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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 enable
members to take a national approach in addressing common issues. As an umbrella association
of the regulatory
authorities, 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 pharmacist
at the point of sale and possibly referral to a practitioner. While a prescription is not required
the drugs are available only from the pharmacist and must be retained within an area of the
pharmacy where there is no
public 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 without
a prescription, these drugs are to be sold from the self selection area of the pharmacy
which 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 accessible
to 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 an
appropriate 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 appropriate
use 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 intervening
person having access to the prescription drug order
b. The prescription must be sent directly from the prescribers office, directly from a health
institution 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 responsibilities
of 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 hospital
authority.

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 of
the 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 spread
through 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 pump
e. 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 patients
in 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
cleaning
Air 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 the
prescription 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:
Journals (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
1. Product oriented

Example of references
PDR
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 oriented

Merck manual
Applied Therapeutics
Clinical Pharmacy and Therapeutics

4. Dispensing oriented

Remington
USP - NF
Merck Index

5. Poisoning Information

Dreisbach'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 supplemented
quarterly 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 a
physician 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 skills

Sensitivity to nonverbal forms of communication

Sensitivity to language barriers and

Sensitivity 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


condition

Uncertainty about the patient's symptoms or condition

Failure 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 confidentiality

Involvement of the patient in the decision-making process, and

the 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 or

A 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 patient

Current medical condition(s) being treated

Name, general description of the drug dispensed and directions for use

The intended therapeutic response

Common or important side effects and appropriate management, and

Storage 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 product

Appears to be having difficulty selecting a nonprescription product

Is perceived or observed to make frequent or repeat purchases, or to

purchase inappropriate quantities of nonprescription products

Is 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 treated

Current, relevant disease state(s) drug allergies or sensitivities

Current medications

Other medications or treatments patient may have already tried

The 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 use

Common adverse effects

Expected response

When 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 medication

Confirm that the person is an agent for the patient

Provide 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, and

Where possible, communicate by telephone or other electronic means with


the patient

Protect 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 medicines

Where Schedule II, III and other nonprescription products are located in the
pharmacy

Why these products are located where they are

When the pharmacist is required or expected to intervene/consult

When 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 products

Signage in particular areas to encourage dialogue between the pharmacist


and the patient with respect to certain disease states, such as:

Diabetes and foot care products

Glaucoma and eye care products

Hypertension and cough/cold products

Shelf talkers

Appropriate supplementary information

Multimedia 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 orders

Bio-equivalency and interchangeability of multi-source drugs

Formulary and drug plan management

Pharmaceutical calculations

Selection of ingredients

Acquisition of pharmaceuticals

Compounding and dispensing, including labelling according to applicable


standards

Appropriate packaging

Preparation of sterile products

Storage, 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 dispensed

Drug recall policies and procedures are in place and enacted if necessary

Dispensed 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 products

Undated, open multi-dose medication, e.g. vials

Opened single-dose vials

Medications handled by patients

Medications returned by ambulatory patients

Improperly 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 is
permitted 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:
Only an 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.