8.1 Introduction
Repeat dispensing services are offered at most community pharmacies, in order to facilitate treatment of chronic conditions. Medication is the most effective way to treat chronic ailments and the processing of repeat prescriptions can be done efficiently by pharmacy team workers. The patient is able to enjoy timely and convenient access to regular medication, without having to contact the GP every time.
Pharmacy workers are also trained to provide monitored dosage dispensation, which is usually performed by an electronic dispensing device. However, a computerised device does not preclude the likelihood of error. Pharmacy assistants should be careful to load and clean the device properly and the equipment should be placed in a clean, tidy area.
Pharmacy assistants are able to download electronic prescriptions directly from the main database (called the Spine) into the pharmacy system. The electronic prescription system is instrumental in reducing patient visits to the GP practice, by reinforcing the relationship between the pharmacy and the patient.
Electronic prescription services help to reduce paperwork and reduce patient waiting times in pharmacies. They also minimise the likelihood of interpretation and dispensation errors due to illegible handwriting and so on. Dispensation errors can result in risks and even fatalities. You can minimise dispensation and misinterpretation errors in several ways. Pharmacy workers should follow a standard system of entering, checking and filling prescriptions. In case of ambiguity or doubt, they should contact the prescriber before dispensing medicine.
8.2 Different Types of Dispensing Services
Routine dispensing: This process has been described in detail in module 7. It involves collection of the prescription, verifying authenticity, assembling the items, printing labels and packaging the items appropriately. Repeat dispensing: Since the year 2005, repeat dispensing has been regarded as an essential service in community pharmacies.
For repeat dispensations of medicines, pharmacy assistants will need to:-
Check that the repeat dispensing prescription has been issued/written by a GP. Nowadays, most repeat dispensation instructions are provided through electronic prescription services. Verify if the repeat supply is required. Ascertain that there is no reason to re-check the prescription details with the GP.
Repeat dispensations allow patients to obtain a supply of their medication or appliances, without producing a hand-signed prescription each time. The ERD system (Electronic Repeat Dispensation) allows the prescriber to generate repeat prescriptions for a period of time, until the patient is due for a medical review. Community pharmacies often cater for patients who require repeat dispensation of drugs or appliances.
A repeat prescription/dispensation instruction will contain two important pieces of information:-
-The interval between each supply of the medication or appliance.
-The number of repeats required for the patient in question.
As a pharmacy assistant, you will βind that patients suffering from chronic ailments often produce repeat prescriptions. The patient will nominate the pharmacy of his choice where he would like to collect the dispensed drug
This is the process workβlow for repeat prescriptions:-
GP issues prescription for X number of repeats à Prescription is transmitted electronically to nominated local pharmacy à The pharmacy assistant retrieves the repeat prescription from the EPS system à Assistant dispenses medication to authorised individual (patient or caregiver).
You should be aware of the following key issues regarding ERD or repeat prescriptions:-
Please ensure that the prescriber has clearly mentioned the number of repeat dispensations required. Each repeat should require the same amount of medication.
You can retrieve the first one, as soon as it is transmitted by the prescribing authority. Subsequent prescriptions will sent to the pharmacy system automatically on the required dates. If you are in the process of dispensing the last dispensation of the prescription, inform the
patient that they should contact the GP for subsequent repeatable prescriptions. Avoid further dispensations, until the GP has sent you the next set of repeat prescriptions.
If the pharmacy uses an automated prescription system, you will receive details of the repeat prescription several days in advance of the due date. This is to allow the pharmacy workers time to prepare the dispensation, before the patient is due to collect the medication. This is
especially helpful for elderly, sick, or infirm patients, as it helps to reduce waiting times. Please note that a dispense notification does not include the time for the subsequent dose. For example, if the notification is sent on January 21 and the due date of dispensation is January
27, the next due dispensation will remain as February 27 (and not February 21).
In the event that you need to dispense subsequent doses ahead of the schedule, you can contact the GP. Repeat prescriptions are often flexible with respect to time (within limitations). This may be especially useful if you have to dispense the drug ahead of time because, say, the patient is going away.
If the repeat dispensation is done by using paper prescriptions, the paper issue forms will contain details regarding the prescriber, patient and medication. The form will also contain handwritten information about the number of repeats and the intervals (which could be weekly, fortnightly, monthly, or quarterly). The pharmacy assistant should also look for a sign that says “RA” on the right hand side of the form and the form must be hand-signed by the prescribing authority.
With regard to paper repeat prescriptions, the maximum number of repeat prescriptions that can be issued is one year's worth. The date on all batch issues and authorising form will be identical. Batch issuing forms need not be signed, but will contain instructions regarding dosage and repeats. Please note that batch issue forms are stamped with “RD”.
The difference between RA and RD is that RA stands for Repeat Authorisation form, whilst RD stands for Repeat Dispensing. The RA form must be signed by the prescriber, but it is not necessary to sign the RD. RD forms must be stamped with the pharmacy name and the correct date of dispensation. Whilst it is not mandatory for community pharmacies to endorse RA forms, it is a good idea to βile them for the purpose of creating a clear audit trail.
Medication is the most effective and common form of managing long term health conditions. Consequently, pharmacy teams and workers play a crucial role in ensuring that patients are able to enjoy timely and convenient access to medication. Efficient process of dispensing repeat prescriptions helps provide flexibility and benefits to patients. Unless there are problems or confusions regarding the prescription, the pharmacy worker need not contact the physician for administrative purposes.
The repeat dispensation process enables the prescription process to be simplified, without compromising on the quality of patient care. For pharmacy staff, using the electronic systems helps reduce the administrative and operational aspects of collecting and dispensing the repeat prescriptions every time.
Repeat dispensations
Pharmacies also offer what is known as “managed repeats”. In this form of service, the patient requests the medication supply for the subsequent month when collecting medication for the current month. The pharmacy then collects the medicines from the practice on behalf of the patient. This is also called repeat collection services. Patients can also call their community pharmacy (as assistant, you can expect to attend to calls) and order their medication from the medical practice. The pharmacy will order the prescription on behalf of the patient. This is known as repeat ordering service.
Pharmacies may also take the initiative and call the patient close to the due date for collecting a repeat prescription. Once the patient confirms the details, the pharmacy will then contact the practice and collect the drugs when they are dispensed. This is called “pharmacy-prompted repeat”. Repeat dispensations provide multiple benefits, including patient flexibility, increased patient safety and minimisation of pharmaceutical wastage. This service is provided by community pharmacies in the UK and is particularly valuable to vulnerable patients. This includes patients who suffer from mental health conditions, low literacy levels and patients who may experience problems with communication.
Repeat dispensing is also a useful for patients who require reminders from the pharmacy for their drug dispensations. Patients who find it difficult to commute to their GP practice to collect prescriptions will also find it convenient to use this system. Vigilant pharmacy assistants and workers will also save records of prescriptions and will be instrumental in detecting errors before it has a chance to have an impact on patient wellbeing. Looking at the larger picture, repeat dispensations by pharmacies helps to reduce foot trafβic in GP practices and also reduce the number of phone calls regarding medications for chronic treatments.
Pharmacy workers should make it a point to order prescriptions from practices beforehand, for the following reasons:-
The time required for processing repeat prescriptions is roughly 2-3 days. The pharmacist (as assistant, it is your duty to bring any errors or anomalies to the notice of the supervising pharmacist) may notice clinical errors or may question the suitability of the drug. The pharmacy may need to order the medicine, if it is not available in the stocks. Appropriate method of delivery of the drug to the patient.
Requesting for the repeat prescription ahead of time allows for time in case any contingencies arise. It is also advisable for pharmacy workers to obtain relevant information from the patient by asking the following questions:-
-Has your health been reviewed, since your last repeat was supplied?
-Have you started taking any new medicines since the last repeat supply, or have you been consuming any over the counter medication?
-Have you been experiencing any side-effects, after the last repeat supply?
-Are there any items on your repeat prescription that you will not require this month?
Pharmacy assistants should carefully note down the responses to each question and pass on the information to the senior pharmacist.
FACT
There are approximately 36,750 high street pharmacies operating in the UK.
Source: bbc.com
8.3 Monitored Dose Dispensing
Pharmacies control and monitor drug dispensation, by using unit dose monitoring procedures. This method offers multiple advantages, including minimisation of dispensation errors, improved safety for patients, efficient use of pharmacy personnel and workers, improvement in overall drug use and improved billing processes.
Pharmacy workers should consider adopting the monitored dose dispensing method, for patients who have difficulties with removing medication from packaging and who struggle to organise their medication. It is also useful for patients who have to take a large number of medications each day, as well as those who have a caregiver who manages their medication.
Modern pharmacies are often equipped with a monitored dose dispensation device, which helps promote patient adherence to prescribed medication. Pharmacy assistants must ensure that the device is placed in a clean and tidy area and is wiped regularly, to prevent cross-contamination. It is also important to be in possession of a valid prescription, before using the automatic dispensing device.
Important features regarding the use of monitored dispensing devices include the following:-
-Appropriate location of the automatic dispenser machine, in a place where there are minimal distractions and interruptions during usage.
-Pharmacy staff should be well trained to incorporate safety and accuracy during operations.
-Staff should be trained in temperature control and efβicient device operation.
-Pharmacy assistants should ensure that there is sufβicient lighting, in order to read prescriptions, labels and so on.
-Pharmacy assistants should be able to transport medicines safely from the pharmacy to the dispensing area.
-Pharmacy staff should also receive training on how to remove drugs from the dispenser which are not required for use.
-As the pharmacy assistant, you should double check to ensure that only authorised personnel have access to the drawers, pockets and bins.
-Monitored dosage systems often provide freestanding access to patient information.
Activity
Estimated time 10-15 minutes
Take five minutes to think about how you would handle an elderly patient who regularly visits the pharmacy in order to collect a repeat dispensation. Write down how you think you could improve your services to help him/her.
8.4 Electronic Prescription Service
Electronic prescription service describes the generation and transmission of prescriptions, as opposed to manual writing. EPS systems are becoming increasingly popular and are expected to reduce the paperwork involved in patient care. Pharmacies will also be able to transmit prescription endorsements electronically, in order to claim reimbursement for products and appliances supplied.
Electronic prescription services are aimed at optimising the process of pharmaceutical and will be expected to reduce time, effort and errors, with regard to medicine dispensation in pharmacies. Electronic prescriptions use advanced electronic signatures of the prescriber, hence pharmacy assistants are able to read the signature more easily.
The electronic prescription service is particularly useful to patients, because they can select (nominate) a pharmacy that is located close to their home or place of work. As a pharmacy worker, you should be familiar with the electronic prescription service, as it is becoming increasingly popular.
Pharmacy team staff can expect to beneβit from electronic prescriptions in the following ways:-
-Electronic prescriptions already contain patient details, so pharmacy workers use less time entering the information in the system.
-Prescribers use a drug dictionary while formulating the prescription and this helps improve accuracy and reduce the likelihood of medication errors.
-Reduced risk of lost or misplaced prescriptions, as the system stores the prescriptions. You can use what is called a “prescription tracker” (explained below).
-Reduced risk of duplication of prescriptions and erroneous dispensing, as a result.
-Pharmacy workers waste less time in sending and collecting paper prescriptions to and from GP practices.
-Electronic prescriptions are speedily delivered to the pharmacy, without delays.
-Advance receipt of electronic prescriptions allows pharmacy assistants to order out of stock items, before the patient's arrival.
-It is possible to integrate electronic prescription services with stock management, in order to minimise administrative work.
-You can reduce waiting times for patients, by preparing and dispensing the drugs before their arrival.
Moreover, electronic prescriptions allow the prescriber to add notes which can be communicated to the patient.
8.5 How to Retrieve a Lost Electronic Prescription
If the patient has nominated the pharmacy, the prescription can automatically be sent to the pharmacy computer system and downloaded. If you are unable to retrieve the prescription, you can enquire from the patient if he/she nominated the pharmacy in question.
Alternatively, you can use the prescription tracker to search for the prescription. You may see a message that says “to be dispensed”. In this case, highlight the text and copy and paste the prescription so that it downloads into the pharmacy system.
Tokens
Pharmacy assistants may need to print paper copies of electronic prescriptions, wherever required. These are referred to as “prescription tokens”. Tokens are hard copies of soft electronic prescriptions. There are two types of prescription tokens - prescription tokens and dispensing tokens.
Prescription Tokens
Prescription tokens must never be signed by the prescribing authority and they can be printed at the GP practice on “FP 10 prescription forms”, which are recognised by the NHS. Prescription tokens are paper copies and will contain the name and address of the nominated pharmacy. This helps to indicate clearly the pharmacy that has been nominated. Prescription tokens need not be printed for repeat dispensing and dispensing for acute ailments. The patient can simply collect the medication from the nominated pharmacy. However, the pharmacy can print a paper copy for the patient at the start of the repeat dispensing schedule.
Prescription tokens must not be amended manually, in any manner. If the prescriber wishes to make changes, then the old prescription should be cancelled and a fresh one should be issued to the patient. In addition, prescription tokens can always be re-printed whenever required. Please note that the latest issue will be printed.
Pharmacy assistants can also consider scanning the prescription token, in order to retrieve the prescription. However, in most cases, the original prescription would already have been received at the pharmacy. Pharmacies will receive the electronic prescription, regardless of whether the prescription token has been printed at the GP practice.
Dispensing Tokens
Prescriptions may be downloaded into the pharmacy system automatically or manually. Pharmacy assistants will often be actively engaged in downloading prescriptions into the pharmacy system, in order to prepare drug dispensations ahead of patient visits. Pharmacy assistants working in hospital pharmacies, for example, may wish to download prescriptions during busy surgery times, as a higher number of prescriptions can be expected.
Similarly, you can download electronic prescriptions into the system during quiet times. Regular monitoring of downloads will help you to order out of stock products and improve patient outcomes. Assistants can consider arranging paper and electronic prescription tokens on different shelves or in different files.
Activity
Estimated time: 10-15 minutes
A patient from a non-English speaking and low literacy background visits the pharmacy to collect an important medicine that has been prescribed to him. What steps will you follow, to ensure correct dispensation and communication?
8.6 Dispensation Errors and how to minimise them
Dispensation errors consist of deviations and inconsistencies from the original prescription. Pharmacy workers may be vulnerable to the following dispensation errors:-
-Misreading a prescription/Illegible handwriting
-Ambiguous abbreviations misinterpreted/non-familiarity
-Ambiguous or misinterpreted units of measurement
-Errors in calculation
-Errors in dosage
Dispensing errors can also occur due to similar sounding medicine names, similar packaging of medication, transposing labels or incorrect labelling of medicines, dispensation of expired medicine and failure to dispense according to the prescription. Pharmacy workers may also be prone to dispensation errors during overly busy times, or when they are short staffed. Other reasons could include stress, distractions, lack of knowledge, or lack of concentration.
How Pharmacy Assistants (and other team workers) can reduce Dispensation Errors
1. Ensure that the prescription is entered correctly
It is advisable to double check the identity of the patient using more than one method of identification, in order to avoid dispensing medicine to the wrong patient. This is especially relevant to pharmacy workers working in hospital pharmacies. It may also be useful to cross-check patient information, such as symptoms, allergies and so on.
2. Confirm that the prescription is interpreted and transcribed properly
One of the most common causes of dispensation errors is second guessing at the meaning of ambiguous symbols, acronyms, units and so on. Instead of guessing at the meaning, the pharmacy worker should contact the doctor for clarification. For prescriptions given over the telephone (in cases of emergencies), transfer it onto a blank prescription pad and read it back to the prescriber for confirmation.
3. Exercise vigilance about similar sounding names
Preconceived notions and prior beliefs can play a large role in confusion between two drugs with similar names. As a result, a new, unfamiliar medicine may sound similar to an old, familiar one - even though they are totally different from each other.
4. Decimals and zeros
Pharmacy workers should be particularly careful with regard to calculating strengths where decimal values and zeros are involved. Errors may result in the patient receiving ten times more or less dosage than prescribed.
5. Organise the counters and workspace
A clean, well-lit and tidy workspace will help pharmacy assistants to dispense medication smoothly, without mix-ups. The pharmacy should also develop a standard system of entering, checking and filling prescriptions. Always remember to cross-check with the senior pharmacist, if you have doubts. Minimise distractions and concentrate on the job at hand.
For example
If you are in the process of entering a prescription, request your colleague to answer the telephone. Take time off regularly, to ensure that you do not get distracted or stressed due to overload.
6. It is extremely important to arrange and stock products correctly.
Pharmacy assistants are typically responsible for stocking shelves and they should ensure that products are labelled correctly and facing forward for improved legibility.
7. Patient counselling can help to identify errors before any damage is done, because it is the last point of contact between the pharmacy worker and the patient.
Open the container and show the medication to the patient, while asking questions. This is a much better option, compared to simply
handing over the medicines in a sealed bag. Counselling can also help to clarify the route and method of administration of medication. Lack of understanding regarding directions for use is one of the major causes for dispensation errors and increase of health risk.
8. Ensure that patients are provided with an information leaβlet, along with prescription medicines.
Information leaflets contain important data regarding dosage, side-effects and contra-indications. Open the pack and ensure that the information leaflet is provided correctly. Pharmacy workers should be particularly vigilant when dealing with vulnerable patients, such as
pregnant women, children, the elderly and patients from non-English speaking backgrounds (because there is a higher likelihood of misunderstanding directions for use). It is always better for two people to be involved in the dispensation process and it is also a good idea
to write down calculations and double check them.
The final check should ideally consist of the following steps:-
-The name of medicines on the bulk pack should match the name on the prescription.
-Strength of item, against the strength mentioned on the prescription.
-All the medicine strengths in a bulk pack should be identical.
-The form of the drug should match the form mentioned on the prescription (pill, syrup, intravenous and so on).
-Expiry date of the medicines.
-Provision of information leaflet.
MODULE SUMMARY
Pharmacy teams are actively involved in drug dispensation, especially in repeat dispensations of medicines for management of chronic health conditions. Assistants should verify the authenticity of the prescription and dispense the drugs in strict accordance with the prescribed dosages and strengths. Every Repeat Authorising form (RA form) should contain the number of repeats and the intervals between the repeats. It is assumed that the repeat dosage and strength of every drug is the same for every repeat.
Repeat prescriptions may be issued electronically, or by paper. If the pharmacy uses the automated system, then the workers will receive intimation of a due repeat dispensation some days before dispensation. This Flexibility reduces waiting time for patients. The electronic prescription service helps patients to collect medication directly from the pharmacy of their choice, without being obliged to make repeat visits to the GP practice. Thus, electronic prescription services are responsible for minimising patient visits to the GP practice (especially in cases of repeat prescriptions for chronic conditions) and reinforces the connection between the patient and the pharmacy.
Pharmacy workers can retrieve prescriptions due for dispensation by downloading prescriptions into the pharmacy system. This process may be performed automatically or manually. Pharmacy workers are able to order out of stock products, as well as reduce patient waiting times due to the advanced retrieval process of electronic prescriptions. Dispensation errors are dangerous and increase patient health risk. They often arise due to misinterpretation of information, including symbols, decimals, dosage and units. It is better to cross- check with the prescriber, before dispensing the medicine. Patient counselling can help to reduce dispensation errors.
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