- Quiz PDF: Quiz 5 — July 17, 2018
- Quiz PDF Answers; Quiz 5 Answers — July 17, 2018
- Compounding Lab
- Below are Pics from the WhiteBoard
Labetalol 10mg/ml recipe used, recipe can be found using the following link: http://www.mipedscompounds.org/sites/default/files/standard-formulations/Labetalol.pdf
- Prescriber: Dr. House
- Dose: 50mg BID
- Days Supply: QS to 30 Days
- Pharmacy Dispensing: Sam’s Discount Pharmacy
- RX# 0023 Date Rx Written: 7/12/2018 Date Rx Compounded: 7/18/2018
- Fictional Patient Name: Fred Johnson
- Compounding Standards used was USP 795: http://www.usp.org/compounding/general-chapter-795
- Pharmacist: S. Blakemore
- How many ml’s must be dispensed for 30 day supply? 300ml
- What is the patient’s dose in milliliters? 5ml bid
- Would it be appropriate to dispense a 30 day supply? No, the stability is only 28 days, but to keep compounding simple, we will use a round number and dispense 300ml.
- How many tablets will we need to compound this prescription? 10mg/ml x 5ml = 50mg/dose x 2 doses/day =100mg/day x 30 days = 3000mg. To compound we will use 300mg tablets. 3000mg/300mg/tablet = 10 tablets will be used to compound.
Homework: Review Compounding Log, Review Compounding Recipe, Create a Prescription Label based on Alabama Law
I’m a visual person.
In the pharmacy, visual cues help me make quick decisions regarding prescription status. As a student at a “chain pharmacy” I would put prescriptions in blue buckets or red buckets. Blue buckets for folks picking up their prescriptions in one to two hours, and red buckets for folks picking up in 30 minutes or less.
Throughout pharmacy school it was blue bucket versus red bucket. It’s a pretty efficient model. So efficient I took the practice up at the independent pharmacy that I manage. These buckets can easily be purchased online.
Then I went to business school and started studying operations management. I started to gain an appreciation for the blue bucket/red bucket workflow process. It was an effective method of ensuring customer satisfaction. It gave the Pharmacist visual cues as to what order prescriptions needed to be filled. Lastly, it helped maintain organization, thus decreasing “defects“. With the buckets you can simply drop the prescription in the bucket with the drug. Thus, things matched up when it was time to enter the order and fill the prescription.
I began reading articles on how other Pharmacist maintained organization. I read an article by a man that discussed how he used multiple colors of buckets. When I read the article, I felt like a pharmacy nerd when I read the article and became giddy. For me I had only known blue bucket and red bucket. How could I incorporate more buckets? I know I know…sounds lame!
I began writing up a method and came up with the following:
DROP OFF —> DATA ENTRY—>FILL PRESCRIPTION–>VERIFY PRESCRIPTION–>PICKUP PRESCRIPTION
BUCKET COLORS (Pharmacy Tech/Pharmacist organize accordingly)
BLUE- prescription to be picked up in 1 to 2 hours
RED– prescription to be picked up in 15 to 45 minutes
GREEN– prescription medication is high dollar; pickup likely next day
YELLOW-prescription has an issue ( order needs clarification, call pharmacy benefit plan, etc.)
BLACK– prescription to be compounded
WHY we WORKFLOW
Workflow improves patient safety. Please keep with the workflow to better serve our patients.
This is what works for me as the manager of a pharmacy. The buckets allow me to remain efficient and organized. Both Technicians and Pharmacist can be on the same page with a simple color cue.
I know some people will think this is entirely too much! I would completely understand if you felt that way. It’s an idea…consider it and think of ways that you can tailor it to fit your own practice. I use this technique for pharmacy, however this same technique could possibly be used in the operations of other business models.
Is your business predicated on “volume” to maintain appropriate profit margins? Colored buckets are a cheap investment and can potentially increase your worker’s efficiency. Increased efficiency will increase worker output. Maintaining appropriate output very well could be the difference in business success or failure.
Extemporaneous preparation of oral suspensions, creams, and ointments by pharmacists is of great importance for the pediatric population. Why? The “one size fits all” model doesn’t work for kids. Dosing for kids is mostly weight-based and is calculated milligram(drug)/kilogram (child’s weight) or dosed based on the child’s body surface area. Most compounded preparations for pediatric patients are considered to be “simple compounds” in that there are only 2 to 3 ingredients in the compound; the drug (crushed tablets or bulk powder) and a suspending agent (simple syrup, ora-blend, cherry syrup).
Parents needing compounding services for their children run into road blocks because not every pharmacy compounds. My suggestion for parents is that they discuss with their pediatrician where compounding pharmacies are located in their area before leaving the doctor’s office or hospital. Parents, if you’re uncertain if a drug needs to be compounded, please ask the pediatrician when he or she writes the prescription.
Typically the pediatrician will be aware of community pharmacies in the area that provide compounding as a service. Some pharmacies in your area may even solely focus on pediatric patients.
When the parent finds a pharmacy they want to use by physician referral, web search, or even word of mouth please give that pharmacy a phone call to ensure that the pharmacy accepts your child’s insurance.
If you have questions or concerns about the compounded medication your child will receive never hesitate to ask to speak to the pharmacist on duty or the pharmacy supervisor. Consultation should always be offered, but never hesitate to speak up on your child’s behalf. The pharmacist should be able to provide information about the drug, how the compound is prepared, how it should be stored, and be able to discuss side effects and concerns that parents typically have with the associated compounded medication.
Lastly, parents please give the pharmacy sufficient time to compound the medication. Compounding is a process that shouldn’t be rushed. Pharmacists must work with their staff to ensure the proper protocol for compounding is followed to ensure patient safety. Typical turn around for compounded medications can sometimes be 24 to 48 hours depending on the pharmacies volume and workflow.
For information about compounded medications please check out the FDA’s website regarding the topic: https://www.fda.gov/drugs/guidancecomplianceregulatoryinformation/pharmacycompounding/ucm339764.htm
Business Management folks love discussing LEAN and KANBAN among ways to ensure quality and inventory control in manufacturing. The overall gist to these concepts is to make things work efficiently, accurately, limit waste, and ensure safety to a manufacturing process. Thus, cost of goods for the consumer can be competitively priced.
So, lets take a minute and think out loud or on paper.
- What is your pharmacy’s workflow?
- What happens when your technician gets sidetracked by an insurance issue?
- What happens when a prescription that should take 15 minutes to fill becomes a prescription that takes 1 hour to fill?
Typical pharmacy workflow is drop off — order entry — fill prescription — pharmacist verification — pickup. This flow becomes so routine that I believe pharmacists sometimes forget how important the “routine of pharmacy workflow” is vital to preventing medication errors.
Practicing pharmacists all understand how things can become sidetracked in the pharmacy fast. A prescriber phones in a new prescription, flu shots need to be given, there’s a patient consultation that needs to be completed, and oh by the way you still need to check prescriptions.
In most chain pharmacies you can stand the waiting room of the pharmacy and quickly pickup on pharmacy operations and how workflow is necessary to keep pace with prescription volume. But even if you’re a pharmacist working for a chain, are you able to realistically follow your company’s workflow for prescription verification or have you tweaked the workflow a bit to get through your day on the job? For the independent pharmacist managing or owning a pharmacy, is your workflow in place and if so is it on paper?
LEAN principles originated with Toyota’s production of cars, and much like Toyota the pharmacy needs to stay LEAN to prevent defects. Defects for Toyota equaled bad cars, defects in pharmacy mean medication errors.
And while ensuring appropriate workflow can’t eliminate all errors it sure can help ensure a level of confidence that if an error does occur during the course of the day, hopefully that error can be caught before the prescription leaves the pharmacy.
Pharmacy workflow is such a foundational concept, but the basis of workflow and operations management are often not discussed with routine during pharmacy school and often glossed over while on the job. Be a good coach to your technicians. Focus on foundational concepts. A good basketball coach has their players practice free throws. A good baseball coach makes sure their players catch the ball with two hands.
As a good pharmacist coach, you need to discuss workflow issues daily. Technicians need to understand their positions in the pharmacy and with time be able to rotate from drop off, pickup, order entry, and filling. Coaching up the principles of pharmacy workflow as it pertains to operations management helps to ensure that patients receive optimal pharmaceutical care while reducing dispensing errors.
Prior Authorizations (PAs) are forms that are completed by the prescriber or prescriber’s agent (person that completes the form for the prescriber’s signature) for the patient to receive his or her medication. Reason’s for prior authorizations include: cost of the medication, the quantity of medication prescribed, early refills, off label use of a medication, or simply because the medication is not on the patient’s drug formulary.
Out of the many questions and answers regarding prior authorizations, the key information that the pharmacy will need to provide the prescriber with are as follows:
- National Provider Identification (NPI) of the Pharmacy
- Street Address, Fax Number, & Phone Number of the Pharmacy
- National Drug Code (NDC) of the medication in format 00000-0000-00 (first five digits are drug manufacturer, second four digits are drug identifier, last two digits are drug package size)
- Inform the prescriber of the package sizes that are available; some drug products only come as kits, unit dosed packages, or need to be reconstituted.
- The patient’s pharmacy benefits Identification number
The prescriber or prescriber’s agent can complete the process by adding the following information to the PA:
- Prescriber’s NPI, if unknown this can be searched via: NPI Lookup
- ICD-10 code that matches the diagnosis of the patient
- Street Address, Fax Number, & Phone Number of the Prescriber
- Last, but certainly not least..Get the Prescriber Signature!
Lastly, a good resource for prescribers and pharmacies is the website covermymeds. The site can be linked into your pharmacy’s software and faxes can be automatically sent to the prescriber with some rejection codes. For prescribers this is a great resource to complete PA’s electronically, and it gives you electronic access to the correct PA forms that correlate with the patient’s pharmacy benefit plan.
“Medication adherence” has become a big topic of discussion. A quick Google search of medication adherence as it relates to rising healthcare costs will lead readers to thousands of news articles.
In this article I will discuss some tips on how to help your child adhere to his/her medication regimen.
1. Pen and paper – If you don’t write it down it never happened. Write down the time and day the medicine was given.
2. Set the alarm– Set an alarm on your phone so that you can remember to give your child their medication.
3. Phone apps– There are some phone apps that can be easily downloaded on your smart phone to help track when medications should be administered.
4. Pill box organizers– Using weekly or monthly pill box organizers can be very helpful for some parents. Discuss with your child’s pediatrician to find out if this is a suitable option for you and your child. First, pill box organizers can’t be used if your child is on liquid medications. Second, the pediatrician will need to discuss with his or her staff to ensure that this can be done safely and effectively by the parent. Lastly, the use of pill box organizers is not suitable for parent’s that can not keep both children and adults out of reach from inappropriate use of the medicine. Appropriate education of families needs to be done by both prescriber, pharmacist, and nurse to ensure everyone is on the same page.
5. Print off a calendar month– Work with your child’s healthcare team on using a printed calendar month that denotes time, day, and dose to administer to the child. This visual cue will ensure that your child gets the right medicine on the right days. I typically see this method used with kids that are being tapered up, down, or off medicine.
6. Bottle for school use– If the medication is being administered both at home and at school then you can discuss with your pediatrician about having a prescription written in a manner to have the pharmacy dispense a bottle for both home and school use. For example, a child is to take the medicine at 8am, noon, and as needed at 4pm. The prescriber requests for the pharmacist to dispense a quantity of 90 tablets. The prescriber can write on the prescription to dispense 60 tablets in a bottle for home use and 30 tablets in a bottle for school use.
Remember to do what works. Use one of the methods or a combination of the methods that I’ve outlined. At the end of the day, the only thing that matters is that your child receives the medicine the way it’s been prescribed.
“Ya’ll charged me $45, and the pharmacy up the street said they were gonna charge me $400!”
When searching for a pharmacy that compounds; ask the pharmacist if they’re able to file a claim for the prescription under the patient’s pharmacy benefits policy.
If a member of the staff states that the pharmacy can not file the claim under the pharmacy benefits ask the following questions:
- Did you attempt to file the claim under the benefits policy?
- If an attempt was made to file the claim on the policy; why was the claim rejected? What were the rejection codes?
- When the claim was filed under the benefits plan did the rejection message include a phone number?
A typical rejection for a compound claim is ingredient(s) non covered/ product service non covered. The phone number listed on the rejected claim can be used by the prescriber or pharmacist to call on your behalf and gain additional information as to why the claim rejected and if additional paperwork can be submitted on the patient’s behalf to get the compound covered under the patient’s benefits policy.
In regards to pricing — the things that a pharmacy takes into consideration when setting a price are as follows:
- Cost of Drug
- Cost of Suspending Agents/Flavorings/Preservatives
- Compounding Dispensing Fees — this factors in the overhead of producing the final product (labels, tech time, gloves, equipment, etc.)
From there, the pharmacy calculates pricing based on the following principles:
- The “Breakeven Price”— this is the price that can be set where the business loses no money.
- The price markup factors — Imagine if the cost of producing the product is $5. The business can then say their markup factor is 2. A markup factor of 2 means the selling price is $10. Gross profit margin can then be calculated as (Revenue-Cost)/Revenue. Thus, profit margin in the above scenario is 50%.
- Supply and demand — The greater the supply the less the demand and the less supply garners greater demand. Price therefore can shift up and down based on conditions in the market.
- Drug shortages in the market can induce price increases.
Be an informed customer at your community pharmacy. Asking questions about compounding can lead some of your pharmacist friends to talk your ear off.
Questioning your pharmacist on this topic will provide that pharmacist with an opportunity to teach, learn, and build trust with a member of their community.