Transcript Pharmacy Technician*s Course. LaGuardia Community College

Inventory Management
 Purchasing Systems
 Independent Purchasing: a single pharmacy entity
establishes a contractual agreement with a
pharmaceutical manufacturer or wholesaler.
 Group Purchasing: contractual agreement between a
manufacturer or a wholesaler and a group of pharmacies
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I.e.. CVS , Walgreens and other chains as well as a health
system pharmacies like the medisys system which includes
Jamaica, Flushing and other hospitals in the NY area
Competitive pricing and better terms
Purchasing Methods
 Direct Purchasing
 Involves buying directly from drug companies
 Not commonly done, only for restricted items
Wholesalers and primary vendors are not direct purchasing venues but rather
are firms whose business is to provide a warehouse of drugs where pharmacies
can order multiple drugs, both brand and generic from a single source.
Examples include Cardinal Health, McKesson and Anda Generics.
They offer next day service (sometimes same day). Higher cost than direct
purchasing but more convenient
Order Process
 Generating the order can be done manually by a technician
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surveying the inventory and creating the order. Automated
methods involve drugs that a pulled from selves which are
scanned and the quantity deducted from inventory. When the
inventory falls below a certain level the drug is ordered.
Confirmation of an order requires an inspection of the order
before it is transmitted
Submit the order (usually by computer)
Processing the order by wholesaler
Order Delivery by courier
Order Verification: matching the invoice with the original order
to determine if any items are missing that should have been sent
Inventory Adjustment: computerized adjustment of inventory
Stocking of medications
Returns and Recalls
 Sometimes drugs can be returned to the wholesaler because it’s
damaged, ordered in error, or simply not needed
 Expired drugs are either destroyed or returned to the manufacturer.
Companies like, Stericycle and Pharmacologistics handle these issues
for hospitals.
 Recalls are FDA or manufacturer initiated and involve the voluntary or
mandatory surrender of drugs by pharmacies and consumers. It may
involve pharmacies contacting customers and retrieve drugs. Often
only certain lots are required to be surrendered.
 This is why state laws requires the NDC to be recorded on the Rx label
when dispensing. Manufacturer will list NDC and affected lots
 Class 1 recalls are serious and can cause death
 Class 2 recalls are not as serious
 Class 3 recalls usually involve misbranding and other regulatory issues
Insurance
 Health Maintenance Organizations or HMOs are
organizations that contract with healthcare providers
to provide services to their clients. Insurance clients
select a primary care physician who acts as a
gatekeeper for other services. Often the most
competitively priced insurance but with the most
restrictions
 Preferred Provider Organizations or PPO’s are similar
to HMO with the exception that clients can see out of
network providers but pay a higher copay for this
privilege.
Government run Health Insurance
 Medicaid and Medicare were formed by title 18 and title 19
amendments to the social security act of 1935 passed in 1965.
 Medicaid serves people of limited income and disabilities.
 Medicaid is funded by the state and federal government jointly.
 Medicare is a coverage program that is offered to elderly people
(over 65) and certain young people with disabilities to include
end stage renal disease.
 Plan A covers hospital costs. Plan B medical expenses. Plan D is the
prescription drug coverage plan established in 2003.
 Plan D is administer through private plans across the country.
 Plan “C” or Medicare advantage offers coverage to patients via
Medicare contracts through private insurance companies.
 Paid for through payroll taxes (FICA) on all working Americans
(2.9% total)
Insurance Billing and Terms
 Copay. The portion of the bill that the patient pays
 Deductible. The amount that an insured pays before
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coverage “kicks in”. Deductibles are satisfied all at once or a
portion at a time.
Pharmacy Benefits Manager (PBM): a processor contracted
by the primary insurance to handle Rx benefits.
Preferred formulary drug: the drug in a class that is paid for
by the insurance. It can be called a tier one drug
Non preferred formulary drug: a drug in a class that is not
covered or covered at a higher copay. Tier 2 drug
Non Coverage Drug is a drug that can not be covered unless
the provider ,usually the doctor, calls the insurance and
receives a “prior authorization”
Introduction to Compounding
 Compounding in Pharmacy refers to the special
preparation of drug products that are uniquely
tailored to a patient’s needs medically and otherwise.
 Extemporaneous is often an adjective that describes
this unique characteristic of compounding.
 Today relatively few prescriptions are compounded but
in 1938 when the FDCA was passed about 50% of Rx
were compounded. Pharmacy is an art as well as a
medical profession. The Pharmacist could add
favorants and other excipients to make a drug more
aesthetic and/or more palpable to children or animals
 Compounded items can be: creams, ointment, solutions,
suspensions, intravenous solutions, capsules, suppository, etc.
 Solutions are homogenized mixtures of drug in aqueous medium.
 Suspensions are heterogeneous mixtures of a drug in aqueous
medium. These mixtures often require the shaking of the drug
before the suspension can be given.
 Intravenous solutions are aqueous drug mediums that are free of
particles; they are sterile and pyrogen free
 Capsules are oral dosage forms that are enclosed in a gelatin casing
that dissolves in the stomach and small intestine
 Suppositories are dosage forms that are applied rectally. They are
usually made of material like glycerin which melts at slightly below
body temperature. Used for patients that can’t swallow due to
neurological disorders (dysphagia)
Special Compounded Dosage
Forms
 Emulsions are mixture of two non mixable liquids in a
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stabilized medium. Normally, oil in water do not mix;
however, a compound can be made (an emulsion) where
the two liquids can be “mixed” with each other.
Examples in pharmacy are creams and lotions.
Examples in food are mayonnaise and milk (fat mixed in
water)
Two types of emulsion are oil in water (o/w) or (w/o)
When a surfactant or an emulsifier in added to the mixture
the mixture ‘solubilizes’. Examples of emulsifiers are
Lecithin, gum Arabic, Polysorbate 80 and stearly alcohol
References for Compounding
 Remington’s Pharmaceutical Sciences
 Trissel’s Stability of Compounded Formulations
 Drug Facts and Comparisons
 United States Pharmacopeia
 The International Journal of Compounding
Pharmacists
Compounding Equipment
 A more complete list is mention in the text
 The more important ones are following
 Balance, class A, required in every pharmacy by the state
board
 Beakers
 Filter papers
 Graduated cylinders
 Hotplates
 Molds
 Mortar and pestle
 Ointment slab
 Spatulas
 Weighing paper
Mortar and Pestle
 Very important in compounding
 represents a symbol of the pharmacy profession. Shown as
 Used to comminutate or triturate a substance to smaller
particle sizes. Smaller particle sizes are a key to make
certain compounds more appealing to the touch and taste.
 Glass mortar is used to triturate gritty liquids and porcelain
is used for granular powders
Suspensions
 Some drugs are in tablet form and are perhaps needed to be given in very small
quantities. (i.e. neonates who need a fraction of the dose an adult would need)
 A required number of tablets are crushed and triturated in a mortar and pestle.
 An agent called a suspending agent is added. A very common one is Ora Plus®.
Others are carboxymethylcellulose, etc. Used to make the particles repel each
other to “homogenize” a suspension when its shaken.
 A sweetening agent can be added like simple syrup or Ora Sweet ®
 After this the suspension is brought to final volume with water.
 Strength of a suspension is measured in usually mass per volume like mg/ml,
g/l , or percentage %v/v. When used without qualification , % strength usually
means grams per 100 ml.
 For example in IV terminology an IV solution of normal saline is 0.9% sodium
chloride USP. Its strength is 0.9 grams of sodium chloride per 100 ml of
solution. Question: one liter of saline has how grams of NaCL?
 Other question: How much volume is needed to deliver 27 grams of saline?
Other Compounded Dosage Forms
 PLO gel. A transdermal gel enhances absorption of drug
through the skin. A gel is a suspension basically that “congeals”
in contact with skin or at a certain temperature. Contains a
suspending agent and surfactant called Pluronic Lecithin
Organogel.
 Ophthalmic Preparations are usually solutions but can be
suspensions or even ointments, which are semisolid mixtures of
drug in a semisolid base. They are usually pH balanced and
sterile.
 Otic Preparations are used for the ear. Can be solutions but are
mostly suspensions that are thick enough to be held in the ear
canal for the drug to act.
 Nasal Preparation are used for the nose and are mostly sterile
and prepared with isotonic fluids like 0.9% sodium chloride USP
Ointments
 Semisolid dosage forms where solid drugs are
incorporated in a solid oily base substance, or just
called a base.
 Normally the drug is triturated in a mortar and pestle
to reduce its particle size and to prevent “grittiness” in
the final ointment dosage form.
 Commonly used bases:
 Vaselin® or simple white petrolatum USP. Its is a high
hydrocarbon base obtained from crude oil processing.
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Forms an occlusive layer on the skin to prevent dryness
Used for drugs that are unstable in water
Commonly Used Bases
 Lanolin, Anhydrous. A base that contains fatty acid
esters that when treated is a water absorbable base.
Comes from the wool of sheep and other animals and
is sometimes called “wool fat”.
 Used for water stable drugs
 Typically has Ok drug –skin penetrating ability
Hydrophilic Petrolatum
 Hydrophilic Petrolatum USP
 It’s a “water Loving” base that is a chemical modified
form of white petrolatum USP
 USP listing requires the following ingredients
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86 grams white petrolatum
8 grams white wax
3 grams cholesterol
3 grams stearyl alcohol in 1,000 grams total preparation
Water in oil base
 Emulsion base
 Has good drug skin penetration
 Has good washablilty
 Examples are Hydrous Lanolin, Cetaphil® and Eucerin®
 Typically called lotions or creams
 PEG bases are made from polyethylene glycol bases
and are excellent for drug penetration and are able to
be washed off easily.
Introduction to Sterile Products
 A sterile product is a product that is free of
contamination, microorganism free, and pyrogen free
 Examples of sterile products are intravenous products
(IV), ophthalmic products (for the eye), and nasal
products (for the nose), Intramuscular (into the
muscle) and subcutaneous (under the skin)
 Aseptic technique refers to the procedure of properly
performing the preparation of sterile products.
 Includes the environment, equipment, and personnel
garb
 Provides guidelines for the procedure
 Normally any agent that bypasses the skin or the
gastrointestinal tract must be both sterile and pyrogen free.
This is because the skin and the GI tract have a protective
role in filtering out damaging foreign substances or
microorganisms.
 The blood is a sterile body fluid that requires sterile drug
products. Blood is filtered by the spleen and then by the
lymph nodes as its becomes lymph; however, when a drug
is introduced directly into the blood it must be sterile.
 Consequences of contaminated IV products can be serious
 Most IV drug products are contaminated by touch
contamination.
 Bacteria, fungus, and other microorganism colonize the
skin
 Common skin microorganisms are: Candida,
Dermatophytes, and Staphylococcus bacteria. Others
are common as well.
 Contaminated products can “colonize” the blood and
produce bacteremia and fungemia. Infections can
evolve into septic shock and death.
 Watch :
http://www.youtube.com/watch?v=KC8qgxNB2FA
Environment for Sterile Products
Preparation
 Class 100 environment is an environment that has air that
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contains no more than 100 particles (0.5 microns) or larger
in one cubic foot of air.
Laminar flow hoods provide this environment.
Horizontal flow hoods filter air and pass it through a HEPA
filter and outward out of the hood.
Vertical flow hoods blow filtered air down towards the
surface of the hood.
Biological Safety Cabinets are vertical flow hoods that pulls
air through vents in the front and back of the hood to
prevent the preparer from receiving this air. It is used to
make chemotherapy drugs.
USP 797
 Introduced in 2004 by the US Pharmacopeia.
 Consists of standards for the environment to be
considered in the preparation of sterile products
 Endorsed by JCAHO and other regulatory agencies
 Followed in most hospitals with others moving towards
compliance.
 Standards include wall/ceiling, wall/wall and wall/floor
junction specifications, etc
 In general, sterile products are prepared in laminar
flow hoods in similarly compliance air quality rooms
 Such rooms are called “clean rooms”
 Usually have partitions that separate areas of the room
for storage of IV products, gloves, and needle and
syringes
 Rooms are usually positively pressurized to “push”
contaminates out and to keep other particles from
being pulled in.
Other Sterile Product Equipment
 Needle are sterile puncturing devices meant to access drug
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solutions in vials and to administer drugs to patients.
Normally are 3/8 of an inches to 3.5 inches in length
The diameter, or bore, of the needle is determined by its
gauge.
The larger the gauge the smaller the bore of the needle
In general, 25 or 27 gauge needles are under for
subcutaneous injections, 22 gauge for IM injections with 18
gauge and 16 gauge meant for pharmacy compounding of
IV products. 13 gauge is typically the larger bore needle you
will find.
 Syringes are the containers that hold the drug solution
after its been drawn from a vial.
 Consists of a tube with graduations marks, a piston, a
plunger with grip collar and at the other end a luer lok
tip (most syringes).
 This luer lok tip is designed to be a twist on to
attached to a needle or to a injection port on a catheter
to administer an injection
Author: William Rafti of the William Rafti
Institute from Wikipedia
Source: wikimedia commons page
Intravenous Solutions
 Normal saline (0.9%) is one of the most common because its isotonic
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with plasma. Isotonic means equal to it in terms of “tonicity”. i.e.
plasma has a tonicity valve of about 290 mOsm. Normal saline or NS is
about 300 mOsm.
Tonicity of a solution determines if bodily fluid shifts will occur
Dextrose 5% in water (D5W) is the second most common type.
Consists of glucose or dextrose in water to make it 285 mOsm
(isotonic)
D5WNS is a combination of the two and is used when some calories in
the form of glucose is needed. Hypertonic (580 mOsm about) but it is
Ok to use.
3 % Saline (NaCL) is only used to treat certain brain conditions. Very
hypertonic and can cause death if used improperly
23.4% saline (NaCL) used only in certain rare conditions and in small
volumes. Will cause death if used improperly (remember Emily Jerry?)
Type of IV therapy
 IV primary infusion consists of a drug that is given
continuously through a large volume parenteral
solution
 IV Piggyback is a IV administration of a drug that is
normally piggybacked to another primary IV via a Y
site connection on the primary IV tubing.
 IV Piggyback sets are designed to be small in volume
usually 50 ml to 100 ml and are hung above the
primary bag on the IV pole. (see next page)
 Rate of infusion can be controlled by gravity and a
roller clamps or by an electronic pump
Picture of IV Piggyback set up
A word about filters
 At times a filter is needed to filter IV solutions
 i.e. when breaking an ampule you need to use a filter
needle to draw the solution to prevent glass particles
from entering the IV.
 A 0.22 micron filter is a special filter that is called a
“sterilizing” filter that can sterilize a fluid as it is
passed through the filter.