Role of Dispensers in Promoting Rational Drug Use

Objectives
To describe the importance of good dispensing practices as part of rational drug use To illustrate the role of the dispenser in promoting quality patient care To understand mechanism of good dispensing practices

Rational Drug Use Cycle

Diagnosis

Adherence

Prescribing

Dispensing
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Outline
Introduction The Dispensing Process Activity One: Identifying the Dispensing Process The Dispenser The Dispensing Environment The Role of the Dispenser in the Proper Use of Medicines Techniques for Ensuring Quality Dispensing Summary of Session
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Introduction
A superficial look at dispensing suggest that it is a process of supplying goods to a patient on the basis of a written order, and that it can be done successfully by anyone who can read the prescription, count, and pour. As a result, dispensing is often delegated to any staff members who has nothing else to do, who then perform this function with out any training or supervision. This situation is irrational and dangerous.
Management Sciences for Health. Ensuring Good Dispensing Practices (chapter 2, Pg 485). In: Managing 5 Drug Supply, Second Edition, Kumarian Press (1997).

Characteristics of Good Dispenser

In addition to reading, writing, counting, and pouring, the dispenser, or dispensing team, needs additional knowledge, skills, and attitudes to complete the dispensing process, including: Knowledge about the medicines being dispensed (common use, common dose, precautions about the method of use, common side effects, common interaction with other drugs or food, storage needs);
Management Sciences for Health. Ensuring Good Dispensing Practices (chapter 2, Pg 485). In: Managing 6 Drug Supply, Second Edition, Kumarian Press (1997).

Characteristics of Good Dispenser

Good calculation and arithmetic skills Skills in assessing the quality of preparations Attributes of cleanliness, accuracy and honesty Attitudes and skills required to communicate effectively with patients

Management Sciences for Health. Ensuring Good Dispensing Practices (chapter 2, Pg 485). In: Managing 7 Drug Supply, Second Edition, Kumarian Press (1997).

Case Report
A female student, age 20, suffering from Tonsillitis, was seen by a doctor in a 200-bed hospital OPD. She obtained a drug from the hospital pharmacy and took it as instructed. She felt very weak after taking the drug. Three days later she became severely comatose and was admitted to the same hospital. She took Chlorpropamide 250 mg four times a day. The OPD doctor claimed that he prescribed Chloromycetine 4x250 mg daily for her Tonsillitis. The patient eventually died two weeks after hospital admission.
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Definition
Dispensing: Dispensing is to ensure that an effective form of the correct drug is delivered to the right patient, in the prescribed dosage and quantity with clear instruction, and in a package that maintains the potency of the drug.

Management Sciences for Health. Ensuring Good Dispensing Practices (chapter 2, Pg 485). In: Managing 9 Drug Supply, Second Edition, Kumarian Press (1997).

Good drug dispensing practices (1)

Good dispensing means ensuring that an effective form of the correct drug is delivered: To the right patient; In the prescribed dosage and quantity; With clear instructions; In a package that maintains potency;

Dispensing is the last step in the drug pathway between manufacturer and patient. No matter how many precautions are taken to guarantee and maintain drug quality during production, packing, transport, storage and distribution, they will all be useless if drug quality is not preserved during this last step;

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Good drug dispensing practices (2)

Safe, clean and organized working environment Disciplined use of effective procedures Qualified and trained staff, regular performance monitoring Safe and clean dispensing / labeling Ensuring patients understanding Good record keeping

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Dispensing cycle
1. Receive and validate the prescription 5. Issue medicine to the patient with clear instruction and advice

Dispensing process

2. Understand and interpret the prescription

4. Record the action taken

3. Prepare items for issue

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Steps in the Dispensing process (1)

1. Receive and validate the prescription 2. Understand and interpret the prescription Read the prescription Correctly interpret any abbreviations used by the prescriber Confirm that the doses prescribed are in the normal range for the patient (noting gender and age ) Correctly perform any calculation of dose and issue quantity Identify any common drug-drug interactions 3. Prepare items for issue
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Steps in the Dispensing process (2)

4. Record the action taken 5. Issue medicine to the patient with clear instruction and advice When to take the medicine (particularly in relation to food and other medicines) How to take the medicine (chewed, swallowed whole taken with plenty of water ) How to store and care for the medicine

Management Sciences for Health. Ensuring Good Dispensing Practices (chapter 2, Pg 485). In: Managing 14 Drug Supply, Second Edition, Kumarian Press (1997).

KEEP WORK ENVIRONMENT CLEAN

Dispensing environment must be clean Physical environment should be kept free of dust and dirt Shelves and cupboard should be kept tidy and clean Working area, and surface used during work should be hygienic and uncontaminated Staff must maintain good personal hygiene and should wear protective clothing Facilities to wash and dry hands should be available

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PREPARATION OF DRUGS AND SUPPLIES (1)

1. Go into the store. Determine the supplies needed. Place the items on a tray. Take them to the dispensing area. 2. Keep supplies in the dispensing area organized 3. Check that the prescription is appropriate for the patient
        Read the prescription and make sure that it is complete. Name of the patient Name of the drug (full name and generic name) and the strength Dosage of the drug ( be particularly careful for children) Route of administration Time and frequency of administration Date and time when the prescription was written Signature of the person writing the prescription
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PREPARATION OF DRUGS AND SUPPLIES (2)

4. Collect a container of an item, and check its expiry

date. 5. Label the package clearly with the patients name, date, name of the item, quantity dispensed, and written instructions for the patient.

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PREPARATION OF DRUGS AND SUPPLIES (3)

6. Open the container. Check the quality of its

contents. Count the quantity needed in a clean, safe manner.

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PREPARATION OF DRUGS AND SUPPLIES (4) 7. Put the prescribed amount of drug into the package for the patient to take home. 8. Put any extra tablets or capsules back into the appropriate container immediately. Explain to the patient how to take the drug (see steps a through d below). If the patient has more than one prescription, dispense one item at a time.
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PREPARATION OF DRUGS AND SUPPLIES (5)

a. Tell the patient the name of the drug, its form (tablet, syrup, etc.), what is for, and the dosage. The dosage includes  When to take the drug ( for example, in the morning)  How much of the drug to take ( for example, 1 tablet)  For how long to take the drug ( for example , 3 days)  How to take the drug ( for example, with food) b. Show the patient how to prepare the dose. Give the patient practice c. Tell the patient to take all prescribed drugs d. Ask the patient to tell you how he will take the drug.
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PREPARATION OF DRUGS AND SUPPLIES (6) 9. Tell the patient to keep all drugs and medical supplies in a safe place at home, and out of the reach of the children. 10. Explain patients that they should not share their drugs with other patients. 11. Register the drugs delivered to patient in a register or daily sheet.
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Promoting Efficient Management in Dispensing Good dispensing practices are under the greatest threat when there is a crowd of patients demanding immediate attention. The need for speed must be balanced with the need for accuracy and care in the dispensing process. At this point the patients care, or even life, is in the hands of the dispenser. In dispensing, accuracy is more important than speed.

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Useful techniques to ensure quality in dispensing include (1)

maintenance of records on what drugs and products have been issued maintenance by the pharmacy department of a daily list of drugs in stock to inform prescribers which drugs are available thereby ensuring that only these drugs are prescribed a two prescription system, whereby two separate prescription are written: one for drugs available in the pharmacy, and one for those that are not but can be ordered this helps avoid rewriting of prescriptions
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Useful techniques to ensure quality in dispensing include (2)

efficient staff scheduling to make the best use of available staff more staff at peak hours, enough coverage to keep one window open during lunch starting and ending items coordinated with patient flow participation by the pharmacy staff in hospital committees to identify and resolve patient flow communication and other problems

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Roles of Pharmacist/Dispenser in Ensuring Rational Drug Use

Procurement Distribution Prescribing Information Additional roles: Communication with physician Treatment guidelines Research on prescribing and utilization Consumer education
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Dispenser-Patient Communication Dispensers communicate with patients how to take drugs Ensuring their understanding is very important

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Patient counseling
Through verbal and written communications, the pharmacist informs, educates and counsels patients about the following items for each drug: Name of drug (Different names with synonyms) Use of drug and its action Route of administration and dosage schedule; dosage form and time of administration Directions for preparations. Direction and precautions for administration Common side effects of the drug. Self-monitoring of drug therapy Adequate storage of drugs Contraindications and interactions of the drug Information about prescription refill What to do in the event of missed dose Specific information to specific patient or drug
27 Source: Hospital and Clinical Pharmacy, Second Year Diploma in Pharmacy A. V. YADAV B. V. YADAV

Factors contributing to Noncompliance

Following are the various factors that result in the patient non-compliance: Poor understanding of instructions Unpleasant taste of medications Fear of becoming drug dependent Side effects of the drug Multiple drug therapy Asymptomatic nature of the patient Delay of physician or pharmacist resulting in bored waiting for the drug Measurement of medication Cost of medication Frequency of administration Duration of therapy Illness
28 Source: Hospital and Clinical Pharmacy, Second Year Diploma in Pharmacy A. V. YADAV B. V. YADAV

Steps to improve compliance:

Identification of risk factors that may contribute to non-compliance Educating the patient : by means of effective verbal and written communication with the patient Development of treatment plan with recognition of patients normal pattern of activities Designation of specific items of day at which medication is to be taken Monitoring therapy Patient motivation

29 Source: Hospital and Clinical Pharmacy, Second Year Diploma in Pharmacy A. V. YADAV B. V. YADAV

Dispensing in the Public and Private Sector

Public Sector Cheap but long delays and frequent stock-outs Generic drugs Private Sector Expensive but convenient Brand name drugs

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Type of dispensing errors

Wrong drug dispensed Wrong strength dispensed Wrong quantity dispensed Wrong form dispensed (e.g. tablet instead of liquid) Labeling error
Wrong drug name, strength or quantity on label Wrong patient name on label

Failure to supply drug

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Standard indicators to measure dispensing practice

Dispensing Indicators Average dispensing communication time Percentage of prescribed drugs actually dispensed Percentage of prescribed drugs properly labeled Percentage of patients knowledgeable about the correct medication dosage/regimen

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Afghanistan Medicine Use Study Study results that illustrate possible irrational use

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Dispensing Times
The average dispensing times at primary health care facilities is 13.3 seconds The range for all health facilities is 4.3 to 27.8 seconds across all facilities studies Average dispensing times are very low and indicate a lack of time and commitment by dispensers to counsel patients on important drug use issues. A secondary indicator, adequate labeling, was also done. No labels met the criteria for being adequate labeled name of patient, name of drug and strength, directions for use.
Source: Green, T., Z. Omari, Z. Siddiqui, J. Anwari, and A. Noorzaee. 2010. Afghanistan Medicine Use Study: A Survey of 28 Health Facilities in 5 Provinces. Submitted to the U.S. Agency for International Development by the Strengthening Pharmaceutical Systems 34 (SPS) Program. Arlington, VA: Management Sciences for Health.

Dispensing Times
Dispensing Times (seconds), by health facility
30.0

Time in Seconds

25.0

20.0

15.0

10.0

5.0

0.0 A B C D E F G H I J K L M N

Health Facility

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Average Dispensing Times Comparison with Other Studies

Afghanistan Medicine Use study March 2009 SCA - Afghanistan May 2003 WHO -International Studies May 2009 13.3 Seconds

149 Seconds 70 seconds

Source: WHO -Medicine Use in Primary Care in Developing and Transitional Countries. May 2009. WHO Press, Geneva Source: SCA - Swedish Committee for Afghanistan, Baseline Drug Indicator Study, A Comparative Cross Sectional Study in SCA Health Facilities in Afghanistan, Part II: Results and Next Steps, April 2003 36

Percentage of Patients with Knowledge of Drug Dosage

Percentage of patients with adequate knowledge of medicine dosage (dosage, frequency of use, duration of use, and route of administration) is 29% The range is 1-63% for across all health facilities The overall knowledge of drug dosage is poor and needs improvement to ensure that patients take their medications correctly and they receive optimal drug therapy
Source: Green, T., Z. Omari, Z. Siddiqui, J. Anwari, and A. Noorzaee. 2010. Afghanistan Medicine Use Study: A Survey of 28 Health Facilities in 5 Provinces. Submitted to the U.S. Agency for International Development by the Strengthening Pharmaceutical Systems (SPS) Program. Arlington, VA: Management Sciences for Health.

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Percentage of Patients Who Have Knowledge of Drug Dosage -Comparison with Other Studies
Afghanistan Medicine Use study March 2009 SCA - Afghanistan May 2003 WHO -International Studies May 2009  29%

 63.4%  71%

Source: WHO -Medicine Use in Primary Care in Developing and Transitional Countries. May 2009. WHO Press, Geneva Source: SCA - Swedish Committee for Afghanistan, Baseline Drug Indicator Study, A Comparative Cross Sectional Study in SCA Health Facilities in Afghanistan, Part II: Results and Next Steps, April 200338

Patient Care Indicators, Iran

Eastern Mediterranean Health Journal, May 2004

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Activity One: Identifying the Dispensing Process

A 45 year old patient come in the dispensing window with a prescription. One person will play the role of the 45 year old patient and another will play the role of the dispenser. The dispenser must analyze the prescription out loud The participants will analyze the actions and behavior of the dispenser during the entire analysis and make comments after the simulation

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Role Play

Prescribing and Dispensing role-play

Writer of the manual should develop this roleplay

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Conclusion
Dispensing is a critical part of drug use Dispensing is often neglected in training and Essential Drugs Program Interventions exist to improve dispensing Patients benefit from better dispensing

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Summary
Good dispensing practices enhance
patient adherence, satisfaction, and treatment outcomes

A dispenser has responsibility to ensure that drugs are given

To the right patient; in the prescribed dosage and quantity; with clear instructions and In a package that maintains potency;

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