Pocket Guide for Pharmacy

Technicians Second Edition

Jahangir MD, MPH, CPhT Professor and Former Director Allied Health Sciences,

including the Pharmacy Technician Program Everest University Melbourne, Florida

CENGAGE Learning-

Australia • Brazil • Japan • Korea • Mexico • Singapore • Spain • United Kingdom • United States

Contents

Preface xxiii

Acknowledgments xxix

About the Author xxxiii

SECTION 1 Introduction 1

The Foundation of Pharmaceutical Care 3 Educational 3

Educational Technician 4

Certification Examination for the Pharmacy Technician 5

Continuing Education 6

Job Opportunities 7

Places of Employment 8

Code of Ethics 9

Pertinent Websites

v i CONTENTS

Drug Regulation and Control Pure Food and Drug Act of

Harrison Narcotics Tax Act of 1914 15

Federal Food, Drug, and Cosmetic Act (FDCA) 15

Durham-Humphrey Amendment of

Kefauver-Harris Amendment of 1963 17

Controlled Substances Act (CSA) of 1970 18

Poison Prevention Packaging Act (PPPA) 22

Occupational Safety and Health Act (OSHA) of 1970 23

Drug Listing Act of 1972 24

Medical Device Amendment of 1976 24

Drug Regulation Reform Act of 1978 25

Orphan of 1983 25

Drug Price Competition and Patent Term Restoration Act of 1984 25

Prescription Drug Marketing Act of 1987 26

FDA Safe Medical Devices Act of 1990 26

Anabolic Steroids Control Act of 1990 26

Omnibus Budget Reconciliation Act of 1990 (OBRA '90) 27

Dietary Supplement Health and Education Act of 1994 28

Health Insurance Portability and Accountability Act 28

CONTENTS vii

FDA Modernization Act of 1997 29

Medicare Prescription Drug, Improvement, and Modernization Act of 2003 30

The Combat Methamphetamine Epidemic Act 2005 30

Food and Drug Administration Amendments 2007 31

Secure and Responsible Drug Disposal Act of2010 31

Patient Protection and Affordable Care Act 2010 32

New Drug Approval 32

Law and the Pharmacy Technician 33

Pertinent Websites 33

Pharmaceutical Terminology and Abbreviations 35 Medical and Pharmacy Abbreviations 35

Medication Errors 41

ISMP's List of Error-Prone Abbreviations, Symbols, and Dose Designations 45

Arabic and Roman Numerals on Prescriptions 57

Drug Names 57

Pertinent Websites 58

Pharmacy Calculations 59 Arabic Numbers and Roman Numerals 59

Rules for Using Roman Numerals 60

viii CONTENTS

The Metric System 62

Basic Units of the Metric System 62

The Household System 63

The Apothecary System 64

International Units 65

Fractions 66 Types of Fractions 67 Reducing Fractions to Lowest Terms 69 Adding Fractions 70 Subtracting Fractions 71 Multiplying Fractions 72 Dividing Fractions 72

Decimals 73 Adding Decimals 73 Subtracting Decimals 75 Multiplying Decimals 76 Dividing Decimals 76

Percents, Ratios, and Proportions 77 Percents 78 Ratios 78 Proportions 79

Calculation of Oral Drug Dosages 80 Ratio and Proportion Method 81 Formula Method 82

Calculation of Parenteral Dosages 83 Calculation of Dosages 83 Insulin Dosages 84 Heparin Dosages 85 Intravenous Calculations 86 Drop Factor 88 Calculation of Intravenous Flow Rates 89 Manually Calculating Drop Rates 90

Pediatric Dosage Calculations 92 Youngs Rule 92

CONTENTS

Clark's Rule 93 Rule 94

Calculate Dosage Based on Body Surface Area (BSA) 94

Alligation Alternate 96

Prescriptions 99 The Prescription Order Form 99

Prescription Blanks 99 Hospital Medication Orders 99

Parts of the Prescription 101

Processing the Prescription Order 102 Receiving 102 Reading and Checking 103 Numbering and Dating 104 Labeling 104 Preparing 106 Packaging 106 Rechecking 107 Delivering 108 Counseling 108 Recording and Filing 108 Pricing 108

Prescription Refilling 109

Controlled Substance Prescriptions

Dosage Forms and Routes of Drug Administration Drug Forms 112

Solid Drugs 113 Semisolid Drugs Liquid Drugs 113 Gases

CONTENTS

Basic Equipment for Parenteral Administration

Medication Containers Topical Route Transdermal Patches 119 Sublingual Administration 120 Buccal Administration 120 Inhalation Administration 121 Ophthalmic Administration 121 Otic Administration 123 Nasal Administration Vaginal Administration 125 Rectal Administration 125

SECTION II Community and Institutional Pharmacy 127

Community or Retail Pharmacy 129 Duties of the Pharmacy Technician in the Community Pharmacy 129

Prescription Processing 130 Record Keeping 130 Pricing 131 Answering Phone Calls 131 Using Computer Applications in the Control

Use 132 Accountability 133 Maintaining Privacy 133 Communication Skills 133 Teamwork Purchasing 134 Inventory Control 134

CONTENTS x i

Billing Records 135 Repackaging Products 135 Preventing Drug Errors 136 Safe Methods of Working 137

Organization of the Retail Pharmacy 138 Customer Service Area 138 Customer Pickup 138 Cash Register 139 Storage Cabinets for Controlled

Substances 139 Refrigerator 139 Storage of Completed Prescriptions 139 Computer Systems 140 Equipment for Filing, Labeling, and

Packaging 140 Pharmacy Sink 141 Storage for Stock Medications 141 Consultation Area 142

Hospital or Institutional Pharmacy 143 Hospital Pharmacy 143

Support Services 144 Product Services 144 Clinical Services 144 Educational Services 145

Organization of the Hospital Pharmacy 145

The Roles and Duties of Pharmacy Technicians in Hospitals 146

Medication Orders Types of Medication Orders 149

xii CONTENTS

Medication Dispensing Systems 150 The Floor Stock System The Unit-Dose System

Purchasing Systems Purchasing 152

Group Purchasing 152 Forms of Purchasing

Order Processing 153

Storage of Medications 153 The Shelf Life of Medications Medications Needing Refrigeration Automation Quality Control 155 Compounding Medications 155

Inventory Management 155

Inventory Turnover Rate 156

Safety 156

The Policy and Procedure Manual Regulatory Agencies That Oversee Hospital Pharmacy 157

The Joint Commission 158 CMS 158 State Board of Pharmacy Department of Public Health

Advanced Pharmacy 161 Mail-Order Pharmacy

Advantages 162 Disadvantages 162 Staff Members 163 The Role of Pharmacy Technicians

CONTENTS

Internet Pharmacy 164 Advantages 165 Disadvantages 166 Staff Members 166 The Role of Pharmacy Technicians 167 Verified Internet Pharmacy Practice Sites

167

Home Infusion Pharmacy 168 Advantages 169 Disadvantages 169 Staff Members 169 The Role of Pharmacy Technicians

Hospice Pharmacy Advantages Disadvantages 172 Staff Members 172 The Role of Pharmacy Technicians

Nuclear Pharmacy Radioactive Drugs 173 Inventory 175 Pharmacy Design 175 Equipment and Supplies Advantages Disadvantages 179 Staff Members 180 The Role of Pharmacy Technicians 180

Long-Term Care Pharmacy 180 Drug Distribution Systems 181 Emergency Medication Supply Advantages 182 Disadvantages 183 Staff Members 183 The Role of Pharmacy Technicians 183

Pertinent Websites 183

CONTENTS

Nonsterile Compounding 185 Equipment 186

Balances 187 Counter Balances 189 Weights 189 Spatulas 189 Compounding Slabs 190 Hot Plates 191 Mortars 191 Pestles 191 Beakers 193 Tongs 193 Heat Guns 194 Graduates 194 Pipettes 196

Compounded Preparations 197

Compounding Processes 197

Compounding Records and Documents 198

Commonly Compounded Products 199 Compounding Solutions 199 Compounding Suspensions 200 Compounding Suppositories 204 Compounding Capsules 208 Compounding Tablets 210 Compounding Powders Compounding Transdermal or Topical Dosage

Form Drugs

Repackaging 217 Unit-of-Use Packaging 218 Single-Unit Packaging 218 Single-Dose Packaging 218 Automated Systems 218

CONTENTS xv

Sterile Compounding 219 Issues Related to Sterile Compounding 219

Role of the Pharmacy Technician in Sterile Compounding 220

Types of Sterile Formulations 222

Equipment for Sterile Compounding 223

Laminar Airflow Hoods 224

Cleaning Laminar Airflow Hoods 228

Large-Volume Parenteral Solutions 230

Small-Volume Parenteral Solutions 233

Factors Affecting Parenteral Products 234 Basic Considerations for Sterile Compounding 235

Uses for Sterile Compounding 236

Aseptic Technique 236 Hand Washing 236 Clean Room 238

Sterile Compounding of Solutions 240 Procedure for Compounding Solutions

Compounding and Drug-Preparation Errors 241

Compounding a Total Parenteral Nutrition (TPN) Product 242

Packaging 243

Labeling 244

Storage 244

Quality Control and Quality Assurance 244

Roles of the Pharmacy Technician in Sterile Compounding 245

United States Pharmacopeia (USP) Chapter <797> 246

CONTENTS

f Medication Errors 249 Occurrence of Medication Errors 249

Prescribing Errors 251

Dispensing Errors 252

Administering Errors 253

The Patient's Role in Medication Errors 254

Avoiding Medication Errors 256

Medication Error Reporting 258 FDA Program 258 USP's Medication Error Reporting

Program 259 Minimizing Liability 259

Negligence and Malpractice Penalties 260

Computer Systems in the Pharmacy 263 Components of a Computer System 263

Computer System Databases 264 Patient and Customer Profiles 265 Prescriber Profiles 265 Drug Databases 265 Pricing Databases 266 Billing Databases 266 Payer Databases 266

Management 267

Computer System Functions 268 Management Functions 268 Labeling 268 Bar Codes 268

Technology and H1PAA 269 Documentation 270

Automation and Robotics 271

CONTENTS x

Pharmacy Operation 273 The Role of the Pharmacy Manager 273

Profitability of the Pharmacy Practice 274 Cost 274 Overhead 275 Markup 276 Discount 276 Inventory Control 277 Inventory Systems 278 Perpetual Inventory 278 Point Sale 278

Inventory Turnover Rates 279

Automated Work Systems 280

Ordering 281

Purchasing Procedures 282

Pricing 282

Average Wholesale Price 282

Repackaging 283

Disposal of Drugs 284

Accounting 286 Billing 286 Invoices 286

Receiving 287

Bar Coding 287

Returning Products 288

Drug Recalls 288

Record Keeping 291

Billing and Health Insurance 293

293

xviii CONTENTS

Coding System 296

Understanding Insurance Policies 298

Types of Health Insurance 298

Insurance Health Plans 299 Blue Cross And Blue Shield 299

Government Plans 299 TRICARE 299 CHAMPVA 300 Workers' Compensation 300 Medicare 301 Medicaid 307

Insurance Forms 307 Forms 308

Pharmacist Care Claim Forms 309

Fraud 310

SECTION III Drug Classifications and Pharmacologic Actions 313

Biopharmaceutics 315 Biopharmaceutics 315

Bioavailability Pharmacokinetics 316 Pharmacodynamics 321 Toxicology 326

. Human Response to Drug Activity 327 Factors Influencing the Effects of Drugs 327

Age 328

CONTENTS x ix

Weight 329 Gender 330 Genetics 330 Psychological Factors 331 Disease States 331 Pregnancy 331 Adverse Drug Reactions Drug Interactions 334 Drug-Diet Interactions 335

Drug Effects and Drug Classifications 337 Central Nervous System 337

Sedatives, Hypnotics, and Antianxiety Drugs 338

Anticonvulsants 340 Anti-Parkinson's Drugs 344 Antidepressants 346 Antipsychotics 350 Narcotic Analgesics 354 Anesthetics 356

Endocrine System 360 Drugs to Control Thyroid

Diseases 360 Drugs to Control Diabetes 362 Oral Contraceptives 368

Cardiovascular System 372 Antiangina Drug Therapy 372 Drugs to Treat Hypertension 375 Antiarrhythmics 381 Heart Failure and Drug Therapy 385 Antihyperlipidemic Drugs 386 Anticoagulant Drugs 389

CONTENTS

Musculoskeletal System Skeletal Muscle Relaxants Analgesics, Antipyretics, and

Inflammatory Drugs 395

Immune System 398 Chain of Infection 399 Beta-Lactam Antibiotics 401 Penicillins 401 Cephalosporins 404

406 Sulfonamides 408 Tetracyclines 410 Aminoglycosides 412 Fluoroquinolones 414 Miscellaneous Antibacterial Agents 415 Antiviral Drugs 417 Highly Active Antiretroviral Therapy

(HAART) 423 Antifungals 424

Respiratory System 426

Antitubercular Drugs 433

Antineoplastic Drugs 433

Sensory System 439 Topical Medications 439 Drugs Used for Skin Diseases 439

Ophalmic Medications 444 Otic Drugs 449

Digestive System 449 Nutritional Products 450 Vitamins 450 Minerals 452

APPENDICES

APPENDIX A Professional Organizations 455

CONTENTS x x i

APPENDIX B Federal Regulatory Agencies 461

APPENDIX C State Boards of Pharmacy 465

APPENDIX D Converting Measurements 477

APPENDIX E Medical Symbols and

Abbreviations 483

APPENDIX F The Most Common Poisonous Substances and their Antidotes 485

APPENDIX G The 100 Most Commonly

Prescribed Drugs in 2010 487

APPENDIX H Controlled Substances in the

United States and Canada 495

APPENDIX I Pregnancy Categories:

FDA Assigned 503

Interactions 505

APPENDIX K Drugs That Should Not Be

Crushed 519

APPENDIX L Pharmaceutical Companies 523

APPENDIX M Common Sound-Alike Drug

Names 529

APPENDIX N Nomogram 541

APPENDIX O Drug Identification Guide 543

P Professional Journals 551

APPENDIX Q Top 200 Drugs by Prescriptions Dispensed 553

Glossary 571

Index 583