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Information retrieval CHAPTER 23
In addition, the UK Medicines Information
(UKMi) network produces a range of resources
available through its own Internet site (www.ukmi.
nhs.uk) or that of the National electronic Library of
Medicines (NeLM) (http://www.nelm.nhs.uk/en/).
They include the UKMi new m edicines portfolio
which comprises early horizon scanning information
on drugs in clinical development through to evaluations of medicines once marketed. Via NeLM,
UKMi also provides a comprehensive daily news
service that includes in-depth assessments of key
published clinical studies (known as In-Focus).
The n ews service generates RS S feeds for a number
of specialist libraries hosted by the National Library
for Health. In addition, a number of UKMi specialist
advisory services make their material available
through NeLM, for example the dr ugs in lactation
database. UKMi also produces ‘Pharm-Line’,a
bibliographic database focusing on medicines management, prescribing and pharmacy practice (subscription based).
Royal Pharmaceutical Society
of Great Britain information
centre
National Pharmacy Association
information services
The National Pharmacy Association (NPA) has an
information service for members only. The department is a complete reference centre, skilled at
assisting members with a wide range of pharmacy
practice-related questions such as drug information,
NHS matters and law and ethics. It also publishes
leaflets and resources on practice and legal issues,
and community pharmacy-focused news updates. In
addition, the NPA information department includes a
specialist library of British and foreign reference
books and a range of technical CD-ROMs. Further
details can be found at http://www.npa.co.uk.
The pharmaceutical industry
medical information
departments
All pharmaceutical companies are able to provide certain types of information on their products. This
source of information can be particularly important
for new products, when there is often a lack of published information.
There is an information centre based at the Royal
Pharmaceutical Society headquarters in London
comprising the Library and Technical Information
Service. The information pharmacists in the Technical Information Service can help answer scientific
and technical questions relating to pharmacy practice or continuing education from members of any
branch of p harmacy. The subject scope includes advice on the usage and availability of proprietary and
other medicinal products, adverse drug reactions
and interactions, and the identification of medicines
from overseas. The Royal Pharmaceutical Society
Library in Edinburgh specializes in pharmaceutics
and quality control. The pharmaceutics information
service is provided by the society’s fellow in pharmaceutics. It is a problem-solving and advisory service on matters that relate to pharmaceutics,
pharmaceutical technology and the practical aspects
of pharmacy. Areas of expertise include the application of physical, chemical and b iological sciences to
the formulation, design, stability, preparation and
presentation of dosage forms. Enquiries about pharmaceutical packaging, es pecially child-resistant
packaging, are also handled.
Conclusion
The ability to retrieve relevant health- and medicinesrelated information in a timely and efficient manner is
central to the practice of all pharmacy professionals.
The advent of the electronic age and the expanse of
available information can make information retrieval
appear a daunting task. However, categorizing information, developing an understanding of search and
retrieval processes, knowing who to approach for help
as well as groundwork and deliberation can all help
facilitate the process. Of course, practice makes perfect and it is only through the practical application of
the advice given in this chapter that the art of information retrieval can be truly accomplished.
KEY POINTS
*
As part of their work, pharmacists handle a large
amount of information. In order to do so efficiently
they must know how to find and evaluate
information sources
259
SECTION THREE Pharmacy prescribing and selection of medicines
*
While the Internet gives access to a vast resource,
but of variable reliability, printed books still play an
important role
*
A web address (URL) gives useful information
about the likely validity of the site content
*
Pharmacists need to develop some form of
bookmarking for sites relevant to their area of work
*
Commercial search engines give access to web
pages, but to use them effectively it is necessary to
understand their operators; this often involves
Boolean logic or something similar
*
No search engine will give access to all relevant
websites
*
There is no control over material placed on the
web, so its reliability must be evaluated by the user,
for which guidance is available including authority,
reputation, currency, peer review, etc.
*
User-generated websites, such as Wikipedia, are
less reliable
*
Information sources are classified as primary,
secondary or tertiary
*
Primary reference sources are original research
publications which normally follow a conventional
layout style – called IMRAD – together with other
useful information including an abstract and
keywords
*
There are many full-text journals available
online
*
The quality of journals is reflected in their impact
factor
*
Secondary sources are searchable indices or
abstracts which lead to primary sources
*
Keywords are often used for searching, especially
in academic databases
*
Tertiary sources present an overview of a topic and
include textbooks, compendia and formularies,
providing access to other sources
*
Textbooks are quick and easy to use, but are
inevitably out of date and may be subject to bias or
be incomplete
*
Bibliographies are created using recognized
citation styles and are often stored using special
software
*
NHS information services are based, mainly, in
hospital pharmacies in the UK. They use
standardized procedures to ensure quality and
efficiency in answering queries
*
The UK Medicines Information (UKMi ) network
produces resources which are available through
its website and the NeLM, including horizon
scanning, medicines evaluations and specialized
databases
260
Section Four Section Four Section Four Section Four Secti
o
Section Four
Dispensing and Related Pharmaceutical
Practice Activities
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Chapter Twenty-Four
The prescription
Ian Smith
24
STUDY POINTS
*
The information required on a prescription
*
The different types of prescriptions presented at a
pharmacy
*
The routine procedure for checking and
dispensing prescriptions
*
Information sources required for prescription
dispensing
Introduction
The access to medicines by the general public varies
dependent on the laws of each country. In the UK, the
Medicines Act 1968 classifies medicines into three
categories, namely:
*
General sales list (GSL)
*
Pharmacy medicine (P)
*
Prescription only medicine (POM).
GSL medicines are available for sale to the public
through many retail outlets. These medicines are for
the treatment of minor ailments orconditionsand have
a history of being safe and effective for patients when
they self-medicate with these products. P medicines
are available only from pharmacies and are sold under
the supervision of a pharmacist. Some P medicines are
those that have recently been ‘deregulated’ from the
POM classification.OtherP medicinesare restrictedin
their supply to the public due to the nature of the
condition they are intended to treat or because they
have a greater tendency to be misused or abused compared to GSLmedicines.POM medicines are normally
supplied to a patient after they have received a prescription from an authorizedprescriber. In the past the
authorized prescribers were doctors, dentists and veterinary surgeons but recently more professions have
been authorized to write prescriptions, including
nurses and pharmacists (see Chs 2, 14).
A prescription is a paper or electronic document
detailing the medicine or medicines to be dispensed
for an individually named patient and issued by an
authorized prescriber. The medicine can be any of
the above three legal categories. A prescription item
is one named medicine on a prescription, e.g. aspirin
tablets. A prescription may contain more than one
prescription item, e.g. aqueous cream, pholcodine
linctus and aspirin tablets (three prescription items),
in which case the prescription may be referred to as a
multiple item prescription. In addition to medicines, a
prescription may contain other items or appliances
required by the patient for their treatment, e.g.
wound dressings, elastic hosiery, blood glucose monitoring equipment, needles and syringes, nutritionally
complete feeds and gluten-free foods.
In the UK, a state-funded National Health Service
(NHS) and a private system of health care run alongside each other. Prescriptions can be provided to
patients by prescribers in both systems. In the NHS
system, not all medicines or appliances available can
be prescribed. Limiting the access to medicines and
appliances has been used as a method to reduce the
cost to the government of providing the NHS (see Ch.
6).
POM medicines can, under certain criteria, be supplied without a prescription to the public by way of an
SECTION FOUR Dispensing and related pharmaceutical practice activities
emergency supply or through a patient group direction
(PGD). PGDs are used for the supply of POM and P
medicines by designated healthcare professionals to
individual patients, subject to any exclusion stated in
the PGD. PGDs are written directions signed by a
doctor or dentist and by a pharmacist relating to the
supply and administration, or administration only, of
certain POM and P medicines. The particulars to be
included in a PGD are detailed in Box 24.1. Records of
supply to individual patientsare required as part of the
PGD process (see Ch. 16). PGDs have been used in
pharmacy for the supply of a number of different types
of medication such as emergency hormonal contraception, nicotine replacement therapy and head lice
treatments.
Although at present the majority of prescriptions
are produced on paper, there will in future be a
continued move towards electronic prescriptions
in both the community and in hospitals. Electronic
prescriptions have the same legal force as prescriptions signed in writing. The benefits of electronic
prescriptions include patient convenience, easier
ordering of repeat prescriptions and more complete
information about prescribing. The production of
electronic prescriptions might in the future mean
an end to incomplete and illegible prescriptions.
Although electronic prescriptions will become the
norm in the NHS, private prescriptions will, for the
foreseeable future, remain as paper documents.
This chapter will concentrate on paper prescriptions in use at the time of writing. The informati on
contained on both paper and electronic prescriptions and the method of dispensing and recording
is essentially the same.
Information required on a prescription
When producing a prescription, the prescriber is giving information and instructions to the person who
will supply the medicine to the patient. A prescription
is in effect three types of document in one, in that it is
a clinical document, a legal document and an invoice.
Law may require some of the information on the
prescription and some of the information is required
to ensure the patient receives the correct medicine.
The dispenser will also have to take payment for the
medicine from the patient or send the prescription to
the appropriate body for them to pay, hence it is also
an invoice.
The information and instructions that are required
as a minimum are detailed below.
Box 24.1
Particulars to be included on a patient group
direction
*
Time period the PGD is in force
*
Class of medicine
*
Restriction on quantity to be supplied
*
Clinical situation
*
Clinical criteria
*
Class of persons excluded
*
Circumstances when advice from a doctor is
required
*
Pharmaceutical form
*
Strength or maximum strength
*
Applicable or maximum dosage
*
Route of administration
*
Frequency of administration
*
Minimum or maximum period of administration
*
Relevant warnings
*
Details of follow-up action
*
Arrangements for referral for medical advice
*
Records to be kept
264
Name and address of the prescriber
This identifies who the prescriber is and informs
the pharmacist where to contact the prescriber
should there be an issu e related to the prescription.
A telephone number on the prescription is helpful,
but if the pharmacist suspects the prescription is a
forgery this number should not be used as there
have been cases where the telephone number has
been changed so the pharmacist has contacted
someone who has then pretended to be the prescriber.
Date of the prescription
This identifies when the prescription was written.
The law usually defines the length of time from
being written that a prescription remains valid. In
the UK, all NHS prescriptions should be dispensed
within 6 months of the date on the prescription except for certain types of controlled drugs
where the requirement is they are dispensed within
28 days.
Name of the medicine (with strength and
dosage form, if relevant)
Dose and dosage regimen
Directionsshould be as specific as possible. Ideally, the
amountto beused and thenumberof timesa day thatit
should be taken should be stated. Vague directions –
in particular ‘Takeas directed’ – are of littlevalue to the
patient and should be avoided. It such situations the
pharmacist will have to ensure that the patient is clear
about how to use or take their medication.
Total amount to be dispensed or length
of treatment time
This can be stated in a number of ways as detailed
below.
Directions for use
The directions for use will include the dose and dosage regimen but the prescriber may include additional
information about the product. This can include how
to use (e.g. spread thinly, dissolve in water), where to
use (e.g. in the eye, in the ear, on the scalp), why they
are using it (e.g. for pain, for sleeping). The prescriber
may also indicate a maximum amount that should be
taken, particularly if the medicine is dosed on a ‘when
required’ basis.
Name and address of the patient
This identifies the patient who is to receive the medicine. The age of the patient would also be useful to
enable the pharmacist to check the dose of the medicine, particularly if the person is very youngor veryold.
Prescriber’s signature
This is usually a legal requirement of prescriptions.
The above details are not totally inclusive, depending
on the prescription type and the legal requirements of
the country.
It is important that the person dispensing the product is aware of the information they require and is able
to take the appropriate action to clarify and complete
any missing or ambiguous information.
A number of specific terms, for example ‘dose’,
‘dosage regimen’, etc. are used in the above list and
are often confused. These terms are explained below
and Example 24.1 demonstrates the terms using an
extract from a prescription.
The prescription CHAPTER 24
Example 24.1
Examine the following details which have been
abstracted from a prescription:
BrufenÒ tablets 200 mg
Two tablets to be taken three times a day
Send 84 tablets
Using the above prescription as an example,
the dosage form, strength, dose, dosage
regimen, total daily dos e, total amount,
proprietary name, generic name and length of
treatment are:
Term Example
Dosage form Tablets
Strength 200 mg
Dose 400 mg (2 tablets of 200 mg)
Dosage regimen 400 mg three times a day
Total daily dose 1200 mg
Total amount 84 tablets
Proprietary name BrufenÒ
Generic name Ibuprofen
Length of treatment 14 days
Dosage form
The term dosage form refers to the type of formulated
product. Examples of different forms would be
tablets, capsules, creams, ointments, ear/eye/nasal
drops, aerosols, suppositories, vaginal pessaries and
creams, mixtures, linctuses and patches and these
are discussed in the following chapters. Each dosage
form may also be presented in a number of specialist
forms. For example, tablets are available as modifiedrelease, enteric-coated, dispersible, buccal, soluble,
and chewable. The dosage form should be stated on
the prescription if there is more than one form available. For example, glyceryl trinitrate is available as
tablets, modified-release tablets, a pump spray, an
aerosol spray, an injection, ointment and patches.
The prescriber will need to state the precise form to
ensure that the required product is supplied.
Strength
Strength refers to the amount of drug in the dosage
form or a unit of the dosage form (e.g. a capsule, a
tablet, a patch). The strength of a dosage form can
be expressed in a number of ways. For example,
the strength of oral liquids is usually expressed as
the amount of drug per usual dose volume (e.g. ampicillin suspension is available as 125 mg/5 mL and
265
SECTION FOUR Dispensing and related pharmaceutical practice activities
500 mg/5 mL) or the strength may be expressed in
units (e.g. nystatin suspension is available as
100 000 units/mL). External liquids, topical preparations and injections are usually expressed as an
amount per millilitre or gram (e.g. naloxone hydrochlorideinjection 400 micrograms/mL,nystatincream
100 000 units/g, terbutaline sulphate nebulizer solution 2.5 mg/mL) or as a percentage (e.g. chloramphenicol eye drops 0.5%, ketoconazole cream 2%, benzyl
benzoate application 25%, lidocaine injection 0.5%).
Single-dose unit forms,e.g. tablets or suppositories, are
usually expressed as the amount of drug in one dose
unit, e.g. diclofenac sodium suppositories are available
in 12.5 mg, 25 mg, 50 mg and 100 mg strengths.
Dose
This is the amount of drug taken at any one time. This
can be expressed as the weight of drug (e.g. 500 mg)
or volume of drug solution (e.g. 5 mL, 2 drops) or as
the number of dose unit forms (2 capsules, half
a tablet, 1 sachet, 1 patch) or some other quantity
(2 puffs, 1–2 inches of ointment).
Dosage regimen
Dosage regimen refers to the frequency of administration or the number of times the dose is to be taken
in a period of time. Examples include: 5 mL twice a
day; use the cream night and morning; 1 injection
every 4 weeks; 3 tablets three times a week.
Total daily dose
The total daily dose can be calculated from the dose
and the number of times per day that the dose is
taken. Some maximum doses of drugs are expressed
in terms of per day rather than each separate dose
(e.g. the total daily dose for paracetamol by mouth
in the British National Formulary (BNF) is 4 grams).
Total amount to be supplied
This refers to the total amount of the medicine to be
supplied to the patient. This can be expressed as a
number of units (e.g. 21 tablets, 12 suppositories), as
a volume (e.g. 100 mL of mixture, 5 mL of eye drops)
or as a weight (e.g. 30 g of cream) or as a single pack
size or multiple thereof (e.g. 1 tube of ointment, 2
inhalers). It may mean that the person dispensing the
prescription may have to calculate the total amount if
the prescriber states a dosage regimen for the prepa-
ration and a number of days of treatment (e.g. one to
be taken three times a day for 28 days).
Generic name
The generic name is also known as the approved
name. All drugs are given an approved name which
is usually related to their chemical structure and
the medical classification of the drug. This name is
adopted by the World Health Organization and is
known as the recommended international nonproprietary n ame (rINN). In the UK these names
are usually co-opted as a British approved name
(BAN). European law (92/27/EEC) requires that
onlytherINNbeusedandasaresultsomeBAN
names have been modified to the rINN (e.g. frusemide has changed to furosemide). Prescribers in the
UK are encour aged to use generic names for costsaving reasons as generic products are usually less
expensive than the equivalent proprietary product
(see below) and hence the generic name is the most
commonly used name on prescriptions. If the prescription is written by the generic name, in the UK,
any equivalent product can be supplied even if it
also has a proprietary name. The person who dispensed the prescription may lose money if they
supply a more expensive proprietary product when
the prescription is written generically.
Proprietary name
This can also be referred to as the brand name, manufacturer’s name or trade name. The company that
first produces and markets a drug will give it a proprietary name. The company will apply for a trademark
in respect of the proprietary name. The granting of a
trademark means that no other company can use that
name. Usually proprietary names are short, distinct
and easy to remember and write. They may reflect the
name of the company or the condition the medication
is being used to treat or the type of medication. After
expiry of the patent (in the UK, 20 years from first
date of discovery or, under a certificate of supplementary protection, 15 years from the date of first marketing) the drug may be produced by other companies
using the approved (or generic) name. Drugs may be
prescribed by their proprietary name. If the prescriber, in the UK, states the proprietary name or the
manufacturer of the product, this product or the
product manufactured by the stated manufacturer
must be supplied.
266
The prescription CHAPTER 24
Length of treatment
The length of treatment may be stated on the prescription (e.g. use for 1 week) or it may be possible to
calculate the length of time from the amount prescribed and the dosage regimen (e.g. 21 capsules to
be taken ‘one three times a day’ will be sufficient for 7
days’ treatment).
Types of prescription forms
As stated previously, in the UK there are two providers of health care: the private sector and the NHS.
Concomitantly there are two categories of prescriptions, namely private prescriptions and NHS prescriptions. Additionally, prescriptions may be provided in
both the primary care sector (e.g. community) and
the secondary care sector (e.g. hospitals). The format
of prescriptions in these two sectors will be different.
Private prescription forms
Private prescriptions do not have a standard format
and can, in fact, be a piece of paper containing all the
required information. Normally some of the information, such as the name, the address and qualifications
of the prescriber, are pre-printed on the paper. The
symbol
to indicate that the form is a prescription. Changes in
the law relating to controlled drugs in the UK have led
to the production of a standard form for private prescriptions for controlled drugs for human use. All
veterinary prescriptions are private prescription.
NHS prescription forms
NHS prescriptions should only be issued to NHS
patients. There are a number of different types of
NHS prescription forms available in the UK that
may be dispensed at any community pharmacy. Each
type of prescription form is given a different number
and colour and might have a different format depending on where in the UK they originate from and the
type of prescriber who generated the prescription.
Hospital prescription forms
There is no standard form for hospital prescribing for
patients staying in hospital, and the actual format and
design will depend on the individual hospital trust.
However, the forms usually contain much of the same
is often used on private prescription forms
information. They usually have space for the prescription details, as well as space for confirmation of the
administration of the medicine by nursing or other
staff. For convenience, most hospital forms are divided into three separate areas, namely medicines to be
administered on a regular basis, medicines to be administered once only and medicines to be administered on an ‘as required’ basis. Some forms may also
have an area for listed medicines that can be administered by nursing staff at their discretion. Such medicines may be simple analgesics, sore throat lozenges,
laxatives, etc. In addition all hospital prescription
forms will require space for identification of the patient and will also have room for important details
about the patient such as if they are allergic to any
medicines.
Routine procedure for dispensing prescriptions
The dispensing of prescriptions requires a logical and
very thorough approach in order to ensure the patient
gets the right product in the right form, at the right
dose with the right advice. It is imperative that the
pharmacist conducts a thorough check of the prescription to ensure that it is complete and clinically
acceptable. The product should then be assembled and labelled in a manner that ensures the product
and all the information is accurate and that it is professional in its appearance. All stages involved in the
dispensing process should be covered by a standard
operating procedure.
The stages involved in dispensing a prescription
are:
*
Receiving the prescription
*
Clinical and legal checking of the prescription
*
Assembly of the product and labelling
*
Accuracy checking the product against the
prescription
*
Delivery of the product to the patient with the
appropriate advice about the product.
Receiving the prescription
It is important at this stage that the person receiving
the prescription has checkedthe patient details so that:
*
The appropriateness of the prescription for that
patient can be assessed
*
Any required records can be completed correctly
267
SECTION FOUR Dispensing and related pharmaceutical practice activities
*
The product can be labelled for that patient (see
Ch. 28)
*
If necessary the prescription can be delivered to the
correct patient at the correct address
*
The patient can be contacted, if necessary, even
after the medicine has been dispensed and supplied
to the patient.
The full name of the patient should be ascertained to
ensure that the medicines reach the person for whom
they are intended. The information should also include the sex of the patient, if it is not given elsewhere
on the prescription. The sex of the patient may be
the product is available in the pharmacy or whether it
needs to be ordered and, if so, how long it will take to
arrive. This information is useful in advising the person collecting the prescription how long it will take
before it is ready for collection.
The person taking in the prescription may also have
to take payment for the prescription. They should
understand how to calculate the cost of the prescription and may be required to understand the rules
about who pays for their prescriptions and what
checks may be required to ensure the patient is making a legitimate declaration of exemption.
necessary in the assessment of the appropriateness of
the medicine for the patient (see Example 24.2).
The full address of the patient is also checked and
completed if required. It may be possible that two
Clinical and legal checking of
the prescription
patients have the same name and so the address will
identify the patient. If two patients have the same
address and name, then it is helpful if the age or date
of birth of the patient is stated. The age of the patient
if they are under 12 years old is a legal requirement
on prescriptions in the UK. Since the advent of
computer-generated prescriptions and with electronic prescriptions, the date of birth of the patient
is being supplied on most prescriptions. On private
prescriptions, the age of very young children may be
expressed as a fraction. If the age is expressed in days,
weeks or months, then the denominator is 7, 52 and
12, respectively. For example, an age of 3 days may be
abbreviated to 3/7, an age of 3 weeks may be abbreviated to 3/52 and an age of 3 months to 3/12.
As well as checking patient details, the person tak-
ing the prescription in should also be able to check if
This is an essential role of the pharmacist to ensure
that the prescription is legally complete and clinically
correct for the patient. The pharmacist should check
that all the information required to select and dispense the right product is available on the prescription. Any information which is missing or ambiguous
will require the pharmacist to take some action before
the prescription can go to the next stage in the dispensing process. If information is not present the
pharmacist should ascertain this information and
the prescription might have to be sent back to the
prescriber for the prescription to be completed or
altered. In the UK, if it is not possible to get the
prescription back to the prescriber or the prescriber
cannot be contacted, the pharmacist can add information relating to the dose, strength and quantity to be
Example 24.2
Examine the following details found on a prescription:
Mrs Joyce Hind
2 High Street
Mediton
Hytrin tablets starter pack
To be taken as directed
Send 1 pack
Hytrin is the proprietary name for terazosin, an alpha-adrenoceptor blocking drug which is used for the treatment of
urinary retention in benign prostatic hyperplasia and for the treatment of mild to moderate hypertension. It is available as
two starter packs with different numbers of different strength tablets in them. In the above prescription the patient is
female and the drug is most likely to be prescribed for the treatment of hypertension. Thus an indication of the sex of the
patient is useful to the pharmacist in this case, since it would indicate that the patient should receive the starter pack for
hypertension. However, it would still be important to check with the prescriber that this is the case.
268