Pharmacy practice Read chapter 20, 21, 22 and 23 in the text book and do the sample questions at the end. When you have finished you should read the web lesson and do the web test Pharmacy practice includes: a. Pharmaceutical care b. Drug consultation c. Ethics and bioethics (which will be addressed in another lesson) d. Pharmacy drugs and health Pharmaceutical care: The goal of pharmaceutical care is to optimize the patients health related quality of life, and achieve positive clinical outcomes, within realistic economic expenditures. To achieve this goal the following must be accomplished: a. A professional relationship must be established and maintained. b. Patient specific medical information must be collected, organized recorded and maintained. c. Patient - specific medical information must be evaluated and a drug therapy plan developed mutually with the patient. d. The pharmacist assures that the patient has all supplies, information and knowledge necessary to carry out the drug therapy plan e. The pharmacist reviews, monitors, and modifies the therapeutic plan as necessary and appropriate, in concert with the patient and healthcare team. Practice principles: a. Data collection b. Information evaluation c. Formulating a plan d. Implementing the plan The National Association of Pharmacy Regulatory Authorities (NAPRA): NAPRA was founded in February 1995 by Canada's pharmacy regulatory bodies, to enablemembers to take a national approach in addressing common issues. As an umbrella association of the regulatoryauthorities, NAPRA offers a number of advantages to its members such as: a. Cost savings and enhanced quality of outcomes from a pooling of financial resources and expertise. b. Harmonization of standards with greater credibility, dependability, and acceptance. c. An ability to evaluate the impact of policies and standards implemented in many jurisdictions. NAPRA is incorporated under the Canada Corporations Act as a voluntary, not for profit association. National Drug Scheduling Overview: Outline of the scheduling process: The national model consists of three schedules or four categories: a. Schedule I b. Schedule II c. Schedule III d. Unscheduled NAPRA has developed national standards for pharmacist corresponding to the level of professional intervention and advice necessary for the safe and effective use of these drugs by consumers, according to each schedule. Schedule I: Drugs require a prescription for sale and are provided to the public by the pharmacist following the diagnosis and professional intervention of a practitioner. The sale is controlled in a regulated environment as defined by provincial pharmacy legislation. Schedule II: Drugs, while less strictly regulated, do require professional intervention from the pharmacistat the point of sale and possibly referral to a practitioner. While a prescription is not requiredthe drugs are available only from the pharmacist and must be retained within an area of the pharmacy where there is nopublic access and no opportunity for patient self selection. For example: Measles vaccine and vaccines in general; Insulins; Nitroglycerin; Niacin extended release; vitamines; epipen, etc Schedule III: Drugs may present risks to certain populations in self selection. Although available withouta prescription, these drugs are to be sold from the self selection area of the pharmacywhich is operated under the direct supervision of the pharmacist, subject to any local professional discretionary requirements which may increase the degree of control. Such an environment is accessibleto the patient and clearly identified as the professional services area of the pharmacy. The pharmacist is available, accessible and approachable to assist the patient in making anappropriate self medication selection. For example: Acetaminophen >650 mg; Al (OH)3 ; 5 % Benzyl peroxide; Benzocaine; Cimetidine, etc Unscheduled drugs: can be sold without professional supervision. Adequate information is available for the patient to make a safe and effective choice and labeling is deemed sufficient to ensure the appropriateuse of the drug. These drugs are not included in schedules I, II or III and may be sold from any retail outlet. Policy for drugs not reviewed; Schedule I by default: This option was identified as most feasible as it supports harmonization. Schedule II by default: Was rejected because, this require most pharmacist intervention. Fax transmission model policy: Prescription drug orders may be transmitted by facsimile by a prescriber to a pharmacy, provided that the following requirements are met: a. The prescription must be sent only to pharmacy of the patients choice with no interveningperson having access to the prescription drug order b. The prescription must be sent directly from the prescribers office, directly from a healthinstitution for a patient of that institution, or from another location,provided that he pharmacist is confident of the prescribers legitimacy. c. The equipment for the receipt of the facsimile prescription must be located within a secure area to protect the confidentiality of the prescription information. d. The pharmacist is responsible for verifying the origin of the transmission and the authenticity of the prescription. e. The prescription drug order must be maintained on permanent quality paper by the pharmacy f. Facsimile transmission can be accepted from a practitioner registered to practice in any Canadian province. g. Pharmacist to pharmacist communication of prescription transfers (for other than narcotics and controlled drugs) may be completed by facsimile transmission. Drug Consultation: Development of effective communication skills: The pharmacist establishes and maintains rapport by using effective communications skills which includes: a. Listening, speaking and writing skills. b. Sensitivity to non verbal forms of communication c. Sensitivity to diversity in the community The best method is verbal and writing. The pharmacist demonstrates a caring and professional attitude. The pharmacist elicits the needs, values, desired level of care and desired outcome of the patient. The pharmacist considers the impact of life style factors on the health of individual patients. The pharmacist discusses with the patient the role of the pharmacist and the responsibilitiesof the patient. The pharmacist encourages patients to participate in decisions about their health and supports the patients right to make choices. The pharmacist develops professional relationship with patients and/or their agents/healthcare providers. To determine the patient's needs, values, desired level of care and desired outcomes regarding drug therapy and to establish the mutual responsibility of each participant. Standards for pharmacists supervising hospital pharmacies: 1. Policies governing pharmacy services: The supervising pharmacist shell ensures that: a. Written policies and procedures are in place to ensure that the standards are met. b. Medication related policies are referred to the appropriate hospital authority. 2. Hours of pharmacy service: Hours of pharmacy services shall meet the needs of hospital clients. 3. Quality assurance process: The supervising pharmacist shall evaluate the quality of the pharmacy services provided 4. Facilities, equipment, supplies and information: The supervising pharmacist shall ensure that there is sufficient space, facilities, equipment, information resources and supplies which are of the type, quality and quantity. 5. Drug procurement and inventory management: The supervising pharmacist shall have input to ensure that all medications purchased for use in the hospital are of acceptable standard and quality as determined by the appropriate hospitalauthority. 6. Medication distribution: The supervising pharmacist shall establish medication distribution services that meet the needs of the hospital patients and optimize safety, efficiency and economy. 7. Return of medications: The supervising pharmacist shall ensure that medications dispensed for individual patients in the hospital,but not used are returned to the pharmacy. Procedures should be undertaken for crediting and returning medications to stock (the meds never left the hospital). 8. Repacking of medications: The supervising pharmacist shall ensure that repacking of medications is done in according to the CSHP guidelines for repacking medications in hospitals listed in the official publications guide. 9. Medication preparation: The supervising pharmacist shall ensure that written policies and procedures are in place for medication compounding, including the preparation of sterile products and cytotoxic drugs. Patient counselling: 1. How to use ophthalmic drops: a. Wash your hands carefully with soap and warm water. b. If the product container is transparent, check the solution before use.If it is discolored or has changed in any way since it was purchased (i.e. particles in the solution, color change), do not use the solution. c. If the product container has a depressible rubber bulb, draw up a small amount of medication into the eye dropper by first squeezing, then relieving pressure on the bulb. d. Tilt the head back with chin tilted up and look toward the ceiling. e. With both eyes open, gently draw down the lower lid of the affected eye with your index finger. f. In the gutter formed, place one drop of the solution. g. Do not touch the tip of the eye drops with your eyelid or any other surface to maintain sterility. h. Close the eye and rotate the eyeball for few seconds. i. You may apply pressure to the eye bridge to prevent systemic absorption. j. Close the eye drops 2. How to apply an ophthalmic ointment: a. Wash your hands carefully with soap and warm water. b. You may want to hold the ointment in your hand for few minutes to warm and soften the ointment. c. Gently cleanse the affected eyelid with warm water and a soft cloth before applying the ointment. d. In front of a mirror, with the affected eye looking upward, gently pull the lower eyelid downward with your index finger to form a pouch. e. Squeeze a thin line (about 1/4 to 1/2 inch) of the ointment along the pouch. f. Important: do not allow the tip of the ointment tube to touch eyelid, your finger or any other surface. g. Close the eye gently and rotate the eyeball to distribute the ointment. You may blink several times to evenly spread the ointment. 3. How to use intranasal drops: a. Wash your hands with soap and warm water b. Lie down on a bed with your head tilted back and the neck supported (allow the head to hang over from the edge ofthe bed or place a small pillow under your shoulders). Tilt your head back so that it is hanging lower than your shoulders. note: for children, lie the child on his/her back over your lap. The head should be tilted back. c. Draw up a small amount of medication into the medicine dropper. d. Breathe through your nose. e. Place the tip of the medicine dropper just inside your nostril (about 1/3 inch). Avoid touching the dropper against the nostril or anything else. f. Place the directed number of drops into your nostril g. Repeat steps c-f for the other nostril if directed to do so. h. Remain lying down for about 5 minutes, so the medication has a chance to spreadthrough your nasal passages. 4. How to use intranasal spray or pump: a. Wash your hands with soap and warm water. b. Hold your head in an upright position. c. Close one nostril with one finger. d. With the mouth closed, insert the tip of the spray /pump into the open nostril Sniff in through the nostril while quickly and firmly squeezing the spray container or activating the pumpe. Hold your breath for a few seconds and then breath out through your mouth. f. Repeat this procedure for the other nostril only if directed to do so. g. Rinse the spray/pump tip with hot water and replace the cap tightly on the container. h. Wash your hands. The principles of sterile compounding: The pharmacist has a responsibility to provide sterile compounding services to their patientsin a manner consistent with expected standards of practice, which are being developed by provincial regulatory bodies to ensure patient safety. 1. Aseptic preparation area: An aseptic preparation area should be followed. A laminar air flow hood is essential for the preparation of sterile products and should be located in the aseptic preparation area 2. Laminar air flow hood: All sterile compounding in a community pharmacy should be performed in a laminar air flow hood. These hoods are designed to reduce the risk of airborne contamination during the preparation of sterile products. Laminar air flow hood have two basic functions: a. To filter bacteria and exogenous materials from the air. b. To maintain constant air flow out of the hood to prevent contaminated room air from entering the hood. After passing through the prefilter, air is channeled through the high efficiency particulate air (HEPA) filter to remove fine bacterial contaminants. This filter is built into the hood and is responsible for the sterile environment in the hood. The HEPA filter is not easily removed and generally requires outside maintenance for cleaningAir flow velocity determines the filtering capacity of the hood. If air flow is reduced, the filter is presumed to be clogged with contaminants and must be cleaned.

There are two types of laminar air flow hood available for compounding non toxic sterile products: a. Horizontal air flow: The air flow is directed forward. Work is preferred in the hood and the product is protected, however, the operator is not protected from the particles or fumes originating from ampules or vials. b. Vertical air flow: The air flow is directed downwards and away from the operator providing a safer working environment. This is the preferred hood for community pharmacists. When working under the laminar air flow hood, these guide lines should be followed for propare use. 1. Ideally the hood should be operating continuously 24 hours a day. Since this is not feasible in a community setting the hood should be turned on at least 30 minutes prior to use. 2. The working counter top and sides should be cleaned with suitable disinfectant (i.e. salvodil) prior to and after each use. 3. Any bottles, vials or containers should be wiped down with alcohol or disinfectant before being brought into the hood to prevent possible contamination. 4. Objects placed in the hood should be suitably placed to provide good air flow with minimum obstruction.Work should be at least 15 cms into the hood. 5. The HEPA filter should be checked, cleaned or re-certified once a year. 6. It is suggested that anyone working under a hood be gowned, gloved and masked. A lab coat should be worn to protect the operator from spills and if hair is long, a suitable cap should be worn. Aseptic Technique: Aseptic technique is defined as procedures that will minimize the chance of contamination with microorganisms. Contaminants may be brought into the aseptic area by equipment, supplies or people, so it is important to control these factors during preparation. A number of simple guide lines should be followed: 1. Anyone using laminar hoods should wash their hands with a suitable antimicrobial at the beginning of their work and when re-entering the aseptic preparation area. 2. Appropriate dress (i.e. gowns, gloves, or mask) suitable for sterile preparation should be worn. 3. Activities unrelated to product preparation should be kept at minimum. 4. Eating or drinking or the storage of food, drinks or personal items should not be allowed into the aseptic area. 5. Only one person should be working in the hood at any given time. 6. All items that will be used during preparation should be checked for defects and expiry dates prior to use. 7. All non sterile items surfaces should be disinfected with appropriate disinfectant prior to being placed into the hood. This includes scissors, clamps, and pumps. 8. All items necessary for the preparation should be placed into the hood prior to commencing the procedure. 9. Direct contact between a sterile product and non sterile product should be avoided. 10. All non sterile surface areas should be swabbed with alcohol and left for 30 seconds before puncturing. This includes ampules, vials and intravenous solutions port holes. 11. Ampules and vials should be opened and contents aspirated using appropriate techniques to avoid particulate contamination. This may require the use of filters for glass containers/ampules. 12. Reconstituted powders should be mixed carefully according to manufacturer's recommendations to ensure complete dissolution of the drug. 13. Needle entry into vials with rubber stoppers should be done at 45 degree angle to minimize rubber core particulates. 14. All finished products should be carefully inspected after preparation for visible precipitation. This should be done outside the laminar air flow hood. 15. Each prepared sterile product should be assigned an expiry date based on available data. If non is available, a short period should be applied (i.e.24 hours). If aseptic technique is not followed, the final product may be contaminated. It is important that proper technique be utilized to ensure the integrity of the product. Minimizing medication errors: Introduction: There is an agreement that since neither dispensing discrepancies (a potential error which does not reach the patient) or medication errors (in which the patient actually receives the erroneous prescription) can be eliminated completely, an open process of evaluation and discussion is required each time a mistake occurs.This will result in practice changes to prevent future errors. Procedures for preventing and handling errors are addressed in this unit. Environments in which medication errors are more likely to occur tend to be characterized by: a. disorganized work flow b. fatigued staff c. frequent interruptions and distractions d. poor physician handwriting e. emphasis on volume over service quality f. stress g. ineffective communication with patients h. improper technician training i. a pattern of inadequate staffing. As pharmacists devote more time to counselling and providing cognitive services in order to achieve desired health outcomes, the need to implement procedures and policies to prevent errors should not be forgotten. Leading edge practitioners commented that all pharmacy practices are prone to medication error, which is due, after all, to the human element inherent in pharmacy practice. It was felt that consumers accept the fact that pharmacists are human and errors will be made,but that the way an error is handled is critical. Common suggestions for practice changes to decrease the risk of errors: Human resources: a. more technical workers b. clear checking procedures for technicians and pharmacists c. maximum of two technicians per pharmacist d. well defined roles and job descriptions for all functions in the dispensary e. technician certification or adequate technician training. f. work in teams g. staff meetings to address annual and regular reviews and discussions after errors.

Dispensing procedures: a. electronic DIN scan b. ensure accountability through identifying staff involved at each step in the process c. do not hesitate to question a prescription if it is unclear. d. be clear about what is wanted/needed by the patient, ensure that checks occur in every step of the dispensing process e. always take the time to do all the checks. Dont be rushed by a "low time" parking meter. f. be aware of other potential sources of error such as looking alike, sound alike drugs names and products, drugs for which a reasonable dose may vary by a factor of 10 (i.e. prednisone 5 mg vs 50 mg) drugs with a high potential for negative outcomes or a large variation in prescribed dosages (i.e. warfarin) g. provide thorough patient counselling beginning by asking the patient what their physician told them the medication was for. h. show the patient the tablets or capsules to ensure they are receiving the medication they expected to receive Policies: Institute a policy for error evaluation and subsequent practice improvement. Insist all sales reps make appointments, dont allow them to "drop in because the doctors; offices are closed". Dispensary re-design to decrease the risk of errors: a. minimize interruptions, like headsets to answer phones, specific staff assigned to phones b. keep traffic flow in the dispensary at a minimum. c. adequate space to perform each function d. non dispensing functions like stock control, filing, etc, should be separated from theprescription filling area. e. ensure adequate storage space for supplies, books, etc to minimize clutter f. UPC computerized scanner to verify product entered - DIN checked. g. Picture of medication on computer screen for technician and pharmacists h. large work counter for technicians and a system in place for checking i. separate pharmacist service counter, where pharmacists discuss therapy with patients,from the rest of the dispensing process. j. a dedicated phone line for physicians/pharmacist communication k. work flow should facilitate pharmacist review with profile and patient without interruptions l. electronic exchange of information to enhance prescription legibility, provide patient history,diagnostic, etc m. shadow box displaying tablets or capsules used in automated counting cells. Canadian error reporting system: 1. Ontario College of Pharmacists: Pharmacy connection journal publishes disciplinary proceedings, which are also a valuable source of information about medication errors. Preventing errors: 1. "Causes and Prevention of Medications Errors"-institute for safe medication practices. This resource is U.S. based, but the advice and practical strategies apply to pharmacy practice in Canada as well. This program can be reached 24 hours/day at 1-800-23-error. 2. Ontario pharmacist's Association: "Quality Assurance in Pharmacy Services - confronting medication Errors" was developed to make pharmacists aware of the incidence, causes and handling of medication errors in practice. It includes consideration of system/work flow factors, communication and documentation. Techniques described by practitioners: To decrease the risk of errors include: 1. Separate all components of each prescription being filled into bins throughout the entire dispensing process 2. Fill from the original prescription, not the label printed when the prescription is entered into the computer system 3. Triple check: The original prescription to the bottle; the label to the original prescription and bottle including the DIN; as pharmacist hands the prescription to the patient, comparing the original prescription to the label and the drug. Handling errors: Although the admission of an error is a controversial issue with the respect to legal liabilities, as professionals pharmacists have an obligation to "make it right" if a patient suggested that an error has been made. Reviewers with experience on discipline committees of the provincial regulatory authorities suggest that often an aggrieved party is more upset by the way an error is handled that the actual error itself. A patient's inconvenience and distress should be recognized and acknowledge. Potential error situations should be handled promptly, with courtesy and professionalism. "Handling Dispensing Errors, Pritchard (1995) offers a brief review on dealing with medication errors and described 2 documents available from OCP: 1. Suggested protocol for handling dispensing errors. 2. An incident form for documentation "The initial contact between a patient alleging a dispensing error and pharmacy is usually conducted over the phone. It is suggested that if the error can be confirmed over the phone the pharmacist should offer to send the replacement medication rather than ask the patient to return to the pharmacy immediately." "After "no discrepancy" the flow chart states "reassure patient/agent". The pharmacist should also consider that the physician might have inadvertently ordered the wrong drug or the correct drug with the incorrect patient name on the prescription form. Another step for pharmacists is to "confirmed with prescriber if necessary" and then: reassure patient/agent". Drug information resources: Definition: Drug information is current, critically examined, relevant data about drugs and drug use in a given patient or situation. There are three sources of drug information: J ournals (primary source) Indexing and abstracting services (secondary resource) Textbooks (tertiary resources) I. Primary Sources: It contains articles and journals. Articles are generally defined as a study that describes step by step evaluation of a drug including experimental procedure, data collection, purpose of experiment, conclusion and result of experience. Examples: Drug Topic; Pharmacy Times; Hospital Pharmacy; US Pharmacist. II. Secondary Sources: Indexing and abstracting services are valuable tools for quick and selective screening of the primary sources for specific information, data, citation, and articles. In some cases, the sources provide sufficient information to serve as reference for answering drug information requests. Example: ClinAlert; Current Contents; Drugs in Use; Drugdex; Index Medicus; Inpharma; International Pharmaceutical Abstracts; Iowa Drug Information System; Pharmaceutical News Index; Reactions; Science Citation Index III. Tertiary Sources:

Contains the reference sources in condensed and compact form such as drug fact and comparisons,American hospital formulary, text books and reference books. References Example of references 1. Product orientedPDR Red Book Facts and comparisons Blue Book Non prescription drug 2. Drug oriented Martindale's the extra Pharmacopeia Hand Book of Injectiable Drugs Drug Interaction Fact Hansten's Drug Inter 3. Therapeutic orientedMerck manual Applied Therapeutics Clinical Pharmacy and Therapeutics 4. Dispensing oriented Remington USP - NF Merck Index 5. Poisoning InformationDreisbach's Handbook of Poisoning To identify or assess product availability, consider using these resources: 1. For drugs manufactured in the U.S, the following resources are available: a. The American Drug Index, which is updated annually b. Drugs Facts and Comparisons, updated monthly and bound annually c. Drugs Topics Red Book, which releases supplements and is updated annually d. The Physicians Desk Reference (PDR) which is updated annually e. The American Hospital Formulary Service (AHFS) Drug Information, which is supplementedquarterly and updated annually f. Martindale: The Extra Pharmacopeia, which is updated every 5 years. 2. For drugs manufactured in foreign countries, the following resources are available: a. Martindale b. Index Nominum c. United States Adopted Names (USAN) and the United States Pharmacopeia (USP) Directory of drugs names 3. For investigational drugs, the following resources are available: a. Martindale b. Drug Facts and Comparisons c. Unlisted Drugs d. The NDA Pipeline 4. For Orphan drugs (drugs that are used to prevent or treat a rare disease and for which the FDA offers assistance and financial incentives to sponsors undertaking the development of the drugs), the following resources are available: a. Drug Facts and Comparisons b. The National Information Center for Orphan Drugs and Rare Diseases c. Drugdex 5. for an unknown drug (one that is in hand but not identified) chemical analysis can be performed or the drug can be identified by physical characteristics, such as color, special marking, and shape. Consult the following sources for help: a. The PDR, CPS, Drug Facts and Comparisons b. Identidex c. The manufacturer d. A laboratory

6. Approved uses of drugs can be checked in: a. Drug Facts and Comparisons b. AHFS c. PDR d. USP DI e. Drugdex (micromedex) f. Clinical Pharmacology g. Drug Information Hand Book 7. Unapproved uses: a. Drug Facts and Comparisons b. AHFS Drug Information c. Martindale d. Drugdex e. Index medicus, Medline f. Inpharma g. USP DI 8. For signs and symptoms of a possible adverse drug reaction, consult the following resources: a. Meyler's side effects of drugs b. A general drug reference c. Reactions (ADIS) d. Index Medicus 9. For signs or symptoms for drug interactions, consult the following resources a. Drug Interaction Facts, Hansten's Drug interaction analysis and management, Evaluations of drug interactions (EDI) b. PDR c. Reactions d. Index Medicus 10. For stability of the drug and its compatibility with other drugs, the administration technique and the equipment that holds it,check the following resources: a. Trissel's Hand Book on injectable drugs b. King's guide to parenteral admixtures c. Trissel's stability of compounded formulations. Sample questions: 1. Which resource will you use to find half life? answer: CPS or USP DI 2. Which resource will you use to find HLB? Answer: Remington 3.Which resource will you use to find solubility? answer: Merck Index 4. Which resource will you use to find infusion rate? answer: Manufacturer leaflet.

Health promotion strategies: What can pharmacist do to help their patients stay healthy?Patients are responsible for making choices but health care professional are responsible for the clarity and accuracy of the information presented. The pharmacist can assist in defining small achievable goals within a specified practical time frame;Education on disease prevention using suitable materials such as pamphlets and booklets from various organizational and support groups, as a way of thinking would help pharmacists realize their potential to health promotion. Exercise: 1. It is a major component of health promotion and disease prevention. 2. Target group: Diabetes mellitus; coronary heart disease; osteoporosis; mental stress; etc. 3. Benefits are maximal if continued. 4. Watch out for signs such as chest pain; dizziness; shortness of breath; and consult aphysician in these casses. Nutrition: 1. Overweight is defined as body mass index >25; obesity is BMI >30. 2. BMI is measured as kg/(weight in cmxcm) 3. Diet high in vegetables and fruits, fiber and whole grains, low in saturated fats, rich in omege - 3 fatty acids, help control calorie intake. 4. Target group: Coronary heart disease; diabetes mellitus; sleep apnea; osteoarthritis; etc 5. Clinical nutritionist or professional with specialized nutritional expertise for patients with Diabetes mellitus, dyslipidemia, and coronary heart disease should be consulted. Smoking cessation: 1. Recommendation from health care professional like pharmacist is one of the most important ways of influencing a patient to consider quitting. 2. Target group: Cardiovascular disease; osteoporosis, lung diseases, pregnant women or planning to be. 3. Address concern for increase in weight, offer solutions like eating healthy snacks like carrot, fruits, sugarless gum, etc. Standards of Practice: Standard 1 The pharmacist, using unique knowledge and skills to meet a patient's drug-related needs, practices patient-focused care in partnership with patients and other health care providers, to achieve positive health outcomes and/or to maintain or improve quality of life for the patient. Refer: Operational Components 1.1 - 1.8 Operational Component 1.1 The pharmacist develops professional relationships with patients and/or patients'agents and/or health care providers: a. To determine the patient's needs, values, desired level of care and desired outcomes regarding drug therapy, and b. To establish the mutual responsibility of each participant. 1.1.1 The pharmacist establishes and maintains rapport by using effective communication skills. Effective communication includes:Listening, speaking and writing skillsSensitivity to nonverbal forms of communicationSensitivity to language barriers andSensitivity to diversity in the community 1.1.2 The pharmacist demonstrates a caring and professional attitude. 1.1.3 The pharmacist elicits the needs, values, desired level of care and desired outcomes of the patient. 1.1.4 The pharmacist considers the impact of life style factors on the health of individual patients. 1.1.5 The pharmacist discusses with the patient the role of the pharmacist and the responsibilities of the patient. 1.1.6 The pharmacist encourages patients to participate in decisions about their health and supports the patient's right to make choices. Operational Component 1.2 The pharmacist ensures that appropriate patient information is gathered and recorded to establish a profile for the provision of patient-focused care and that the information is maintained in a manner which ensures ease of use for patient care activities and confidentiality for the patient. The pharmacist reviews relevant information from the patient profile with each new prescription, change of prescription, and repeat prescription. The profile shall include demographic information about the patient as articulated under the Drug and Pharmacies Regulation Act and Regulations or the CSHP Standards of Practice and may also include, where appropriate, other information that is considered important for continuity of care and achievement of an optimal therapeutic outcome. This could include known patient risk factors for adverse drug reactions, drug allergies or sensitivities; known contraindications to prescription drugs, nonprescription drugs, natural health products, and complementary or alternative medicines, and other medications or treatments the patient is currently taking that may contribute to their condition or interact with suggested therapy. Operational Component 1.3 Prior to dispensing any medication, the pharmacist shall review the prescription to ensure that it is authentic, accurate, appropriate, and complete. In a hospital, when the review of each medication order is not possible at time of dispensing or use, the pharmacist should review medication orders for appropriateness within a reasonable amount of time. With the information available, the pharmacist evaluates the patient's drug therapy and identifies potential and actual drug-related problems. 1.3.1 The pharmacist determines whether the drug therapy is appropriate including appropriate dosage form, route, and length of therapy. 1.3.2 The pharmacist determines if the correct amount of the drug is being received and taken appropriately. 1.3.3 The pharmacist recognizes and takes steps to avoid or minimize adverse outcomes related to drug therapy such as side effects, toxicity, adverse drug reactions, drug-disease incompatibilities, drug-drug interactions, and duplication of therapeutically similar medications. 1.3.4 The pharmacist recognizes and takes steps to avoid problems related to intravenous administration including potential incompatibilities, drug stability, volume of intravenous fluid for medication administration and rate of administration. 1.3.5 The pharmacist recognizes and addresses patterns of inappropriate use of drugs. 1.3.6 The pharmacist detects and responds appropriately to activities which would divert drugs from their intended legitimate use. 1.3.7 The pharmacist provides appropriate information to facilitate the patient's understanding of his or her drug therapy and ability to comply with the therapy regimen. Operational Component 1.4 If any potential or actual drug-related problems are identified, the pharmacist determines appropriate therapeutic options to solve or prevent them. 1.4.1 The pharmacist prioritizes identified problems. 1.4.2 The pharmacist proposes alternative strategies, including non-drug and drug therapies. 1.4.3 The pharmacist selects the most appropriate therapeutic option through consultation with the patient and/or other health care providers. 1.4.4 The pharmacist refers the patient to an appropriate health care provider or health care agency after determining with the patient if such a referral is necessary. The following situations may prompt such a referral:Information from the patient indicating a potentially severe or worsening conditionUncertainty about the patient's symptoms or conditionFailure of treatment to remedy a condition within a predetermined period of time 1.4.5 The pharmacist explains the rationale of the proposed treatment to patients and/or patients' agents and/or other health care providers. Operational Component 1.5 The pharmacist ensures documentation of significant observations arising from the patient assessment, recommendations made and actions taken, in a readily retrievable format. The pharmacist shall resolve any questions regarding the order and shall document the resolution in the patient's health record. Operational Component 1.6 The pharmacist is clearly identifiable and is available, accessible and approachable to consult with the patient who is seeking to self-medicate with a nonprescription drug, a natural health product, or a complementary or alternative medicine. Operational Component 1.7 The pharmacist documents and reports any unexpected adverse drug reactions* to the prescriber and other health care providers as appropriate, and complies with formal adverse drug reaction reporting programs. * "Unexpected adverse drug reaction" is an undesirable patient effect that is inconsistent with the product information or labelling; is serious; or results from administration of a recently marketed drug whether serious or not. Operational Component 1.8 The pharmacist takes appropriate action to acknowledge and prevent medication discrepancies* and errors**, takes the necessary steps to resolve issues arising from medication discrepancies and errors, and implements measures to prevent recurrence. 1.8.1 The pharmacist discusses the error with the patient, prescriber and other health care providers as appropriate. 1.8.2 The pharmacist documents the error according to the protocol of the workplace. * "Medication discrepancy" - an event which does not involve the actual administration of a drug to a patient, but where an error in the medication process has been detected and corrected before reaching the patient. ** "Medication error" (may also be referred to as a medication incident) is an event which involves the actual prescribing, dispensing, delivery or administration of a drug or the omission of a prescribed drug to a patient. Standard 2 The pharmacist practices within legal requirements and ethical principles, demonstrates professional integrity and acts to uphold professional standards of practice. Refer: Operational Components 2.1 - 2.4 Operational Component 2.1 The pharmacist complies with legal requirements and ethical principles of practice including federal and provincial legislation governing the sale of drugs and practice as a pharmacist, and provincial regulatory authority by-laws, standards of practice, policies and guidelines. Operational Component 2.2 The pharmacist upholds and acts on the ethical principle that the primary accountability of the pharmacist is to the patient, with respect to:Patient confidentialityInvolvement of the patient in the decision-making process, andthe right of the patient to make their own choices 2.2.1 In the course of fulfilling the duty of care for the patient, the pharmacist has the right to refuse to provide a product or service. 2.2.2 The pharmacist has the right to dispense less than the quantity prescribed, if the proper exercise of professional judgement by the dispenser so requires (DIDFA, Reg.936, Section 3). Operational Component 2.3 The pharmacist demonstrates personal and professional integrity. 2.3.1 The pharmacist accepts responsibility for his or her actions and decisions. 2.3.2 The pharmacist shows respect for the dignity of the patient. 2.3.3 The pharmacist collaborates with other health care professionals to enable the patient to achieve his or her health care goals. Operational Component 2.4 The pharmacist continuously strives to gain knowledge and maintain professional competence. 2.4.1 The pharmacist identifies learning needs and seeks, evaluates and participates in learning opportunities to meet these needs to enhance practice through education and experiential learning. 2.4.2 The pharmacist recognizes and practices within the limits of his/her professional expertise. Standard 3 The pharmacist identifies, evaluates, interprets and provides appropriate drug and pharmacy practice information to achieve safe and effective patient care. Refer: Operational Components 3.1 - 3.5 Operational Component 3.1 The pharmacist identifies and evaluates appropriate sources of relevant information. Operational Component 3.2 The pharmacist critically evaluates drug information. Operational Component 3.3 The pharmacist determines the critical content to be provided. Operational Component 3.4 The pharmacist provides information in a manner suitable for the recipient's use. Operational Component 3.5 The pharmacist organizes and provides drug information to appropriate recipients. Standard 4 While respecting the patient's right to confidentiality, the pharmacist communicates and educates to provide optimal patient care and promote health. Refer: Operational Components 4.1 - 4.5 Operational Component 4.1 The pharmacist respects the patient's rights to confidentiality and privacy by taking all reasonable steps to ensure that personal health information is communicated in a manner in which the discussion cannot be overheard by others. This may involve the use of an acoustically private area such as:A semi-private area with suitable traffic and/or noise barriers orA private counselling room 4.1.1 The pharmacist respects the confidences of the patient and protects the information received as privileged communication between a patient and healthcare provider. (Also see Principle 3 of the Code of Ethics.) Operational Component 4.2 The pharmacist communicates using effective and appropriate communication skills while respecting the patient's personal, cultural and educational differences. The pharmacist demonstrates flexibility in recognizing the unique qualities of each patient in order to find workable solutions. Operational Component 4.3 Prescribed Drugs The pharmacist takes reasonable steps to enter into dialogue with the patient or agent on all initial prescriptions in a community setting, in established programs in an institutional setting, or when made necessary by professional judgment of the pharmacist, the need of the patient or agent, or upon their request. Hospital pharmacists should include patient dialogue in their practice. Such dialogue includes, but is not necessarily limited to:Confirmation of the identity of the patientCurrent medical condition(s) being treatedName, general description of the drug dispensed and directions for useThe intended therapeutic responseCommon or important side effects and appropriate management, andStorage requirements 4.3.1 The pharmacist documents the dialogue in a readily retrievable format, including the date the dialogue occurred, with whom, and the identity of the pharmacist. 4.3.2 Should dialogue not take place in the community setting, the pharmacist documents the reason. 4.3.3 Where it is deemed important for continuity of care, the pharmacist documents any relevant information in a readily retrievable format such as the patient's profile or health record. Operational Component 4.4 Nonprescription Drugs The pharmacist takes reasonable steps to enter into a dialogue with the patient or agent and offers service, assistance or advice, if the patient:Requests help in selecting a Schedule II, III or other nonprescription productAppears to be having difficulty selecting a nonprescription productIs perceived or observed to make frequent or repeat purchases, or to purchase inappropriate quantities of nonprescription productsIs recognized as someone for whom self-selection and use of a nonprescription product may pose a risk (such as pregnant or nursing women, the elderly, infants or young children, and those with known medical conditions or those currently on other drug therapy)In an institution, requests information and advice 4.4.1 When entering into dialogue, the pharmacist interacts with the patient or agent to receive and provide information needed. 4.4.2 The pharmacist interviews the patient or agent to determine and assess as appropriate to the request:Condition or symptom(s) to be treatedCurrent, relevant disease state(s) drug allergies or sensitivitiesCurrent medicationsOther medications or treatments patient may have already triedThe need for referral to another health professional, the appropriateness of drug therapy or the advisability of non-drug therapies As part of the patient/pharmacist dialogue, the pharmacist consults and reviews the patient profile and ensures that it is updated as appropriate. 4.4.3 The pharmacist discusses with the patient any recommended drug therapy including, where appropriate:Directions for proper useCommon adverse effectsExpected responseWhen to seek the attention of another health professional 4.4.4 Where it is deemed important for continuity of care of the patient, the pharmacist documents relevant information in a readily retrievable format, such as the patient's profile or health record. Operational Component 4.5 Delivered Drugs Upon a request from a patient in the community or outpatient setting, for the delivery of a scheduled product, the pharmacist takes reasonable steps to dialogue with the patient or agent. 4.5.1 If a prescribed drug is being released to a person other than the patient or for delivery to another premise, the pharmacist takes reasonable steps to:Inform the patient through written or electronic communication that he or she is available to provide information about the medicationConfirm that the person is an agent for the patientProvide the agent for the patient with the necessary information if the pharmacist is satisfied that it is in the patient's best interest to do so, andWhere possible, communicate by telephone or other electronic means with the patientProtect patient confidentiality 4.5.2 If a Schedule II drug is being released to a person other than the patient or for delivery to another premise, the pharmacist must make the decision to sell the product and take reasonable steps to dialogue with the patient or their agent. 4.5.3 If a Schedule III drug is being released to a person other than the patient or for delivery to another premise, the pharmacist informs the patient that he or she is available for consultation. Standard 5 The pharmacist, in collaboration with the designated manager or hospital pharmacy manager, manages drug distribution by performing, supervising, or reviewing the functions of selection, preparation, distribution, storage and disposal of drugs to ensure safety, accuracy and quality of supplied products. Refer: Operational Components 5.1 - 5.4 Operational Component 5.1 The pharmacist ensures that all pharmacy support personnel know when to refer a question or query to a pharmacist. Operational Component 5.2 - (Applies to community practice) The pharmacist locates drugs in the area of the pharmacy consistent with the appropriate drug schedule classification, regulations and safety consideration which reflect the level of risk of the drug for the patient. 5.2.1 Schedule I drugs must be located in the prescription services department (dispensary) or in a secure storage area accessible only to authorized personnel. 5.2.2 Schedule II drugs for sale to the public must be located in the prescription services department (dispensary) or in a secure area adjacent to the prescription services department, ensuring the area is readily accessible for the pharmacist but provides no opportunity for self selection by the patient. The pharmacist must always be involved in the decision to sell a Schedule II drug to the public. 5.2.3 The pharmacist ensures that all personnel know:That only a pharmacist, intern, or registered pharmacy student under the direct supervision of the pharmacist may provide information or advice respecting the use of nonprescription products, natural health products and complementary or alternative medicinesWhere Schedule II, III and other nonprescription products are located in the pharmacyWhy these products are located where they areWhen the pharmacist is required or expected to intervene/consultWhen to refer patients to the pharmacist 5.2.4 Schedule III drugs and all other nonprescription products should be located in an area of the pharmacy adjacent to the prescription services department (dispensary) which should allow self selection of Schedule III drugs by a patient, and provide opportunities for patient/pharmacist consultation. 5.2.5 The pharmacist should endeavour to enhance patient awareness of the benefits, limitations, appropriate use and risks associated with nonprescription products through one or more of the following:Signage which encourages patients to consult with the pharmacist regarding the selection of nonprescription productsSignage in particular areas to encourage dialogue between the pharmacist and the patient with respect to certain disease states, such as:Diabetes and foot care productsGlaucoma and eye care productsHypertension and cough/cold productsShelf talkersAppropriate supplementary informationMultimedia communication encouraging patients to consult with pharmacists Operational Component 5.3 The pharmacist performs, supervises and reviews drug distribution activities in accordance with federal and provincial legislation, policies and guidelines, and/or institutional policies and CSHP Standards of Practice. 5.3.1 The pharmacist applies knowledge relevant to:Interpretation of prescription medication ordersBio-equivalency and interchangeability of multi-source drugsFormulary and drug plan managementPharmaceutical calculationsSelection of ingredientsAcquisition of pharmaceuticalsCompounding and dispensing, including labelling according to applicable standardsAppropriate packagingPreparation of sterile productsStorage, handling conditions and stability Operational Component 5.4 The pharmacist ensures the removal of outdated, mislabeled or deteriorated drugs and those recalled from regular stock, for storage in a separate area for appropriate disposal. The pharmacist ensures that:Expired and recalled drugs are not dispensedDrug recall policies and procedures are in place and enacted if necessaryDispensed drugs will not expire prior to the patient completing the course of therapy Operational Component 5.5 The pharmacist shall not return to stock, or dispense a drug previously dispensed and delivered to the patient or the patient's agent. In a hospital practice, a drug shall only be considered to have been dispensed and delivered to the patient when the drug has been given, or administered to the patient by a nurse or other health care practitioner. 5.5.1 In a hospital practice, the pharmacist shall ensure that medications dispensed for individual patients, but not delivered to the patient, are returned to pharmacy. Procedures for crediting and returning medications to stock shall ensure:Integrity of the returned drug package;Proper storage of the medication in the patient care area;Ability to identify the drug, including the lot number and expiry date Operational Component 5.6 When the pharmacist accepts the return of unused drugs, he/she ensures the safe and appropriate storage and disposal of those drugs according to environmental regulations under written policies and procedures. 5.6.1 In a hospital practice, the following medications shall be properly discarded when returned to the pharmacy:Opened topical medications (e.g. creams, ointments, lotions, ophthalmic/otic/ nasal drops/ointments);Used inhalation productsUndated, open multi-dose medication, e.g. vialsOpened single-dose vialsMedications handled by patientsMedications returned by ambulatory patientsImproperly stored medications Operational Component 5.7 While cognitive functions of dispensing can not be delegated, where appropriate, the pharmacist may assign or delegate technical functions to authorized personnel. 5.7.1 The pharmacist determines whether such personnel are adequately trained and qualified. 5.7.2 The pharmacist ensures that all pharmacy support personnel know when a pharmacist is required or expected to intervene and consult. 5.7.3 In an institutional setting, the technical aspects of dispensing may be delegated to non-pharmacists provided the pharmacist meets the requirements of the Protocol for Delegating Dispensing and Compounding in Health Care Facilities. Standard 6 The pharmacist applies knowledge, principles and skills of management as they pertain to the site of pharmacy practice, with the goal of optimizing patient care and inter-professional relations. Refer: Operational Components 6.1 - 6.3 Operational Component 6.1 A pharmacist only practices under conditions which do not compromise his or her professional independence or judgement, and does not impose such conditions on other pharmacists. Operational Component 6.2 The pharmacist, or the pharmacist in collaboration with pharmacy management, ensures that pharmacy operations protect the public and the people working on the premises. 6.2.1 The pharmacist uses the space, facilities, equipment and supplies available in the pharmacy to ensure patient safety through proper storage, preparation, dispensing, distribution, and disposal of drugs. 6.2.2 The pharmacist ensures that appropriate procedures for the handling and evaluation of medication discrepancies and errors are followed. Operational Component 6.3 The pharmacist or the pharmacist in collaboration with pharmacy management takes reasonable steps to maintain adequate and appropriate staffing to ensure that pharmacy practice is in accordance with these Standards. 6.3.1 The pharmacist assumes professional responsibility for and supervision of pharmacy support personnel with whom they have direct interaction in their role and/or assigned tasks. Narcotic, Controlled drugs, Benzodiazepines and other Targeted Substances 1. When refills are permitted (for controlled drugs) a record is kept of each refill, the refill ispermitted if less than 1 year has elapsed since the day on which the prescription was issued by the doctor. Refills must be abide by any intervals noted by the prescriber. 2. A pharmacist may transfer a prescription for targeted substance to another pharmacy only once. The pharmacist can not transfer Rx that was already been transferred before. 3. Licensed dealers: No person except a licensed dealer, shall manufacture, import, export, sell, give, transport, send, deliver or distribute a narcotic. Licensure is controlled by Health Canada. 4.Ordering supplies of Controlled Substances:Onlyan authorized pharmacist (Narcotic signer) can order controlled substances by: 1. written order 2. through computer from remote input device 3. by verbal order for verbal prescription narcotic that specifies name and quantity of the narcotic. To become a narcotic signer in Ontario, the pharmacy owner must notify OCP. Pharmacy manager is automatic a narcotic signer. For order from remote input device or verbal order, licensed dealer must receive receipt within 5 working days stating: name and quantity of narcotic; date received; signature of pharmacist (who received order) If receipt is not received, licensed dealer shall not supply any further orders by remote input device or phone.