrico, VA Phone: (804) Fax: (804) Website: Elite Continuing Education Page 20