National Healthcareer Association ExCPT Pharmacy Technician Exam Focused Review

Product Verification and Pharmacy Layout Fundamentals

• Final Product Release: Pharmacists must verify and release the final product to the patient. This vepensing.

• Role of the Pharmacy Technician: Technicians are critical to the safety of prescriprification involves a rigorous, detailed process to ensure accuracy, safety, and legal adherence before medication distion verification. Their duties include:

  • Meticulously reviewing prescriptions for completeness, accuracy, and legality.

  • Verifying patient information, dosage instructions, medication interactions, and potential allergies.

  • Checking for proper labeling and packaging before the pharmacist provides the final verification.

• Pharmacy Layout and Workflow Strategy: The design and flow of the pharmacy environment are structured to decrease the likelihood of errors and ensure verification occurs for every prescription.

Community Pharmacy Layout and Workflow

• Intake Area:

  • Often called the drop-off or check-in area.

  • Patients drop off written prescriptions here.

  • Pharmacy technicians are typically the first point of contact, making the initial impression. The area should be kept clean, uncluttered, and structured.

  • Prescriptions should be scanned promptly for all necessary information to prevent callbacks and delays.

• Processing Area:

  • This is the environment for data entry and prescription processing.

  • It should be free from distractions to ensure an accurate patient record, which is the basis for health decisions.

  • Contains sub-areas for prescriptions requiring processing, awaiting preparation/dispensing, requiring verification, and needing intervention.

  • Uses separate bins or totes for each prescription to prevent mislabeling.

  • Houses equipment: counting machines, distilled water, compounding/repackaging tools, scales, calculators, containers, and labels.

• Pharmacist Final Verification Area: Designated space where prescriptions reside while awaiting and receiving the pharmacist's final check.

• Processed Prescriptions Area (Will Call):

  • Stores completed, verified prescriptions alphabetically by last name in large bins until patient pickup.

• Out Window:

  • The designated area for patient pickup. It houses cash registers and point-of-sale (POS) software.

  • POS software helps ensure safety: if a prescription is scanned that has not been verified by a pharmacist, a notification appears, and the item must be returned for verification.

  • This area also facilitates third-party billing if info was missing at intake. If insurance is adjudicated here, a new label is printed, and the pharmacist must verify the product again.

  • Includes a separate or nearby area for private consultation.

Institutional Pharmacy Layout and Workflow

• Workflow Differences: Unlike community settings, medications are released to a nursing and healthcare team. Pharmacists must verify orders prior to this release.

• Verification Indicators: Technicians must look for the pharmacist’s signature or initials on the preparation to confirm it has been verified.

• Technician Check Technician (TCT):

  • In some states, certified technicians may verify the work of other technicians before release to the healthcare team.

  • This practice is limited specifically to automated dispensing machine refills and unit dose batching.

• Main Dispensary and Computer Stations: Areas where pharmacists receive electronic orders from hospital floors to validate accuracy, appropriateness, and adherence to medication profiles.

• Pullout Shelves/Carousel: Technicians access prepackaged, individualized medications based on pharmacist entries. Labels print directly from the system during entry for efficiency.

• Ward Box Area:

  • Ward Boxes: Storage containers or units used to organize and dispense medications for specific hospital wards/units.

  • Medications prepared by technicians move here for final pharmacist verification and packaging for delivery to specific units.

• Bulk Medication Storage: Shelves dedicated to storing bulk medications used for compounding, filling, or replenishing stocks/robots.

• Refrigerated Storage: Specialized fridge areas to maintain the stability and integrity of temperature-sensitive medications.

• Medication-Filling Robot:

  • Robot: An automated system or machine designed to assist with medication dispensing tasks.

  • The robot fills prescriptions based on overnight orders for morning delivery to floors.

• Aseptic Suite:

  • Aseptic Suite: Sterile compounding areas or clean rooms.

  • Technicians prepare sterile IV medications under controlled conditions. An anteroom is located outside for proper garbing.

• Unpacking Area: Designated for unpacking and checking incoming products from distributors for quality and accuracy before they are stocked.

Medical Terminology and Sig Codes

• Word Construction: Terms are often based on Greek or Latin.

  • Prefixes: Found at the beginning of a word.

  • Roots: Usually in the middle.

  • Suffixes: At the end.

  • Example: "Rhinitis" involves "rhin-" (nose) and "-itis" (inflammation).

• Signa (Sig) Codes: Standardized abbreviations for dosage and administration routes.

Table: Routes of Administration

• $ad$: Right ear

• $as$: Left ear

• $au$: Both ears

• $bu$: Buccal

• $im$: Intramuscular

• $it$: Intrathecal

• $nare$: Nostril

• $od$: Right eye

• $os$: Left eye

• $ou$: Both eyes

• $po$: By mouth

• $pr$: Rectal

• $pv$: Vaginal

• $sc, sq, sub q$: Subcutaneous

• $sl$: Sublingual

• Note: Abbreviations with asterisks ($ad, as, au, od, os, ou, sc, sq, sub q$) are on error-prone or "do not use" lists due to potential confusion.

Table: Frequency Abbreviations

• $ac$: Before meals

• $bid$: Twice daily

• $hs$: At bedtime

• $pc$: After meals

• $prn$: As needed

• $qh$: Every hour

• $qid$: 4 times a day

• $tid$: 3 times a day

• $wa$: While awake

Table: Miscellaneous Abbreviations

• $aaa$: Apply to affected area

• $gtts$: Drops

• $ha$: Headache

• $qs$: Quantity sufficient

• $ung$: Ointment

Medication Classifications by Body System

Cardiovascular System Classifications

• Nitrates: (Prefix $nitr-$); Generic: Isosorbide mononitrate; Use: Antianginal.

• Calcium Channel Blockers: (Suffix $-pine$); Generic: Nifedipine; Use: Antianginal, Antiarrhythmic.

• Beta-blockers: (Suffix $-lol$); Generic: Atenolol; Use: Antianginal, Antiarrhythmic, Antihypertensive.

• HMG-CoA Reductase Inhibitors: (Suffix $-statin$); Generic: Atorvastatin; Use: Antihyperlipidemic.

• Fibric Acid Derivatives: (Suffix $-fibr$); Generic: Fenofibrate; Use: Antihyperlipidemic.

• Alpha-blockers: (Suffix $-azosin$); Generic: Terazosin; Use: Antihypertensive.

• ACE Inhibitors: (Suffix $-pril$); Generic: Benazepril; Use: Antihypertensive.

• Angiotensin Receptor Blockers: (Suffix $-sartan$); Generic: Irbesartan; Use: Antihypertensive.

• Loop Diuretics: (Suffix $-mide$); Generic: Furosemide; Use: Antihypertensive.

• Thiazide Diuretics: (Suffix $-thiazide$); Generic: Hydrochlorothiazide; Use: Antihypertensive.

• Potassium-sparing Diuretics: Generic: Spironolactone; Use: Antihypertensive.

• Antiplatelets: Generic: Clopidogrel; Use: Thrombus prevention.

Gastrointestinal (GI) System Classifications

• Anticholinergics: Generic: Dicyclomine; Use: Antiemetic.

• Antacids: Generic: Magnesium; Use: GERD.

• H2 Blockers: (Suffix $-tidine$); Generic: Famotidine; Use: GERD.

• Proton Pump Inhibitors: (Suffix $-prazole$); Generic: Esomeprazole; Use: GERD.

• Osmotic Laxatives: Generic: Polyethylene glycol; Use: Constipation.

• Stool Softeners: Generic: Docusate sodium; Use: Constipation.

Musculoskeletal System Classifications

• DMARDs: (Suffix $-ine$); Generic: Methotrexate; Use: Antirheumatic.

• Xanthine Oxidase Inhibitors: (Suffix $-inol$); Generic: Allopurinol; Use: Gout.

• NSAIDs: (Suffix $-ofen$); Generic: Ibuprofen; Use: Anti-inflammatory.

• COX-2 Inhibitors: (Suffix $-oxib$); Generic: Celecoxib; Use: Pain, Anti-inflammatory.

• Bisphosphonates: (Suffix $-onate$); Generic: Alendronate; Use: Osteoporosis.

• Muscle Relaxants: (Suffix $-prine$); Generic: Cyclobenzaprine; Use: Muscle relaxation.

Nervous System Classifications

• Benzodiazepines: (Suffix $-zepam, -zolam$); Generic: Lorazepam; Use: Antianxiety, Anticonvulsant.

• Tricyclic Antidepressants: (Suffix $-tyline$); Generic: Amitriptyline; Use: Antidepressant.

• SNRIs: Generic: Duloxetine; Use: Antidepressant.

• SSRIs: Generic: Citalopram; Use: Antidepressant, Antianxiety.

• Atypical Antipsychotics: (Suffix $-pine$); Generic: Quetiapine; Use: Antipsychotic.

• Prostaglandin Analogs: (Suffix $-oprost$); Generic: Latanoprost; Use: Glaucoma.

• Alpha Agonists: (Suffix $-ine$); Generic: Brimonidine; Use: Glaucoma.

• Narcotic Analgesics: Generic: Morphine; Use: Pain.

Endocrine System Classifications

• Insulin: Generic: Insulin degludec; Use: Diabetes.

• Sulfonylureas: Generic: Glimepiride; Use: Diabetes.

• SGLT2 Inhibitors: (Suffix $-gliflozin$); Generic: Canagliflozin; Use: Diabetes.

• Biguanides: Generic: Metformin; Use: Diabetes.

• Thiazolidinediones: (Suffix $-glitazone$); Generic: Pioglitazone; Use: Diabetes.

• GLP-1 Agonists: (Suffix $-glutide$); Generic: Dulaglutide; Use: Diabetes.

Essential Pharmacy References and Resources

• Orange Book: Comprehensive list of approved products with therapeutic equivalence evaluations. Used to determine if a generic is the same as a brand-name medication.

• Red Book: Standard reference for finding average and wholesale costs for prescription and nonprescription drugs.

• Yellow Book (CDC Health Information for International Travel): Health recommendations for travel, published every 2 years.

• Purple Book: Lists all biologic products, reference products, biosimilars, and interchangeability.

• United States Pharmacopeia-National Formulary (USP-NF): Provides access to official FDA standards and lists new product development and approvals.

• Safety Data Sheets (SDS): Explain the dangers of hazardous chemicals and necessary actions for exposure.

• Drug Facts and Comparisons: Resource for medication monographs and interaction data.

• Handbook on Injectable Drugs: Guide for parenteral medication compatibility and stability, critical in inpatient pharmacies.

• ISMP Medication Safety Alert!: Newsletter published every 2 months regarding error prevention and near misses.

• Ident-A-Drug: Online listing for identification of tablets and capsules using more than 38,000 entries.

• IDENTIDEX (Micromedex): Medication identification by shape, color, and imprint; utilized by law enforcement.

• Martindale: The Complete Drug Reference: Global medication information.

Security and Controlled Substances

• Access Control: Only pharmacists, technicians, and cashiers are permitted in the pharmacy. External access (law enforcement, FDA, boards of pharmacy) must be approved by the pharmacist on duty. Individualized access codes should be changed regular and inactivated upon termination.

• Storage of Controlled Substances:

  • Option 1: Locked in a secure cabinet.

  • Option 2: Dispersed throughout the pharmacy shelves among non-controlled (legend) medications.

• DEA Forms:

  • Form 222: Used for ordering C-II medications. A triplicate form (Copy 1 to supplier, Copy 2 to DEA, Copy 3 stays in pharmacy for 2 years). Electronic orders use CSOS.

  • Form 106: Used to report loss or theft of controlled substances.

  • Form 41: Used for the disposal of controlled substances due to expiration or damage.

• Inventory Requirements: Must be performed every 2 years after initial inventory. C-II substances require an exact count; C-III to C-V can be estimated. Records must be kept for at least 2 years at the DEA-registered location.

• DEA Number Verification Formula:

  • 1st Letter: Code for registrant type (A, B, F, M, X).

  • 2nd Letter: First letter of registrant's last name.

  • Math: (Sum of 1st, 3rd, and 5th digits) + [(Sum of 2nd, 4th, and 6th digits) $\times$ 2]. The last digit of the total must match the 7th (last) digit of the DEA number.

Pharmacy Calculations and Temperatures

• Temperature Ranges:

  • Room Temperature: $20^{\circ} \text{C to } 25^{\circ} \text{C}$ ($68^{\circ} \text{F to } 77^{\circ} \text{F}$).

  • Refrigerator: $1.7^{\circ} \text{C to } 7.8^{\circ} \text{C}$ ($35^{\circ} \text{F to } 46^{\circ} \text{F}$).

  • Freezer: $-15^{\circ} \text{C}$ ($5^{\circ} \text{F}$) or lower.

• Conversion Formula:

  • $5F = 9C + 160$

  • Alternatively: $C = \frac{F - 32}{1.8}$ and $F = (C \times 1.8) + 32$

• Quantity and Days' Supply:

  • Quantity = (Dose per administration) $\times$ (Frequency per day) $\times$ (Duration in days).

  • Example: Sig 2 tabs po bid for 15 days = $2 \times 2 \times 15 = 60$ tablets.

  • Days' Supply = (Total Quantity) $\div$ (Total daily dose).

• Body Surface Area (BSA): Expressed in meters squared ($m^2$). Used primarily for chemotherapy and pediatric dosing.

  • Total Dose = (Ordered Dose per $m^2$) $\times$ (Patient's BSA in $m^2$).

Quality Assurance and Error Prevention

• Just Culture:

  • Human Error: Inevitable, unintentional failure; managed through system redesign.

  • At-Risk Behavior: Loss of perception of risk or belief that risk is justified; managed by coaching.

  • Reckless Behavior: Conscious disregard of substantial risk; managed through disciplinary action.

• The 9 Rights of Medication:

  1. Right medication

  2. Right dose

  3. Right time

  4. Right patient

  5. Right education

  6. Right to refuse

  7. Right route

  8. Right effects

  9. Right documentation

• Tall Man Lettering: Used to differentiate look-alike, sound-alike (SALAD) drugs (e.g., hydrALAZINE vs. hydrOXYzine).

• Root Cause Analysis: Investigation process used after an error to prevent recurrence. Required by The Joint Commission within 45 days of detection.

Sterile and Nonsterile Compounding

• USP <797> (Sterile): Covers garbing, HEPA filters, and aseptic technique. Cleaning frequency for hoods: start of shift, before each batch, every 30 mins during continuous work, or after a spill.

• USP <795> (Nonsterile): Regulates design, maintenance, hygiene, and documentation for non-sterile preparations.

• Garbing Order:

  1. Shoe covers

  2. Bouffant cap

  3. Beard cover (if applicable)

  4. Face mask

  5. Aseptic handwashing (minimum 30 seconds)

  6. Gown

  7. Sterile powder-free gloves

• Critical Sites: Areas that must never be touched or blocked by air: vial top, needle, syringe tip, plunger, and fluid bag ports.

• Needle Bevel: The slanted part of the needle tip. Insertion into vials should be at a $45^{\circ}$ angle with bevel up to avoid coring.

Insurance and Adjudication

• Adjudication: Electronic transmission of a claim to the insurer.

• DAW Codes:

  • 0: No product selection indicated (Substitution allowed).

  • 1: Substitution not allowed by prescriber.

  • 2: Patient requested brand.

  • 4: Generic not in stock.

• Third-Party Identifiers:

  • BIN: 6-digit processor ID.

  • PCN: Secondary identifier for routing.

  • Group Code: Identifies the specific employer plan.

• Medicare Parts:

  • Part B: Covers Durable Medical Equipment (DME) like canes, hospital beds, and nebulizers.

  • Part D: Primary coverage for outpatient prescriptions.

Questions & Discussion

• Question: If a medication expires on 06/2027, what is the exact date it becomes unusable?

• Response: The medication expires on the last day of the month: June 30, 2027.

• Question: What is the procedure if a technician notices a Class I recall notification?

• Response: Immediately stop dispensing the affected medication, remove it from shelves, notify patients who recently received the medication to return it for a replacement, and update the inventory system.

• Question: When converting $68^{\circ} \text{F}$ to Celsius, what is the result?

• Response: Applying the formula $(68 - 32) \div 1.8 = 20^{\circ} \text{C}$.

• Question: Which law requires pharmacists to offer counseling to Medicaid patients?

• Response: The Omnibus Budget Reconciliation Act of 1990 (OBRA ‘90).