Pharmacy Technician Exam Study Guide: Medication Safety and Quality Assurance

Medication Adherence

Monitoring patient adherence is crucial for medication safety. Discrepancies in refill requests can signal adherence issues. Days' supply calculation, dividing units dispensed by daily doses, is key for identifying adherence.

Example: Penicillin i po tid, #21 yields a 7-day supply: days'\ supply = \frac{number\ of\ tablets\ dispensed}{number\ of\ doses\ used\ by\ the\ patient\ each\ day} = \frac{21}{3} = 7

Correct days' supply is essential for insurance billing. "Refill too soon" rejections prompt adherence discussions, possibly revealing dose changes, misuse, misunderstanding, or diversion.

Prescription Monitoring Programs (PMPs) track controlled substances to prevent abuse. Pharmacies report data to databases, flagging overuse by monitoring refill frequency, multiple providers, and cash payments.

Days’ Supply Definition: The number of days a prescription will last a patient.

Assessing Patient Adherence

Underuse is as risky as overuse. Delayed refills trigger alerts, prompting investigation into affordability, side effects (e.g., ACE inhibitors causing coughs), dose reductions, or forgetfulness.

Mathematical Formulas for Adherence

Two key formulas for measuring patient adherence are:

1. Proportion of Days Covered (PDC):
   PDC = \frac{number\ of\ covered\ days}{number\ of\ days\ in\ the\ period} × 100

   Example: 85 covered days out of a 90-day period equals 94% adherence.
   PDC = \frac{85}{90} x 100 = 94.4\% = 94\%

2. Medication Possession Ratio (MPR):
   MPR = \frac{sum\ of\ days'\ supply\ for\ all\ fills}{number\ of\ days\ in\ the\ period} × 100

   Example: Three 30-day refills with two 5-day delays in a 100-day period equals 90% adherence.
   MPR = \frac{90}{100} x 100 = 90\%

PDC is used by Medicare to assess adherence and determine plan star ratings and reimbursement rates.

PDC Definition: A percentage representing patient medication adherence.

Avoiding Errors

Medication safety relies on the rights of medication administration which are:

Right medication, route, time, patient, dose, documentation, medication, action, form, and response.

Right Medication

Safety checks, including tall man letters, differentiate similar drug names (SALADs) to prevent mix-ups. The ISMP provides lists and resources for medication safety.

Example: hydrALAZINE (heart conditions) vs. hydrOXYzine (allergies), with similar packaging and routes, necessitate careful differentiation.

NMBA and chemotherapy drugs are stored separately, often in distinct bins.

FDA-Approved Generic Medication Names with Tall Man Letters

The tables list examples of medications with similar names that can be confused and use tall man lettering to differentiate them:

• buPROPion vs. busPIRone
• chlorproMAZINE vs. chlorproPAMIDE
• clomiPHENE vs. clomiPRAMINE
• cycloSERINE vs. cycloSPORINE
• DOBUTamine vs. DOPamine
• glyBURIDE vs. glipiZIDE
• medroxyPROGESTERone vs. methylPREDNISolone
• methylTESTOSTERone
• niCARdipine vs. NIFEdipine
• prednisoLONE vs. predniSONE
• sulfiSOXAZOLE vs. sulfADIAZINE
• TOLBUTamide vs. TOLAZamide
• vinCRIStine vs. vinBLAStine

Rights of medication administration Definition: Verification process created to minimize the occurrence of medication errors.

Tall man letters Definition: A system of using lowercase and uppercase letters for medication names to prevent mix-ups.

Soundalike and lookalike drugs (SALAD) Definition: Medications that either sound alike when spoken or look alike when viewed; also called lookalike soundalike (LASA) medications.

Institute for Safe Medication Practice (ISMP) Definition: A not-for-profit organization dedicated to preventing medication errors.

Right Route

Administration route must match dosage form. Auxiliary labels indicate routes to prevent errors (e.g., "for the ear" on ear drops, "topical use only" on Dakin's solution).

IV doses are typically lower than oral doses.

Error-prone abbreviations lists from The Joint Commission and ISMP guide pharmacies.

ISMP Error-Prone Abbreviations

The Joint Commission definition: A not-for-profit organization that accredits health care organizations.

Right Time

Giving a dose 30 minutes early or late constitutes a wrong-time error. Some drugs require specific timing (e.g., zolpidem at night, ACE inhibitors to avoid hypotension).

Right Patient

Barcode technology and two-factor identification (name, DOB) by nursing staff ensure correct patient administration. Patients should verbally state their DOB, rather than confirming what the nurse says.

National Patient Safety Goals (NPSGs) from The Joint Commission include correct patient identification and safe medication use, especially for blood thinners.

Organizations ignoring NPSGs risk losing Medicare billing privileges.

Right Dose

Doses are verified before pharmacy dispensing and by nursing staff. High-alert drugs require extra verification, specialized bags, and auxiliary labels. Dual verification by nurses with documentation can help decrease errors.

High-alert drugs Definition: Medications identified by Institute for Safe Medication Practice to be a high risk for causing patient harm if used inappropriately.

ISMP High-Alert Medications

Right Documentation

Accurate documentation in electronic medication administration records tracks trends, ensures timing, prevents double doses, correlates vital signs, and supports auditing/billing.

Right Response

Medication Guides accompany drugs with potential risks, providing FDA-approved information to avoid adverse events. REMS programs, like iPLEDGE for isotretinoin (Accutane), manage risks by mandating patient enrollment and pregnancy tests.

Other REMS drugs include transmucosal immediate-release fentanyl, buprenorphine-naloxone (Suboxone), and dofetilide (Tikosyn).

Medications Dispensed with a Medication Guide

MedGuide Definition: A document that is required to be dispensed with specific medications that have potential adverse reactions and is written in a language that the patient can understand.

Medication Safety and Quality Assurance

Following safety standards is everyone's responsibility in the pharmacy.

Medication errors are preventable events related to practice, products, and systems, occurring during prescribing, communication, labeling, compounding, dispensing, etc.

Hospital pharmacies use automation to reduce errors. Pharmacist verification is required before dispensing. Some states allow technician check technician (TCT) for ADM refills or floor stock.

Automated dispensing machine (ADM). A piece of equipment in the institutional pharmacy setting that allows for dispensing and charging of common medications on the nursing unit.

Floor stock Definition: An approved list of medications allowed to be stored on a nursing unit for easy access and patient use.

Best practices to reduce medication errors include:

• Regular allergy and condition updates.
• Pharmacist clarification for illegible prescriptions.
• Comparison of the physical script to the electronic label.
• Pharmacist review of DUR notifications.
• NDC verification between label and bottle.
• Expiration date checks.
• Double-counting controlled substances, circling, and initialing.
• Two-factor patient ID during pick-up.
• Pharmacist counseling per OBRA '90.

Providers use two patient identifiers consistently, excluding room number. Concentrated electrolytes and NMBAs are not floor stock due to their high risk.

Long-acting insulin is pre-drawn in the pharmacy. Medications for ADMs are verified with barcode scanning. Nurses verify medications added to ADMs, and narcotics delivery requires nurse verification.

Monthly unit inspections check storage, temperatures, multi-dose vials (MDVs), and floor stock. Opened MDVs are dated, initialed, and discarded after 28 days.

TPN compounding uses barcode technology and calibrated scales. Chemotherapy orders undergo pharmacist double-checks and nurse verification. Patient weights are in kilograms.

Annual competency assessments involve technique tests. Pharmacy and Therapeutics (P&T) committees maintain formularies. Warfarin and epoetin alfa require INR and hematocrit checks, respectively.

Pharmacy and therapeutics (P&T) committee Definition: A committee in the hospital made of physicians, pharmacists, and administration who make decisions about the hospital formulary.

Quality Assurance Checks

Medication safety necessitates continuous review. Outdated medications are removed monthly, identified at year-start with color-coded dots. Expired stock is quarantined and returned for credit or destruction, with inventory adjustments. Controlled substances are secured and documented.

Perpetual inventory Definition: An exact record of inventory at any given time by adding all orders received and removing every order dispensed from inventory in real time.

Refrigerators/freezers have monitored thermometers with alarms. Out-of-range temperatures prompt door and power checks, documentation, relocation of medications, and work orders.

Crash carts are checked monthly for expirations. Schedule II drugs aren't stored in patient areas.

Crash cart Definition: A cart full of emergency medications used during a code stored on nursing units for easy access.

Communication and Customer Service

Effective communication requires adaptability, respect, and cultural awareness.

Adaptability Definition: Tailor interactions to the understanding level of recipients. Respect Definition: Treat everyone with dignity. Cultural awareness: Acknowledge cultural differences.

Product Verification

Pharmacist final verification is paramount. Pharmacy layout and workflow ensure this.

Community settings have intake, processing, processed prescription (will call), and out windows. Point-of-sale systems prevent selling unverified prescriptions, requiring return to the pharmacist.

Institutional workflows separate unverified/verified medications, with technician check technician (TCT) in some states for specific tasks, subject to BOP policies.

Pharmacy Security

Access control is important. Only authorized personnel are permitted in locked pharmacies. Codes are confidential and regularly changed. Controlled substances are secured or dispersed among other medications.

Legend medication Definition: Medication that requires a prescription for dispensing. Board of pharmacy (BOP) Definition: State board that regulates pharmacy practice. Food and Drug Administration (FDA) Definition: Federal agency that regulates medication manufacture and safeguarding.

Expired and Recalled Products

FDA determines expiration dates. Inventory checks ensure medications are used before expiration. Storage impacts expiration dates (e.g., famotidine, insulin). Expired controlled substances require DEA-41 forms, two witnesses, and reverse distributors for disposal. Credits are given upon return.

Pharmacy Inventory

Maintaining suitable inventory is essential. Technicians handle ordering, receiving, and stocking, balancing overstocking (expiration, diversion) and understocking (delays).

Reorder points/quantities (ROP/ROQ) trigger orders. Technicians review orders, prepare DEA-222 forms for C-II substances, check stock levels, and inform pharmacists of backorders. Receiving involves verifying details against purchase orders, inspecting shipments, and noting discrepancies. Personal protective equipment (PPE) is used for hazardous drugs. Expiration dates are checked, invoices are signed, and discrepancies are reported.

Brand/trade name Definition: Trademark of a medication or device created by the originating manufacturing company for marketing purposes. National Drug Code (NDC) number Definition: Identifying number given to each prescription medication before it is marketed that identifies the manufacture, medication, and package size.

Stocking follows FIFO (first in, first out) to use earlier expirations first. Technicians inspect products, report shortages, monitor expiration dates, and adjust ROP/ROQ accordingly. Extra care goes into checking refrigerated products; personnel use PPE when handling hazardous medications.

First in, first out (FIFO)Definition: Process of stocking shelves so the earliest expiration dates are used first.

Laws, Regulations, and Controlled Substances

Prescription Fulfillment

State licensing boards govern prescribers. Pharmacists verify veterinarian prescriptions for humans. Prescriptions, legal documents conveying treatment plans, vary in format and requirements. Outpatient Definition: Patient who is undergoing diagnostic or therapeutic procedures and care outside an acute care hospital or a residential medical facility.

Prescriptions need patient information (name, address, DOB), date, medication details (name, strength, dosage, refills, generic permission), sig code, prescriber information (signature, address, DEA number).

Prescriptions arrive in various forms (written, phone, fax, computer) but C-IIs are restricted. Standards from The Joint Commission and ISMP address error-prone abbreviations. The rights of medication administration prevent mistakes.

OBRA '90 mandates patient profiles and counseling (expanded to all patients), contributing to medication reconciliation. Pharmacists counsel; technicians gather data for records.

Manufacturer's Label

Medications arrive in stock bottles that display brand/generic names, strength, legend statement (“Rx only”), storage, quantity, dosage, manufacturer, controlled substance mark, lot number, expiration date, and National Drug Code (NDC) number.

Suspension Definition: A liquid preparation consisting of solid particles dispersed throughout a liquid in which they are not soluble.

Recalls Definition: A required return of a possibly harmful or defective product.

The National Drug Code (NDC) number has parts indicating the manufacturer (four or five digits), drug (three or four digits), and package size (two digits). Codes must be eleven digits. Technicians use this code when labeling and scanning.

Preparations (eye/ear drops, creams, inhalers, oral contraceptives) are prepackaged, and the technician labels the individual package.

Many states have label specifications. Over-the-counter labels include name, address, ingredients, amount, warnings, and directions. Procedures for handling medication orders in an inpatient setting are significantly different.

Topical Definition: Referring to a cream, ointment, lotion, or other preparation for external application only.

Collection, Storage, and Disposal of PHI

Protected health information (PHI) includes patient identifiers. HIPAA requires shredding papers containing PHI, securing files, and prohibiting PHI sales without permission. Employers must train staff on HIPAA and update it. Facilities have a HIPAA privacy officer. Only authorized personnel access data. Electronic records require safeguards and unique identifiers for providers and codes for information/transactions. Every pharmacy has a National Provider Identifier (NPI). HIPAA created the Healthcare Fraud and Abuse Control Program.

Controlled Substance Schedules

Controlled substances have abuse potential. The Controlled Substances Act of 1970 set five schedules, C-I to C-V, with varying abuse/dependence potential.

• Schedule I (C-I): Illegal drugs with no accepted medical use (heroine, LSD, marijuana).
• Schedule II (C-II): High abuse potential (morphine, oxycodone, methamphetamine).
• Schedule III (C-III): Moderate potential (ketamine, acetaminophen with codeine, anabolic steroids).
• Schedule IV (C-IV): Low potential (diazepam, zolpidem).
• Schedule V (C-V): Limited quantities of narcotics (diphenoxylate with atropine).

Methamphetamine Definition: A Schedule II synthetic medication that acts as a stimulant. Anabolic steroid Definition: Usually synthetic hormones that are derivatives of testosterone, used to promote tissue growth.

The DEA Diversion Control Division's website has an updated list of all controlled substances and their CSA schedules.

Medication Classifications

Over-the-Counter Products

Familiarity with OTC indications is crucial, including combination products, vitamins, and herbal supplements.

Vertigo Definition: The sensation that the room is spinning when getting up or changing positions. Allergic reaction Definition: A hypersensitive response to a medication, food, or other substance, ranging in intensity from mild itching to severe rash to anaphylaxis. Rhinitis Definition: Nasal inflammation, resulting in nasal congestion, nasal itch, sneezing, postnasal drainage, and sometimes itchy, watery eyes. Flatulence Definition: Excessive formation of gases in the stomach or intestine, which exit via the rectum and anus.

Indications of Common OTC Medications

OTC medications are listed to aid patients include:

• Acetaminophen (Tylenol) for fever, pain.
• Alpha-galactosidase (Beano) for flatulence.
• Aspirin for inflammation, pain.
• Benzocaine (Anbesol) for mouth irritation, toothache.
• Bismuth subsalicylate (Pepto-Bismol) for diarrhea.
• Calcium carbonate (Tums) for stomach acidity.
• Carbamide peroxide (Auro, Debrox) for ear irritation, swimmer's ear.
• Cetirizine (Zyrtec) for nasal allergies, congestion, runny nose.
• Cimetidine (Tagamet) for stomach ulcers, acidity, heartburn.
• Dextromethorphan (Robitussin) for cough.
• Dimenhydrinate (Dramamine) for nausea, vomiting, motion sickness, vertigo.
• Diphenhydramine (Benadryl) for allergic reactions, seasonal rhinitis.
• Docosanol (Abreva) for cold sores.
• Docusate (Colace) for constipation.
• Esomeprazole (Nexium) for stomach ulcers, acidity, heartburn.
• Famotidine (Pepcid) for stomach ulcers, acidity, heartburn.
• Fexofenadine (Allegra) for nasal allergies, congestion, runny nose.
• Fluconazole (Diflucan) for yeast infections.
• Fluticasone (Flonase) for allergies.
• Guaifenesin (Mucinex) for cough.
• Ibuprofen (Advil, Motrin) for inflammation, pain.
• Lansoprazole (Prevacid) for stomach ulcers, acidity, heartburn.
• Lidocaine (Solarcaine) for sunburn.
• Loperamide (Imodium) for diarrhea.
• Loratadine (Claritin) for nasal allergies, congestion, runny nose.
• Meclizine (Bonine) for nausea, vomiting, motion sickness, vertigo.
• Methylcellulose (Citrucel) for constipation.
• Minoxidil (Rogaine) for hair loss.
• Naproxen (Aleve) for inflammation, pain.
• Omeprazole (Prilosec) for stomach ulcers, acidity, heartburn.
• Pheniramine maleate, naphazoline (Visine) for eye irritation.
• Phenylephrine (Sudafed PE) for nasal allergies.
• Phosphoric acid, glucose, fructose (Emetrol) for nausea, vomiting.
• Polymyxin, bacitracin, neomycin (Neosporin) for cuts, scrapes.
• Psyllium (Metamucil) for constipation.
• Pyrethrins, piperonyl butoxide (Rid) for lice.
• Ranitidine (Zantac) for stomach ulcers, acidity, heartburn.
• Salicylic acid (Compound W) for warts.
• Simethicone (Gas-X) for flatulence.
• Tetrahydrozoline (Murine) for eye irritation.
• Zantac (Ranitidine) for heartburn

Medication Classifications

Keep in mind that some of these lists change yearly or every few years, and different sources have different rankings of these medications. Becoming familiar with the medications that providers most often prescribe is a good place to start.

Remember the generic name, brand name, and classifications of common medications.

Top 10 Prescribed Medications in the U.S.

The medications prescribed most are listed, along with their classifications:

• Hydrocodone plus acetaminophen (Vicodin, Norco, Lortab) - Opioid analgesic
• Levothyroxine (Synthroid) - Thyroid hormone
• Prednisone (Rayos, Deltasone) - Corticosteroid
• Lisinopril (Prinivil, Zestril) - Antihypertensive, ACE inhibitor
• Amoxicillin (Amoxil) - Antibiotic
• Gabapentin (Neurontin) - Anticonvulsant
• Metformin (Glucophage) - Hypoglycemic
• Atorvastatin (Lipitor) - Antilipemic, statin
• Alprazolam (Xanax) - Benzodiazepine
• Amlodipine (Norvasc) - Calcium channel blocker

Narcotic Definition: A controlled substance that includes central nervous system depressants, strong analgesics, and medications capable of causing physical dependence. Hypoglycemic Definition: An agent that lowers blood glucose levels. Benzodiazepine Definition: A group of medications that treat seizures, anxiety, panic, insomnia, muscle spasms, alcohol withdrawal, and other conditions.

Medication Classifications by Action

It is important to become familiar with the most common medication classifications and gain a working knowledge of what common medications fit into those classifications.

Medication Classifications by Body System

Prostate gland Definition: A structure in males that surrounds the urethra and produces fluid that protects sperm cells. Antihistamine. A medication that blocks the effects of histamine, thus relieving allergy symptoms

Routes of Administration

Routes are enteral (GI tract) or parenteral (outside GI tract, commonly injections).

Parenteral Routes of Administration

Enteral Routes of Administration

Other Routes of Administration

Side Effects and Adverse Reactions

Side effects are expected at therapeutic doses. Adverse effects are undesirable and can be dangerous.

Adverse Effects of Common Medications

Side Effects include:

• Acetaminophen (Tylenol) Liver damage
• Baclofen (Lioresal) Dizziness, drowsiness
• Clindamycin (Cleocin) Diarrhea
• Diclofenac (Voltaren) Heart failure, heart attack, stroke
• Hydroxychloroquine Plaquenil Seizures
• Lisinopril (Prinivil, Zestril) Cough, low blood pressure
• Morphine (Duramorph) Constipation, respiratory depression

Respiratory depression Definition: A decreased rate of breathing that can become life-threatening without intervention.

Frequently Prescribed Medications

Brand and Generic Names

Medications have generic (nonproprietary) and brand (proprietary) names. Generic names are lowercase; brand names are capitalized.

Generics must meet the same standards as brand-name products. They can save patients money.

• Carvedilol (Coreg) - Hypertension, heart failure
• Clindamycin (Cleocin) - Bacterial infection
• Clonidine (Catapres) - Hypertension
• Enalapril (Vasotec) - Hypertension
• Fenofibrate (Tricor) - Elevated cholesterol
• Fentanyl (Duragesic) - Moderate to severe pain
• Fluconazole (Diflucan) - Fungal infection
• Glipizide (Glucotrol) - Diabetes mellitus
• Latanoprost (Xalatan) - Glaucoma
• Losartan (Cozaar) - Hypertension
• Meloxicam (Mobic) - Arthritis inflammation and pain
• Pantoprazole (Protonix) - Excess stomach acid
• Paroxetine (Paxil) - Depression
• Pravastatin (Pravachol) - Elevated cholesterol
• Propranolol (Inderal) - Hypertension, palpitations, angina
• Sitagliptin (Januvia) - Diabetes mellitus
• Spironolactone (Aldactone) - Hypertension, edema
• Sumatriptan (Imitrex) - Migraine headache
• Vancomycin (Vancocin) - Bacterial infection.
• Venlafaxine (Effexor) - Depression, anxiety

Glaucoma Definition: A group of eye diseases that cause increased pressure within the eyeball and result in damage to the optic disc and gradual loss of vision.

Contraindications and Medication Interactions

Contraindications make medications unsafe. Medications also have precautions. Medication interactions are present. Food and herbal supplments as well as drugs can also interact with medications. Computer flags medication interactions for the pharmacist to review with patients. It shows a necessity for new prescriptions being reviewed.

Prescription and Medication Order Intake and Entry

Abbreviations

Technicians have to be able to do prescriptions. Also know route and dosage abbreviations.

Routes of Administration

• EN = Each nostril
• IV = Intravenous
• IVPB = Intravenous Piggyback
• LOC = Locally
• TOP = Topically
• VAG = Vaginally
• UD, UT = As directed

Dosage Forms

• AMP = Ampule
• CAP = Capsule
• CR = Cream
• ELIX = Elixir
• EXPECT = Expectorant
• FL = Fluid
• LIQ = Liquid
• LOT = Lotion
• PULV = Powder
• SOL = Solution
• SUPP = Suppository
• SUSP = Suspension
• SYR = Syrup
• TAB = Tablet
• TINC = Tincture
• UNG, OINT = Ointment

Dosage Frequency

• AD LIB = As often as needed
• AM = Morning
• ASAP = As soon as possible
• ATC = Around the clock
• H, HR = Hour
• N