DISPENSING II

UNIT 1: PRESCRIPTION ANALYSIS

OBJECTIVES III. Public Health importance of Pharmacist

 Review origin of Pharmaceutical care
 Pharmacist are recognized as crucial healthcare health workers expected to be at
 Review roles of Pharmacist in Healthcare system and Public Health
 Interpret and analyze prescriptions and medication orders the forefront of the fight against this outbreak
 Design and analyze appropriate dosing schedules based on special populations such as  Community pharmacy is the most strategic health establishment where patients
geriatrics, pediatrics and individuals with comorbidities. can get directions to navigate our health systems.
 Identify extemporaneous compounded preparations
 Determine appropriate dosage regimens deemed appropriate for medication order
 Role of pharmacist during the pandemic:
 Plan and integrate the prescriptions requiring special instructions .
o Alleviating the fear and reducing panic through public health education
o Preventing the spread of infection in the community and in the workforce
o Providing directions for patients to access the health care services that
The Pharmaceutical Care they need
Traditional Era Scientific Era Clinical Era Era o Ensuring availability of essential medicines and supply by preventing
1900 1930 1960 (Current Era) panic buying and rational use of medicines.
1990
Formulating and Development of new Pharmacist Patient centered, IV. Introduction to Presciption Analysis
Dispensing drugs drugs; scientific testing dispensing drug outcomes oriented What is Pharmaceutical care?
derived from natural mass; production of information, pharmacy practice
sources synthetic drugs and warnings, advice
Responsible provision of drug therapy for the purpose of achieving definite
antibiotics and suggestions to outcomes that improve a patients quality of life.
patients  FOUR outcomes:
o Cure of the disease
I. The Pharmaceutical Care Era (Current) o Elimination of reduction of symptoms
o Arrest or slowing of a disease process
Pharmacist need to work together with the patient and the patient’s other healthcare o Prevention of disease or symptoms
providers to promote health, to prevent disease, and to assess, monitor, initiate, and modify Why the need for prescription Analysis?
medication use to assure that drug therapy regimens are safe and effective.  Rise in unethical promotion of drugs
 Ensure rational use of drug
II. Role of pharmacist in the Health Care system  Exercise patient’s autonomy over medications
1. Ensuring rational use of medicine
 Improve patient outcomes
 Participation in the development of formulary
 Adherence to clinical guidelines
 Analysis of prescribing information
 Drug use evaluation
2. Disease Management
 Enhancement of patient compliance
 Adherence to evidence-based guidelines
 Monitoring of patient outcomes
3. Drug therapy
 Ensure safe and effective medications
 Ensure Accessibility of medications
 Collaboration with othe healthcare professionals
 Mandatory Patient counseling
 Patient monitoring to identify problems and resolution

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DISPENSING II
 Pregnancy (if women)
V. Benefits of Prescription Assessment  Lactating
 Geriatric/Pediatric Patient
Benefits include:  Renal or Hepatic Failure
 Improving patient safety Step 3. Counseling Issues Needed
 Developing a personal learning plan for self-appraisal and the appraisal process  The instruction on how to uses the device such as inhaler,dropper etc.
 Reducing prescribing cost by reducing unnecessary prescriptions (eg. Antibiotics),  Lifestyle changes (especially on smoking, hypertension,etc.)
making most efficient use of therapeutic agents, encouraging generic prescriptions  Dosage, interactions, side effects, Contraindication etc.
within the bounds of bioavailability and reducing polypharmacy.  Other inquires and concerns of the patient.
 Improving patient care and management and reducing noncompliance and waste.
VII. Principles of 3 checks and 7 rights
Common Dispensing Errors Take note of the principle of three checks and seven rights. In dispensing, the following
Prescriber’s Intention Misinterpretation principle of “Three checks and seven rights “ should always be observed . These are:
AD,AS, AU, (right ear, left ear, each ear) OD,OS,OU (right eye, left eye, each eye) 3 checks:
qod (every other day) qd (daily) or qid (4 times a day) 1. First check the container label before taking container from the shelf
U or u (units) Zero, causing a 10-fold increase in dose 2. Second check of the container label against th prescription during actual
(eg. 4U to 40)
dispensing
Trailing zero (1.0 mg)
3. Third check of the container labeling putting the container away (labeling shall be
Naked decimal point (.5 mg) .5 mg mistaken as 5 mg
Large doses without properly placed 100000 units mistaken as 10,000 units done in the next activity)
commas 7 Rights:
AZR (zidovudine) Mistaken as azathioprine or aztreonam 4. Right date
5. Right patient
VI. Prescription Analysis Steps 6. Right drug
7. Right dose
Step.1 Check for the Legality of the Prescription (Based on RA 10918, Generics Act etc.) 8. Right route
9. Right frequency
 Name of patient
10. Right container
 Age
 Sex
 Date VIII. Prescription Analysis for Rx on Elderly Patients
 Signature Stamp, Address of the prescriber Definition of Geriatric:
Step 2. Check for the Clinical Aspects of the prescription:  Geriatric refers to all aspects relating to the aged and the characteristics of aging
 Name of the Drug (Generic/brand name) BNF states the following considerations when prescribing to Elderly Patients:
1. Appropriate prescribing – the elderly often have multiple drugs for multiple
 Dosage
diseases. The need to have appropriate prescribing is even more important to
 Frequency
prevent drug interactions. Therefore there is a need to constantly review
 Route of Administration
appropriateness of drugs taken.
 Indication (using literature)
2. Form of medicine – Elderly patients have difficulty swallowing. Need for liquid
 Drug Interaction (using lliterature) preparation or even milling the tablets etc before swallowing.
 Side effects and Contraindication (using literature) 3. Manifestations of ageing – when prescribing, considerations must be taken for
 Any compounds needed the effects of ageing and to be cautious in prescribing medications for an effect of
Can be part of your case/or can be ask to your simulated patient below: ageing e.g. age, related muscle weakness must nto be taken as neurological
 Patient medical history deficits
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 DISPENSING II
4. Sensitivity – Nervous system of the elderly is more sensitive to commonly used
drugs e.g analgesics. XII. STOPP/START TOOL
5. Pharmacokinetics – the elderly has poor renal clearance and therefore affects the
elimination of drugs in the body. Aims of STOPP/START
6. Adverse Reactions – Especially elderly patients taking hypnotics, diuretics,
 Provide explicit, evidence based rules of avoidance of commonly encountered
NSAIDS etc.
instances or potentially inappropriate prescribing and potential prescribing
7. 4 Classes of Medications giving the most problems for the elderly are: warfarin
omissions
(33%), insulin (14%), oral antiplatelets (13%), oral antihyperglycemics (11%)
o Improve medication appropriateness
o Prevent adverse drug events
IX. The importance of regular medication review in older people o Reduce drug costs

Older people + Regular medication =

Increase in co-morbidities with Increases susceptibility to:
age  Polypharmacy
 Drug interactions
Physiological changes  Adverse drug reactions
 Pharmacokinetics  Prescribing cascade
 pharmacodynamics  Poor compliance

X. BEERS CRITERIA
 Published in its entirety in journal of the American geriatrics Society, the AGS
Beers Criteria is a compendium of medications potentiality to avoid to consider
with caution because they often present an unfavorable balance of benefits and
harms for older people
 The Beer’s criteria serve as standard guidance for clinicians to prevent
potentially inappropriate prescribing in patient’s age 65 years and older. This
update of the Beers criteria examined current evidence to determine changes
required to keep the recommendations in step with current practice and
knowledge. Nearly 70 modifications have been made to the 2015 set.
XI. Common Mediations Used in hospice that are Considered Inappropriate Based
on BEERS XIII. Strategies for Managing Polypharmacy
 Check medication administration timing
Medication Indication Concerns  Check for potential drug interactions
Dipenhydramine, Itching, insomnia, nausea Cognitively impairing, highly  Identify duplication of therapy
Hydroxyzine, promethazine anticholinergic o Vitamins
Benzodiazepines, Insomnia, anxiety Cognitively impairing, increased
o Nonprescription vs prescription
Non-benzodiazepines risk for falls, sleep impairment
Insomnia, pain Highly anticholinergic;prolonged o Herbal vs.prescription
Tricyclic Antidepressants
Q-T interval  Check doses of each medication
Psychosis, agitation, delirium Increased risk of mortality and  Perform side effects inquiries
Antipsychotics
morbidity
Pain Cognitively impairing,  Identify cognitive-impacting medications
Opioid, Non-opioid analgesics Constipating, increased risk of  Identify fall-risk medications
falls  Identify swallowing-risk medications

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 DISPENSING II
XIV. Suggested Times of Administration for Selected Medications XVII. Good Palliative Geriatric Practice Algorithm

Drug Categories Ideal Time of Administration

Antihypertensives Morning
Lipid Lowering Agents Evening
Biphosphates Morning on an empty stomach
Morning on an empty stomach > 30 minutes away
Synthroid
from other medications and food
Sex Hormones Morning
Antiplatelet Morning
Acid Secretion Inhibitors Evening
Sedating agents Evening
Diuretics Morning
Stimulating Drugs Morning
Sleep Aids Evening
Coumadin Evening

XV. Target Medications for Deprescribing

 Proton Pump Inhibitors/H2A blockers
 Benzodiazepines
 Psychotropics
 Polypharmacy regimens for specific diseases
 Nonprescription and Herbal medicine
XVI. Geriatric Syndromes
 Falls XVIII. Dispensing Considerations
 Incontinence 1. Need to constantly review medications given to the elderly with the prescriber and
 Low body index to be alert for possible drug interactions and adverse reactions mentioned
 Dizziness above. Need or clear explanation
 Vision impairment 2. Need to consider appropriate dosage form of medication e.g liquid, how to
advice to crush tablets and try not to dispense controlled release tablets that
 Cognitive impairment
cannot be crushed; advice on drink adequate quantity of water on taking
 Hearing Impairment
medication e.g. Forsamax etc.
3. Need to consider and involve caregivers and get their cooperation.
XIX. Consideration in calculation of doses
 Geriatric patients – classified as persons over 60 years of age
 Physiologic functions start to decline
 Kidney function and liver function decline
 Both affect the absorption and elimination = TOXICITY
 Kidney malfunction = reduce dose prescribed
 Creatinine clearance = lab value to determine kidney function and appropriate
dosing for elderly patients

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 DISPENSING II
XX. Prescription Analysis for Pediatric Patients
Stages:
 Neonate: Just born babies (up to first 30 days of life)
 Pediatric: Also referred to as Infant (up to 1 year)
 Early childhood: 1-5 years
 Late childhood: 6-12 years
Need for vigilance in prescribing and dispensing. Why?
 Children and particularly neonates, differ from adults in their response to drug.
Special care is needed and does should be calculated with care.
 The risk of toxicity is increased at this stage because of
o reduced drug clearance (the kidney and liver are not yet fully
developed)
o And that the organs have differing target organ sensitivity
 wherever possible intramuscular injections (IM) should not be given as there are
painful
Important points to note on Dispensing Pediatric Prescription
From the Legal Point
1. The age of the child must be states (years or months) clearly
2. The strength and dosage form must be stated e.g., Tablet Salbutamol 2mg.,
Syrup Paracetamol 125mg/5ml
From the Clinical Point
1. Good to provide body weight in kg.
2. Liquid preparations are best advised to be used for children and neonates
3. For long term treatment, choose a sugar free formulation to avoid dental decay.
From the Counseling Point
1. Provide syringe for dosage below 5 ml
2. Always dispense and give counsel to the caregiver and not to the neonate, infant
or child.
3. Label as “Give…” and not “Take…”
4. Warn parents to keep all medicines out of reach of children. Cautionary labels
are to be placed on pediatric dispensed medicines.
5. Parents should be advised not to add any medicines to infant’s feed, since the
drug may interact with the milk or liquid; or sometimes the infant does not drink
all the contents of the feed
XXI. Prescription Analysis: Dosage in Children
Children’s dose in the MIMS/BNF are stated in the individual drug entries. except where:
a. pediatric use is not recommended
b. information is not available, or
c. there are special hazards
Dose are generally based on body-weight (in kilograms) or the following age ranges: first
months (neonates)
 infant (up to 1 year)
 1-5 years
 6-12 years
Dose Calculation
1. Many children’s doses are standardized by weight (and therefore require
multiplying by the body-weight in kilograms to determine the child’s dose).
3
2. Occasionally, the does have been standardized by body surface area (in m )
NOTE: These methods should be used rather than attempting to calculate a child’s
dose on the basis of doses used in adults.
3. Important: Always consult reliable literatures such as MIMS, BNF, etc.
4. For most drugs, the adult maximum dose should not be exceeded for children
Example:
The dose for drugs A for children is tasted as 8 mg/kg
Mas. dose for adult is 300 mg
Weight of child is 40 kg
This child should receive 300 mg NOT 320 mg
5. For obese and overweight children, calculation by body-weight may result in higher
doses than necessary. In such cases, calculate using ideal weight use the chart
provided.
General Guidelines by BNF/MIMS for Pregnant Patient
 Drugs should be prescribed in pregnancy only if the expected benefit to the
mother is thought to be greater than the risk to the fetus, and all drugs
should be avoided if possible, during the first trimester.
 Drugs which have been extensively used in pregnancy and appear to be usually
safe should be prescribed in preference to new or untried drugs
 The smallest effective dose should be used.
 Drugs proven to be teratogenic in human should be avoided
Classification used in BNF
BNF/MIMS identifies drugs which:
1. May have harmful effects in pregnancy and indicates the trimester of risk
2. Are not known to be harmful in pregnancy
NOTE: BNF/MIMS will indicate clearly for the relevant drug entry the care needed which
taking this drug during pregnancy
NOTE: MIMS uses a more complex classification based on the FDA classification
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 DISPENSING II
XXIV. Extemporaneous Compounded Drugs
XXII. Prescription Analysis: Drugs and Pregnancy  Extemporaneous compounding is the preparation of a therapeutic product for an
 Drugs can have harmful effects on the embryo or fetus at any time during individual patient in response to an identified need
pregnancy.  Compounding refers to the sum of processes performed by a pharmacist in drug
 It is important to note that all women of childbearing age or for men trying to father preparation including the calculations, mixing, assembling, packaging, or labeling
a child. of a drug:
 During the first trimester (the first three months of pregnancy) drugs can produce o as the result of a prescription or drug order by a physician, dentist, or
congenital malformations (teratogenesis) and the greatest period of risk from veterinarian; or
rd th
the 3 to 11 week of pregnancy. (RELATING TO THE DNA) o for the purpose of, or in relation to, research, teaching, or chemical
 During the second and third trimesters drugs can affect the growth or analysis; (RA10918)
functional development of the fetus or they can have toxic effects on fetal
tissues. (DAMAGE TO THE DEVELOPMENT AND TISSUE).

Table 1. FDA Drug Risk Classification

Category Description
A Controlled studies in humans show in risk to the fetus
No controlled studies have been conducted in humans; animal studies
B
show no risk to the fetus
C No controlled studies have been conducted in animals or humans
Evidence of human risk to the fetus exists; however, benefits may
D
outweigh risks in certain stations
Controlled studies in both animals and humans demonstrate fetal
X abnormalities; the risk in pregnant women outweighs any possible
benefit

XXIII. Prescription Analysis: Drugs and Breast-Feeding

 Breast-feeding is beneficial: the immunological and nutritional value of breast milk
to the infant is greater than that of formula feeds.
 Although there is concern that drugs taken by the mother might affect the infant,
there is very little information on this. However, in the absence of evidence of an
effect, the potential harm can be inferred by drug absorption, distribution,
 Extemporaneous Compounding: “The timely preparation of a drug product
metabolism studies etc.
according to the physician’s prescription, in which the amounts of the ingredients
 The amount of drug or its metabolites transferred in breast milk is rarely
are calculated to meet the needs of a particular patient or a group of patients
significant to produce clinical effects on the infant especially to poorly absorbed
according to Good Manufacturing Practice”
drugs.
Compounding
BNF/MIMS Classification
BNF/MIMS identifies drugs:
Extemporaneous compounding
1. That should be used with caution or are contraindicated in breast-feeding
2. That can be given to the mother during breast-feeing because they are present  On0demand preparation of a drug product.
in milk in amounts which are too small to be harmful to the infant  According to a physician’s prescription
3. That might be present in milk in significant amount but are not known to be  Meets the unique needs of an individual patient
harmful.
Manufacturing
NOTE: BNF/MIMS states that care is needed in dispensing drug during breast-feeding, this  The production or processing of a drug in a LARGE quantity by various
is indicated under the relevant drug in the BNF/MIMS. mechanisms.

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DISPENSING II
XXV.
Why Compound?
 Pediatric patients requiring diluted adult strengths of drugs.
 Patients needing an oral solution or suspension of a product that is only
available in another form.
 Patients with sensitivity to dyes, preservatives, or flavoring agents found in
commercial formulations.
 Dermatological formulations with fortified (strengths) or diluted concentrations of
commercially available products.
 Specialized dosages for therapeutic drug monitoring.
 Care for hospice patients in pain management.
 Compounding for animals
Common Problems with Specials Prescriptions
1. If short dated-will patient use up quality prescribed within that time.
2. Cost if using specials company-very important if private prescription
3. Lack of detail on prescriptions especially creams and ointments where no base is
indicated.
4. Computer generated prescriptions where unlicensed preparations are not in the
standard menus.
5. Finding a formula.
6. National Differences with non-compendial formula
Prescription Analysis Compounding Considerations:
1. Always consider the use of commercially available products as far as possible.
2. If no suitable commercial product exists, consider a therapeutic alternative that is
available in a suitable dosage form. This must be discussed with the physician.
3. Extemporaneous preparations should be done based on evidence-based
references.
4. Always check for the suitability of the product/brand for extemporaneous
reparations.
5. Preparations should be done according to what is stated as far as possible unless
stated otherwise in the product leaflet.
6. When no information is available, compounding an oral medication by
dispensing a tablet and/or capsule and directing the caregiver to mix just prior to
administration.
7. Stability for shelf storage in the pharmacy is applicable without opening. Once
opened, the stability of the preparation should be no longer than 30 days.
Maximum quality of the extemporaneous preparations to be dispensed should not
`exceed one mouth.
8. Refrain assumptions on the therapeutic equivalence in the case of suggesting
alternative agents as the possibilities and supporting data may be limited.
9. Techniques in compounding preparations and manipulations should always be
in line with the standard Good Preparation Practice as delivering an accurate
dose in paramount.
10. Staff and facilities are challenged to undertake intermittent competency
assessments in order to achieve the standards requirement.
11. Documentation after each preparation should include details on the materials
used, processes
Considerations for Preparing Extemporaneous Compounds
1. Pharmacy personnel are reminded not to empirically change flavorings or
suspending agents because they can affect the pH stability of the product and
result in an unstable product.
2. Please consider ingredients in the formulations that require special precautions
in neonates.
3. Mixing of a compounded formulation should always be in line with the following
principles:
a. Ensure that all ingredients used are within the expiry date.
b. Ensure that all utensils are clean; including mortar and pestle,
graduates, pill cutters and stirring rods.
c. Product should be labelled clearly and stored as recommended within
the formula/
d. For solution or suspension products, emphasis on the importance of
thorough shaking before administration.
Sources of Formulae
 Compendia e.g., BP, Martindale 28th / USP/NF etc.
 Hospital-often continuation of treatment in primary care
 GP’s own e.g. Dr. Ives wart paint etc.
 Published literature/journal articles available on internet. Often American/European
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 DISPENSING II
 Chapters <795> - called Pharmaceutical Compounding – Nonsterile Preparations  Consequences can be tragic
o Publised in 2000  Establish rules and routines
o Enforceable  Standard Operating Procedures and Worksheets
 Chapter <797> - called Pharmaceutical Compounding – Sterile Preparations,
o Became official in 2004 XXVII. Summary – Dealing with Prescription
 Other Chapters 1. Often lacking in detail
o Containers <661> 2. Don’t take at face value
o Good Compounding Practices <1075> 3. Usual clinical assessment
o Pharmacetical Stability <1150> 4. Has patient had medicine before-possibly from hospital
o Pharmaceutical Dosage Forms <1151> 5. Save details – worksheet or record

XXVI. Formulation General XXVIII. Summary – Managing Your Patient

 Physical problems – cracking, caking, precipitation 1. Collection and delivery arrangement
 Chemical degradations – usually pH dependent 2. Good Practice-Establish a routine
 BP limits for actives are usually 95% - 105%. Published data may accept wider 3. Consider bank holidays
limits such as 90%. What are acceptance criteria? 4. Logistics – especially fridge lines
 Microbial – preservative system, closed pack shelf life may be longer than opened 5. Compliance – e.g., administering 1 ml may be easier than administering 5 ml
pack e.g., use 14 days after opening. 6. Accurate dosing – counselling, oral syringes
7. Accurate packaging
Oral Liquids
 Is drug soluble in vehicle at dose required?
 if not could a suspension be prepared
 Crush tablets or use powder
 Use highest strength tablets to reduce overall excipients
 Check tablet characteristics: Controlled release, Sugarcoated, Film coated,
Enteric coated
 Good practice: Always use same brand and strength. Care with generics.
 Good practice: Standardize to dose/5ml or dose/1ml
 May dilute injection fluid from ampoules

Making a Suspension From Tablets

 Crushing, grinding
 Wetting and pasting
 These steps are vital to give homogenous product

Importance of Calculation Skills

 A full understanding of what’s required can prevent dispensing errors
 Ensures correct clinical interpretation of prescription
 Overdose or Sub-therapeutic?
 Letter from Dermatologist translated into computer generated prescription
 Beware of progressive mis-interpretation!

Beware of Complacency
 We all know
 1+1=2
 Check this every day as a pharmacist
 Errors are usually silly mistakes
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DISPENSING II
XXIX. Label for Extemporaneous Preparations
 Details of the Community / Hospital
 Expiry Date
 Drug’s Name with Strength
 details of Patient
 Administration Instructions
 Storage
 Special Instructions / Precautions
 Pharmacist Name Prepared

The worksheet of the product should contain the following details:

 Patient’s name
 ID number
 Prescription number
 Date of preparation
 Name of drug
 Dose
 Volume of diluent/vehicle
 Batch number of preparations and starting materials
 Name and signature of preparing personnel
 Name and signature of checking personnel

A Basic Approach To Risk Analysis

 Picture the worst case scenario
 What would be the consequences to the patient
 How likely (frequency) is this type of error to occur?
 Would the checking pharmacist or the patient be able to detect the error?

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DISPENSING II

UNIT 1: EXTEMPORANEOUS COMPOUNDED PRESCRIPTION

COMPOUNDING • AR (ANALYTICAL REAGENT)

○ Very high purity.
EXTEMPORANEOUS COMPOUNDING • HPLC
• On-demand preparation of a drug product. ○ Very high purity.
• According to a physician's prescription. ○ Used in high pressure chromatography.
• Meets the unique needs of an individual patient.
STORAGE TEMPERATURE DEFINITIONS
MANUFACTURING
• The production or processing of a drug in a LARGE quantity by various mechanisms. Freezer -20°C to -10°C
Protect from Freezing Store above 0°C
WHY COMPOUND? Cold Any temperature not exceeding 8°C
• Pediatric patients requiring diluted adult strengths of drugs. Refrigerator Between 2°C and 8°C
• Patients needing an oral solution or suspension of a product that is only available in Cool Between 8°C and 15°C
another form. Room Temperature Temperature in the work area
• Patients with sensitivity to dyes, preservatives, or flavoring agents found in Controlled Room Temperature Thermostatically controlled at 20°C to 25VC
commercial formulations. Warm Between 30° and 40°C
• Dermatological formulations with fortified (strengthened) or diluted concentrations Excessive Heat Any temperature above 40° C
of commercially available products.
• Specialized dosages for therapeutic drug monitoring. STABILITY
• Care for hospice patients in pain management Stability
• Compounding for animals. • The extent to which a dosage form retains the same properties and
characteristics that it possessed at the time of its manufacture.
US PHARMACOPEIA Expiration date
• Established in the 1906 Pure Food and Drugs Act. • The date until which the manufacturer can guarantee of the safety and full
• Has the federal authority to set standards pertaining to pharmacy compounding. potency of a drug- usually determined after extensive study of the product's
• Develops “STANDARDS” where various topics are grouped into "CHAPTERS." stability.
• Publishes its standards in the resource book called the USP/NF Beyond-use date
• Used for compounded preparations only and are generally in the order
COMPOUNDING REGULATIONS APPLIES "days" or "months."
• Personnel Shelf life
• Facilities and Equipment • Length of time a packaged drug will last without deteriorating
• Ingredient Standards
• Quality Assurance and Quality Control ASSIGNING A BEYOND-USE DATE
• Packaging and Storage • Non-aqueous liquids and solid formulations
• Documentation and Record Keeping ○ If the source of the active drug is a manufactured drug product, the beyond-
use date is not later than 25% of the time remaining until the drug product's
INGREDIENT STANDARDS expiration date, or 6 months, whichever is earlier.
• USP/NF ○ If the source of the active drug is a USP or NF substance, the beyond-use
○ Meets standards set by the USP/NF. date is not later than 6 months.
• ACS REAGENTS • Water containing formulations
○ High purity ○ When prepared from ingredients in solid form, the beyond use date should
○ Meets specifications of the Reagent Chemicals Committee of the American be not later than 14 days when stored at cold temperature.
Chemical Society.
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DISPENSING II

• For all other formulations USING A PRESCRIPTION BALANCE

○ The beyond-use date is not later than the intended duration of therapy or 30 1. Lock the balance by turning the arrest knob.
days, whichever is earlier. 2. Set the internal weights to zero.
3. Unlock the balance and level it left to right.
TYPES OF EQUIPMENT 4. Lock the balance. Place a weighing boat or paper.
• Measuring 5. Unlock the balance by releasing the arrest knob.
○ Balance, weights, weighing containers, volumetric glassware (graduates, 6. Lock the balance and place the required weights in the boat.
pipets, flasks, syringes). 7. Unlock the balance and note the shift of the pointer.After an accurate measurement
• Molding is made, check your work.
○ Hot plates, suppository molds, capsule shells, ointment slabs.
• Mixing
○ Beakers, Erlenmeyer flasks, spatulas, funnels, sieves, mortar and pestle.
• Packaging
○ Prescription bottles, capsule vials, suppository boxes, ointment jars.

CLASS “A” BALANCE SCALE

• A two pan torsion that uses both internal and external weights
• Weights go on the right pan and powder on the left pan
• Sensitivity: up to 6 mg
• Capacity: 120 mg to 60 gms
• Degree of error: 5% REASONS FOR ACCURATE WEIGHING
• Weights: 1gm to 50 gms • Weighing of the product is one of the most essential parts of the compounding
○ fraction weights 10mg to 500mg process.
• Electronic or Analytical Balance • Weighing the exact amount prescribed is essential in compounds for several reasons:
○ The product cannot be “checked” for content once mixed.
USING A BALANCE ○ The quantities weighed out are often very small, and a slight overage could
1. Place on a level surface in a draft free area. mean a serious overdose for the patient.
2. Use clean weighting papers or boats.
3. Must be readjusted after a new paper or boat has been placed on the pan. SPATULAS
4. Arrest the balance before adding or removing weight. • Spatulas
5. Use a spatula. ○ Used to transfer solid ingredients or prepare ointments and creams or
6. Clean the balance. loosening material from the surfaces of a mortar and pestle.
• Types
USING AN ELECTRONIC BALANCE ○ Stainless steel
1. Keep balance where it will not be moved. ○ Hard rubber
2. Turn the leveling feet. ○ Plastic
3. Turn on the balance • Spatulation
4. First use of the day, check internal weight calibration. ○ Mixes powders using a spatula.
5. Removed top ring of the draft shield. Place weighing boat in the center. ○ Mixing can be done in a mortar, on an ointment slab, or in a plastic bag.
6. Add ingredients.
7. Clean spills with a lint-free towelette. MORTAR AND PESTLE
8. Turn off balance at the end of the day. • Mortar and Pestle
○ The coarser the surface of the mortar and pestle, the finer the triturating, or
grinding, that can be done.

2
DISPENSING II

• Types Measuring Liquid Volumes

○ Glass • Pour the liquid to be measured slowly into the graduate, watching the level of the
○ Wedgwood liquid in the graduate as you do so.
○ Porcelain • If the liquid is viscous, or thick, then you should attempt to pour it toward the center of
• Trituration the graduate to avoid having some of the liquid cling to the sides.
○ The process of grinding powders to reduce the particle size. ORAL SYRINGES
COMPOUNDING SLAB • Available for accurately administering liquid medication to the patient.
• This is an ideal surface for mixing compounds because of its nonabsorbent surface. • Have tips that are larger than tips on hypodermic syringes so needles cannot be
• Levigation placed on these syringes.
○ Technique used to reduce the particle size of a powder drug by triturating it • After the dose is drawn into the syringe, a cap is placed on the tip to prevent leakage
with a solvent in which the drug is insoluble. and prevent contamination.
• Oral syringes can be used with a device called an Adapt-a- Cap®
VOLUMETRIC EQUIPMENT ○ An example of an oral syringe cap the screws onto the bottle containing the
• Droppers liquid, and the oral syringe is fitted into the other side of the cap.
• Graduates
• Flasks MIXING POWDERS - GEOMETRIC DILIUTION
• Pipettes • When mixing powders of unequal size, the smaller amount is mixed (triturated) with an
• Syringes equal amount of the other.
• Oral syringes • That mixture is then mixed with an equal amount of the larger amount powder.
GRADUATED CYLINDERS • This process is repeated until the mixture is completed.
• Cylindrical and cone shaped.
• Used for measuring and transferring liquids. SOLUTIONS
• Available in sizes ranging from 5 ml to 4,000 ml. • The most commonly compounded products.
• Selecting a graduated cylinder. • Clear (but not necessarily colorless) liquids in which the drug is completely dissolved.
○ Choose the smallest one capable of containing the volume to be measured. • The solubility of the drug must be known before attempting to dissolve it in a solution.
○ Rule: Avoid measurements of volumes that are below 20 percent of the If a drug is not soluble in a vehicle, then no amount of mixing will help
capacity of the graduated cylinder. • Some solids need to be triturated before mixing in a solution.
→ Example, a 100 ml graduated cylinder cannot accurately measure
volumes below 20 ml. SUSPENSION
• When measuring small volumes, such as 20 ml and less, use a syringe or pipet. • A two phase system consisting of a finely divided solid dispersed in a liquid.
SYRINGES ○ Flocculating Agent
• Range from 0.5 ml to 60 ml and in a variety of materials and styles. → Electrolytes used in the preparation of suspensions to form
• Contain graduation marks on the barrel for measuring partial volumes. particles that can be easily redispersed.
• A disposable hypodermic syringe or an oral syringe made of plastic is used for ○ Thickening Agent
most compounding tasks involving small volumes. → Ingredient used in the preparation of suspensions to increase the
• Always choose the smallest syringe capable of containing the volume to be viscosity of the liquid.
measured.
ADDITIVES
LIQUID MEASUREMENTS • Flavoring
DROPPERS ○ The human tongue contains about 10,000 taste buds which distinguish salty,
• Used to deliver small doses of liquid medication. bitter, sour, and sweet tastes
• Medicine dropper must first be calibrated because The drop size will vary from • Sweeteners
dropper to dropper. ○ Colorless, odorless, solubility in water at the concentrations needed for
• Personal factors can also contribute to the inaccuracy of droppers. sweetening, pleasant tasting with no “after-taste,” and stable over a wide pH
range.

3
DISPENSING II

• Coloring ○ Can be formulated by molding or compression in a wide range of hardness

○ Not required in every formulation. and melting points.
○ Contraindicated in all sterile solutions. ○ Do not melt at body temperature, but dissolve slowly to provide a prolonged
○ Dark colors, such as dark purple, navy, black, and brown may also be release of drugs.
rejected because they are often associated with poisons. • Available in various molecular weight ranges.
EMULSIONS ○ 200, 400, or 600 molecular weight are liquids.
• Unstable system consisting of at least two immiscible liquids. ○ Molecular weights over 1,000 are solids.
○ One is dispersed in the form of small droplets throughout the other. CAPSULES
○ The other is a stabilizing agent. • Hard gelatin capsules consist of a body and a cap which fits firmly over the body of
• Types the capsule.
○ Oil-in-water (o/w) emulsion • For human use, eight sizes of capsules are available.
○ Water-in-oil (w/o) emulsion SIZES VOLUME
• Emulsifier - a stabilizing agent in emulsions. 000 1.37
○ commonly used emulsifying agents include tragacanth, sodium lauryl sulfate, 00 0.95
sodium dioctyl sulfosuccinate, and polymers known as the Spans® and
0 0.68
Tweens®.
1 0.50
• Primary emulsion - the initial emulsion to which ingredients are added to create the
2 0.37
final product.
• Mucilage - a wet, slimy liquid formed as an initial step in the wet gum method. 3 0.30
OINTMENTS 4 0.20
• Used for many different purposes, e.g., as protectants, antiseptics, emollients, 5 0.13
antipruritics, kerotolytics, and astrigents. • Punch Method
• Ointments are generally compounded on an ointment slab ○ Used when filling a small number of capsules.
• Transferring ointment into an ointment jar.
SUPPOSITORIES LABELING, RECORD KEEPING, AND CLEANUP
• Three types of bases: • After compounding
○ Oleaginous: primarily synthetic triglycerides. ○ The product must be labeled with a prescription label, and a careful record
○ Water soluble: containing glycerinated gelatin or polethylene glycols of the compounding operation should be kept.
(PEGs). • Once the compounding operation is finished
○ Hydrophyllic: mixtures of oleaginous and water soluble bases. ○ The equipment and area should be cleaned.
Cocoa butter (Theobroma Oil) USP ○ Everything should be returned to their proper places in storage.
○ A well-known oleaginous base. • Compounding should never be rushed.
○ At room temperature, cocoa butter is a solid. • Regardless of their apparent stability, all suspensions
○ At body temperature, it melts to a bland, non-irritating oil. ○ Should be dispensed with an auxiliary label reading “Shake Well.”
○ No longer the base of choice because preparing suppositories with it is • The qs abbreviation means to add “as much as necessary” to the specified amount.
difficult, and the suppositories require refrigeration. ○ JCAHO recommends using text words rather than abbreviations to minimize
• Synthetic triglycerides can be used that do not have the formulation difficulties of a medication error.
cocoa butter, but they are more expensive. • Refer to a standard reference work on the subject.
• There are newer bases composed of mixtures of fatty acids that do not have the ○ Example: Remington: The Science and Practice of Pharmacy
formulation problems or the expense (e.g., FattiBase®, Witepsol®).
WATER SOLUBLE OR MISCIBLE BASES
• Glycerinated gelatin or polyethylene glycol (PEG) polymers.
○ Useful for vaginal suppositories.
○ Dissolve slowly to provide prolonged release of active ingredients.

4
Medication Orders
A medication order is written directions provided by a prescribing
practitioner for a specific medication to be administered to an individual. The
prescribing practitioner may also give a medication order verbally to a
licensed person such as a pharmacist or a nurse.

Examples of some different types of medication orders are:

• Copy of a written prescription
• Written order on a consultation form, signed by the practitioner
• Written list of medication orders, signed by the practitioner
• Copy of a pharmacy call-in order, given to you by the pharmacist*
• A verbal order given to a licensed person*
• Electronic prescriptions signed electronically via a secured system

What do we mean when we use the term "prescribing practitioner"?

This is a term that describes the various health care professionals who can
give medication orders.
The following health care professionals are "prescribing
practitioners":
• Physicians (MD, DO)
• Nurse Practitioners (APRN, NP)
• Dentists (DMD, DDS)
• Physician's Assistants (PA)
• Optometrist (OD)
• Podiatrist (DPM)

As an authorized provider, you must have a medication order in order

to administer medications to individuals.
You may not take verbal medication orders from a prescribing practitioner.
This is outside the scope of what you can do as an authorized provider.
PRN Medication Orders
PRN medications are given on an "as needed" basis for specific signs &
symptoms. Signs or symptoms of illness or discomfort can include:
• Tiredness
• Increased anxiety or agitation
• Headache
• Earache
• Redness in a cut or a scrape
• Coughing
• Sneezing
• Fever
• Itching
• Cramping

PRN medications may be prescription medications or over-the-counter

medications (non-prescription).
In order to give a PRN medication, you must have a medication order and
a PRN Protocol.
The PRN Protocol gives you directions about how to administer an as
needed medication.

For example:
Mary has a medication order and a PRN protocol for Tylenol, 650 mg
by mouth every four hours as needed for pain or fever.
Mary has a headache. You have checked the medication log to see that
Mary has not received any Tylenol within the past 4 hours.
According to the PRN protocol, the specific symptoms that Mary can
have the Tylenol for are "pain” and "fever".

This means that you can give Mary Tylenol for her headache.
When administering a PRN medication, you must follow the
medication order and the directions in the PRN Protocol.
A PRN protocol is needed for PRN medication orders because, unlike
medications that are ordered on a regular daily basis, you have to know
when a PRN medication should be given.
The PRN Protocol gives you additional information about the medication
order and helps you to understand when and how much of the medication
to give.
ONLY the prescribing practitioner or a nurse trainer can write or approve the
PRN protocol.
The PRN protocol will include:
• All of the information found in the medication order, plus:
• The specific signs and symptoms that the medication should be given
for
• A maximum daily dosage
• Any special instructions, such as when to call a nurse or the prescribing
practitioner

You must follow the PRN Protocol exactly when giving a PRN medication.
This is the procedure that you will follow when an individual is
showing signs or symptoms of illness:
1. Check to see if the individual has a medication order and PRN protocol for
the signs or symptoms that the individual is showing.

2. If there is no medication order or PRN protocol for the signs or symptoms

of illness or discomfort that the individual is showing, follow your agency's
policy or procedure for notifying a supervisor or nurse.

3. If there is a medication order and PRN protocol for the signs and
symptoms that the individual has, check the medication log to see when
the medication was last given.

4. If the medication has not been administered or if enough time has elapsed
since it was last given, administer the PRN medication according to the
PRN protocol, following the Six Rights and the Three Checks.

5. Write a note about why the PRN medication was given.

6. Watch to see if the PRN medication has taken care of the signs or
symptoms of illness and you must document the effect of the PRN
medication on the individual.
The Seven Important Questions
Whenever a medication is ordered for an individual, you must get
the answers to the Seven Important Questions before you can give
the medication:
1. What is the name of the medication?
2. What is the purpose of the medication?
What is the medication supposed to do?
3. What effect will the medication have on the individual?
How will I know that it is working?
4. How long will it take the medication to work?
Will it take hours, days or weeks to work?
5. What are the side effects, adverse reactions and/or signs of over
dosage of this medication?
What are the signs or symptoms of these?
Are blood levels or other blood tests needed to monitor the effects of
this drug?
6. Are there any interactions with the medications that the
individual is taking?
Based on review of the individual's medications, are there any
medications that will interact with this medication?
7. Are there any special administration or storage instructions for
this medication?
Does this medication need to be given with meals, before meals, with
water or with milk?
Is this medication a controlled medication?
Does this medication need to be refrigerated?
You must get this information from the prescribing practitioner
and/or nurse (if px is hospitalized) and keep the information in the
medication log so that you can review it frequently.
Remember: never give a medication if you do not have all of the
information that you need to give the medication safely!
Liquid medication orders
Medication orders for liquid medications are similar in many ways to the
medication orders that you get for pills.
There are some important things to consider for liquid medications.
Medication orders for liquid medications contain information about the
strength or concentration of the drug in the liquid.
Liquid medication orders also contain information about the amount of the
liquid medication to be given.

The Medication Log/ Medication Administration Record

(Hospitalized patients)
All medication logs will contain at least the following:
Individual's name
The guardian's name and contact information, if applicable
Allergies, if applicable
For each medication prescribed:
�

�
applicable, as directed by the prescribing practitioner or the
pharmacist.

�
signature
Transcribing a Medication Order
To “transcribe” means to write down or copy.
To transcribe a medication order, take the information from the prescribing
practitioner's order and write it in the proper place on the Medication Log.
This is called making a medication log entry.
As an authorized provider, it is your responsibility to transcribe medication
orders.
You may want to ask another authorized provider to double-check your work,
if possible, after you have transcribed an order.
Remember:
All medication log entries must match the prescribing practitioner order and
pharmacy label.
This means that:
• The medication log entry and the order must match
• The medication order and the prescription label must match
• The medication log entry and the prescription label must match

Scheduling Times to Give Medications

Some medication orders include a specific time of day that you are supposed
to give the medication.
If this is the case, make sure to follow the order and transcribe the
medication for that time of day.
Remember that:
• Some medications will interact if taken together, and
• Some medications must be given:
_
�
_
�

If the medication order does not include a specific time or times to

give the medication, consult with the physician or the pharmacist
to determine the best time(s) to give the medication.
Also consider:
When does the individual take other meds? Try to schedule medications so
that they will have the least impact on the individual’s daily activities.
If you must choose a time of day that differs from the time that other
medications are administered, beware! New or “off-time” meds are more
likely to be forgotten or overlooked.
If the person is receiving enteral feedings, you must ask the pharmacist if
the medication and the feeding will interact. If the answer is yes, you will
need to separate the enteral feeding and the medication by at least 30
minutes.

Controlled Medications
• If you are not sure if a medication is a controlled medication, ask the
physician. This is one of the "Seven Important Questions" that you
have learned.

• A controlled medication log must be started as soon as a controlled

medication is received from the pharmacy.

• Controlled medications must be counted as soon as they are

received from the pharmacy, and the count must be documented
on the controlled medication log. Always "physically" count the pills.
Never "assume" that the bottle or supply contains the number of pills
listed on the label.

• Controlled medications must be counted before administering the

medication to confirm that the count is correct before giving the
medication.

• Controlled medication must be counted at least daily, even if not

given, and documented on the controlled medication log.

• Controlled medications must be disposed according to PDEA or FDA

regulations.

• Controlled medications must be kept under double-lock (in a locked

container within a locked container or cabinet.)

• If a controlled medication order is discontinued by the prescribing

practitioner or if the medication supply has expired, you must
continue to count the supply daily.
 STANDARD MEDICATION ADMINISTRATION TIMES
Unless otherwise indicated (by specific MD order or by P&T/MAC approved interchange), the following time schedules
shall be used in the administration of medications.
** Medications administered initially at ‘non-standard’ times will be staggered to the appropriate standard administration
times using the charts on pages 3-6 of this document.

Schedule Description Standard Times

daily, q24h Once daily General: 0900
***do NOT use “qd”, “od” Paediatric (PE1) unit admissions: 0800
abbreviations **see exemptions page 2**

General: 0900 1700

bid Twice daily NICU admissions: 0900 2100 (to coincide with feed times)
Paediatric (PE1) unit admissions: 0800 2000

General: 0900 1300 1700

tid Three times daily NICU admissions: 0900 1500 2100 (to coincide with feed times)
Paediatric (PE1) unit admissions: 0800 1400 2000

General: 0900 1300 1700 2100

qid Four times daily NICU admissions: 0900 1200 1500 2100 (to coincide with feed times)
Paediatric (PE1)unit admissions: 0800 1200 1600 2000

All units: 0730 1100 1500 1900 2300

Five times daily

General: 2100
hs, qhs At bedtime Paediatric (PE1) unit admissions: 2000

All units: 0730 1130 1630

ac Before meals **adjust for appropriate once, twice, or three times daily

with food All units: 0800 1200 1700

**do NOT use “cc” With meals **adjust for appropriate once, twice, or three times daily
abbreviation
All units: 0900 1300 1800
pc After meals **adjust for appropriate once, twice, or three times daily

q2h Every two hours All units: 0000 0200 0400 0600 0800 1000 1200 1400 1600 1800 2000 2200

q3h Every three hours All units: 0000 0300 0600 0900 1200 1500 1800 2100

General: 0100 0500 0900 1300 1700 2100 (to mimic the ‘usual’ standard admin times)
q4h Every four hours Paediatric/NICU unit admissions: 0000 0400 0800 1200 1600 2000

Every six hours All units: 0000 0600 1200 1800

q6h *** q6h oral medications – 0600 1200 1800 2200

All units: 0500 1300 2100 (to mimic the ‘usual’ standard admin times)
q8h Every eight hours Paediatric/NICU unit admissions: 0600 1400 2200

General: 0900 2100

q12h Every twelve hours Paediatric/NICU unit admissions: 0800 2000

*** Respiratory therapy may manually adjust administration times of aerosols and metered-dose inhalers accordingly to
allow for monitoring/assessment:
BID / q12h 0800 2000
TID 0800 1400 2000
q8h 0800 1600 2200
QID 0800 1200 1600 2000
q6h 0200 0800 1400 2000
q4h 0000 0400 0800 1200 1600 2000
November 2014
Medication Fluid SOP Team
 P&T and MAC approved administration time automatic substitution list

Antibiotics (oral and IV): (P&T/MAC approved Jan 2007) Unless specific orders are written to the contrary, antibiotics ordered
BID, TID, or QID will automatically be changed to the appropriate 24hr schedule
BID will be changed to q12h TID will be changed to q8h QID will be changed to q6h
****Antibiotics started at non-standard dosing times must be staggered back to hospital standard administration times.
Exceptions: a) q24h antibiotics for pediatric/NICU patients will be kept at the initial administration time
b) q24h aminoglycosides (gentamycin, tobramycin, amikacin) and vancomycin will be kept at the initial
administration time

Anticoagulants: (P&T/MAC approved Feb 2012)

 DVT prophylaxis (injectable and oral – including warfarin) dosing will be at the usual “qhs” dose.
 DVT/PE treatment – appropriate around-the-clock frequency (kept at the initial administration time)
 Injectable (i.e. heparin, Low Molecular Weight Heparins (i.e. dalteparin, enoxaparin)): Unless specific orders are
written to the contrary, injectable anticoagulants ordered BID or TID will automatically be changed to the appropriate
24hr schedule
BID will be changed to q12h TID will be changed to q8h

Beta-blocking agents: (P&T/MAC approved Jan 2007)

i.e. Acebutolol, Atenolol, Bisoprolol, Metoprolol, Nadolol, Propranolol, Timolol
Unless specific orders are written to the contrary, beta-blocking agents ordered BID, TID, or QID will automatically be changed to
the appropriate 24hr schedule
BID will be changed to q12h TID will be changed to q8h QID will be changed to q6h

Diuretics: (Medication Incident Indicator / Clinical Practice Teams Feb 2012) – Unless specific orders are written to the contrary,
BID dosing will be administered at 09:00 & 13:00

Hypoglycemics: Hypoglycemic medications (oral and insulin) will be administered at the appropriate ‘with meal’ frequency.
*** nateglinide and repaglinide – doses may be held if meal is skipped (notify physician)

Statins: (Medication Incident Indicator / Clinical Practice Teams Feb 2012) – Unless specific orders are written to the contrary,
statin medication will be administered daily at the usual “qhs” dose.

Sustained / Controlled Release Medications: (P&T/MAC approved Jan 2007) Unless specific orders are written to the contrary,
sustained/controlled-release medications ordered BID, TID, or QID will automatically be changed to the appropriate 24hr schedule
BID will be changed to q12h TID will be changed to q8h QID will be changed to q6h

Specific drug administration time adjustments:

Drug ordered Interval Autosub Comments
Aldactazide suspension for q12h For therapeutic drug
NICU distribution
Calcium Adjust to appropriate with meals frequency For therapeutic effectiveness
Domperidone Adjust to appropriate AC/HS frequency For therapeutic effectiveness
Florababy for NICU 0900 To coincide with am feeds

Immunosuppressants Appropriate around-the-clock frequency For therapeutic effectiveness

(i.e. q24h, q12h, q8h)
Iron (oral liquid) for NICU 0900 To avoid drug interactions &
coincide with feeds
Levothyroxine QHS To avoid drug-food & drug-
drug interactions
Metoclopramide (PO) Adjust to appropriate AC/HS frequency For therapeutic effectiveness
Octreotide Adjust to appropriate AC/HS frequency For therapeutic effectiveness
Phenytoin Appropriate around-the-clock frequency For therapeutic effectiveness
(i.e. q24h, q12h, q8h)
November 2014
Medication Fluid SOP Team
 Prednisone Adjust to appropriate with meals frequency To minimize GI side effects
Quinine for restless leg QHS For therapeutic effectiveness
Terazosin (Hytrin) QHS For therapeutic effectiveness
Tri-Vi-Sol for NICU patients Daily at noon To avoid drug interactions &
coincide with feeds
Vitamin D drops for NICU Daily at noon To avoid drug interactions &
patients coincide with feeds
*** when substituting the administration times as above … pharmacy will enter ‘MAC note (ADMINISTRATION
TIMES ADJUSTED BY PHARMACY PER MAC APPROVED DIRECTIVE) to the CMAR so the RN is aware
of the reason for change.

Staggering doses to achieve standard administration time

The following charts may be used as a guideline for staggering medication doses (which are begun off
schedule) back to standard hospital administration times.
Identify the time of administration of the initial dose, then administer the second and third doses at the
tabulated times. The fourth and subsequent doses should be given according to standard administration
times.
**staggered admin times will not be pre-populated on the CMAR by the pharmacy system – a manual adjustment
will be needed

FOR Q24H or Once daily doses

Time of 1st/stat dose Time of 2nd dose Time of 3rd dose Time of 4th dose
0100 Following day at 0400 Following day at 0700 Standard 0900 time
0200 Following day at 0400 Following day at 0700 Standard 0900 time
0300 Following day at 0700 Following day at 0900 Standard 0900 time
0400 Following day at 0700 Following day at 0900 Standard 0900 time
0500 Following day at 0700 Following day at 0900 Standard 0900 time
0600 Following day at 0700 Following day at 0900 Standard 0900 time
0700 Following day at 0900 Standard 0900 time Standard 0900 time
0800 Following day at 0900 Standard 0900 time Standard 0900 time
0900 Following day at 0900 Standard 0900 time Standard 0900 time
1000 Following day at 0900 Standard 0900 time Standard 0900 time
1100 Following day at 0900 Standard 0900 time Standard 0900 time
1200 Following day at 0900 Standard 0900 time Standard 0900 time
1300 Following day at 0900 Standard 0900 time Standard 0900 time
1400 Following day at 0900 Standard 0900 time Standard 0900 time
1500 Following day at 1300 Following day at 0900 Standard 0900 time
1600 Following day at 1300 Following day at 0900 Standard 0900 time
1700 Following day at 1300 Following day at 0900 Standard 0900 time
1800 Following day at 1300 Following day at 0900 Standard 0900 time
1900 Following day at 1300 Following day at 0900 Standard 0900 time
2000 Following day at 1700 Following day at 1300 Standard 0900 time
2100 Following day at 1700 Following day at 1300 Standard 0900 time
2200 Following day at 1700 Following day at 1300 Standard 0900 time
2300 Following day at 1700 Following day at 1300 Standard 0900 time
2400 Following day at 1700 Following day at 1300 Standard 0900 time

November 2014
Medication Fluid SOP Team
 **adapted from the 2001-2002 Formulary of Drugs – the Hospital for Sick Children (20th edition)

FOR Q12H or bid doses

Time of 1st/stat dose Time of 2nd dose Time of 3rd dose Time of 4th dose
0100 0900 Standard Standard
0200 1000 Standard Standard
0300 1100 Standard Standard
0400 1200 2100 Standard
0500 1300 2200 Standard
0600 1400 2300 Standard
0700 1500 2400 Standard
0800 Standard Standard Standard
0900 Standard Standard Standard
1000 Standard Standard Standard
1100 Standard Standard Standard
1200 Standard Standard Standard
1300 2100 Standard Standard
1400 2200 Standard Standard
1500 2300 Standard Standard
1600 2400 Standard Standard
1700 0700 Standard Standard
1800 0700 Standard Standard
1900 0700 Standard Standard
2000 Standard Standard Standard
2100 Standard Standard Standard
2200 Standard Standard Standard
2300 Standard Standard Standard
2400 Standard Standard Standard

**adapted from the 2001-2002 Formulary of Drugs – the Hospital for Sick Children (20th edition)

November 2014
Medication Fluid SOP Team
 FOR Q8H or tid doses

Time of 1st/stat dose Time of 2nd dose Time of 3rd dose Time of 4th dose
0100 0800 1400 Standard
0200 0800 1400 Standard
0300 1000 1900 Following day standard
0400 1000 1900 Following day standard
0500 1300 2100 Following day standard
0600 1400 Standard Standard
0700 1400 Standard Standard
0800 1400 Standard Standard
0900 1400 Standard Standard
1000 1700 2200 Following day standard
1100 1700 2200 Following day standard
1200 1700 2200 Following day standard
1300 2000 Following day standard Standard
1400 2000 Following day standard Standard
1500 2000 Following day standard Standard
1600 2200 Following day standard Standard
1700 2200 Following day standard Standard
1800 2400 Following day standard Standard
1900 2400 Following day standard Standard
2000 0100 Following day standard Standard
2100 Following day standard Standard Standard
2200 Following day standard Standard Standard
2300 Following day standard Standard Standard
2400 Following day standard Standard Standard

**adapted from the 2001-2002 Formulary of Drugs – the Hospital for Sick Children (20th edition)

November 2014
Medication Fluid SOP Team
 FOR Q6H or qid doses

Time of 1st/stat dose Time of 2nd dose Time of 3rd dose Time of 4th dose
0100 Standard Standard Standard
0200 0700 1300 Standard
0300 0700 1300 Standard
0400 0800 1300 Standard
0500 1100 1800 Standard
0600 1100 1800 Standard
0700 1200 1800 Standard
0800 1300 1800 Standard
0900 1300 1800 Standard
1000 1500 2200 Following day standard
1100 1700 2200 Following day standard
1200 1700 2200 Following day standard
1300 1800 2400 Following day standard
1400 1800 2400 Following day standard
1500 2100 Following day standard Standard
1600 2100 Following day standard Standard
1700 2400 Following day standard Standard
1800 2400 Following day standard Standard
1900 2400 Following day standard Standard
2000 2400 Following day standard Standard
2100 0200 0700 1300
2200 0200 0700 1300
2300 0500 1100 1800
2400 Standard Standard Standard

**adapted from the 2001-2002 Formulary of Drugs – the Hospital for Sick Children (20th edition)

November 2014
Medication Fluid SOP Team