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Dispensing includes everything between the act of prescribing and a medicine being issued to the owner to administer at home, or administered to the patient in the practice. Medicines have the potential to cause serious harm if used inappropriately and incorrectly and so the dispensing process aims to ensure that the right patient gets the effective form of the right medicine, in the correct dosage and quantity, with the right instructions and packaging. If any of these steps fail, serious harm can be caused by medication errors. Part 1 of this module focused on the physical dispensary This part 2 of the module focuses on the dispensing process. These are mainly general guidelines for good practice, and we do point out any legal obligations. Your practice may have its own specific dispensing procedures. By doing this module you will:

  • Understand who is responsible for dispensed medicines

  • Know how medicines are named

  • Know the legal requirements for labelling dispensed medicines

  • Be aware of best practice for accurate dispensing

  • Understand how dispensing errors occur

In a veterinary practice, the prescribing vet is the person who takes personal responsibility for the supply of the medicine. However, many vets delegate the dispensing of medicines to colleagues. For colleagues to be able to do this safely, they must be deemed competent, although there is no requirement for a dispenser to have a specific qualification. Importantly, if a person other than the vet dispenses the medicine, the responsibility for ensuring that the medicine is dispensed correctly remains with the prescribing vet. Note that for POM-VPS (prescription-only – vet, pharmacist, SQP) medicines, a suitably qualified person (SQP) in the practice can be responsible for the prescribing and supply, provided the medicine is within the scope of the SQP’s registration (i.e. avian, equine or farm animal).

If a veterinary practice participates in the RCVS Practice Standards Scheme, the practice can achieve an award if a team member has recently attended further training in dispensing and medicines legislation, which can include an external course, webinar, online resources and documented self-study. 

Before discussing the dispensing process, it is useful to discuss the naming of medicines. Most medicines have two names: 

  • One of these is the international non-proprietary name (INN). Examples include fipronil, and meloxicam.

  • The other is the proprietary or brand name. Examples include Frontline and Carprofen

 In veterinary practice, you will be most familiar with, and usually refer to a product, using its brand name but you might find it interesting to know a little about a medicine’s generic name.  

A drug’s generic name is approved by the World Health Organization under a scheme known as the International Non-Proprietary Name (INN). It is also known as the generic name.  A drug’s generic name is the one by which it is recognised throughout the world. There are very few exceptions, such as paracetamol, which is known as acetaminophen in some other countries. The generic name usually indicates the class of chemical to which the drug belongs and so it can give us clues about the action of a drug. 

 For example, names ending in -caine are used for local anaesthetics (e.g. lidocaine, prilocaine)

                         names ending in -bendazole are used for wormers (e.g. albendazole, fenbendazole)

                         names ending in -cillin are used for certain antibiotics (e.g. ampicillin, benzylpenicillin).

 Some products contain more than one drug. For example Milbemax (brand name) contains milbemycin and praziquantel (INNs or generic names).

 A medicine’s brand name is chosen by the manufacturer and approved by the regulatory authority in the country in which it is being sold, which in the UK, is the Veterinary Medicines Directorate (VMD). Whilst generic names are usually standard throughout the world, brand names often differ from country to country. 

 Brand names are designed for marketing purposes. Manufacturers often choose catchy words in order to increase sales. Brand names are usually shorter than generic names and are easier to remember, pronounce and spell: for example, the brand names Apoquel and Cytopoint are much easier to say and remember than their respective generic names oclacitinib and lokivetmab.  

There is no legal requirement to label authorised veterinary medicines that are dispensed in their original packaging for an authorised use. However, both the VMD and the Royal College of Veterinary Surgeons (RCVS) consider it good practice for all prescription-only (POM-V) medicines to have a dispensing label attached containing the following information: 

  • Name and address of the animal owner

  • Name and address of the premises supplying the medicine

  • Date of supply

  • Name, strength and quantity of product

  • Dosage and directions for use

  • The words ‘For animal treatment only’

  • For topical preparations the words ‘For external use only’.

For medicines prescribed under the ‘cascade’ (i.e. unauthorised medicines or unauthorised uses of medicines) note that there are specific rules set out in law (the Veterinary Medicines Regulations) about what information must be included on the label. So as well as the information listed above, it is a legal requirement to also include the following information: 

  • Name (or initials) of the veterinary surgeon who prescribed the medicine

  • Identification (including the species) of the animal or group of animals

  • Expiry date of the product (if it is not on the container)

  • Any special storage precautions

  • Any necessary warnings for the user, target species, administration or disposal of the product

  • Withdrawal period, if relevant

  • The words 'Keep out of reach of children’ 

If not all of this fits on the label it is reasonable to place some of the required information on a separate sheet. 

Whenever you are dispensing it is crucial that you are able to solely focus on the task, and not be disturbed by other staff members or clients. If you have to stop dispensing and do a different task, you should try to stop between two completed acts of dispensing, and never leave half-dispensed medicines on the counter unattended. Best practice when dispensing is strictly no talking and keeping all disruptions to a minimum.

As soon as the label has been generated, place it on the container in which the medicine is being dispensed, taking care to ensure that the label does not obscure important information (e.g. batch numbers or expiry dates) on the packaging. 

If the medicine is being removed from its original pack, the new container must be labelled before medicine selection because medicines should never be transferred to unlabelled containers or syringes. The label should be checked three times to make sure the selected product matches the label:

1. Check the label against the product you are selecting from the shelf. Do not base product selection on the location, or colour or shape of the box. Read the name of the medicine. Remember, the brain may see what it expects to see, not what is really there. This is also the time to do quality assessment of the product and ensure it is in date.

2. The second check should be done when dispensing from the selected container. When pouring liquids, they should be held face up so that any spilled medicine does not damage the label.

3. Finally, check the label and what you are holding in your hand when putting the product back on the shelf. 

Whenever possible dispensed items should be double-checked by another person. When dispensing tablets or pouring liquids into a new container, the original container should stay with the labelled one so that the checker can see what was used. However, if the double-checking is done by the person who did the dispensing, there should be a mental break between dispensing and checking. The label should be signed by everyone involved in the process.

Never assume that clients will know how to use a medicine. People’s lack of knowledge about medicines might surprise you. For example, there are reported cases of people giving spot-ons to dogs by mouth. So it’s really important to make sure that clients receive clear written instructions and it’s a good idea to reinforce these with verbal instructions if possible.

  • The use of medical abbreviations on the labels must be avoided. For example, Latin instructions such as ‘p.o.’ or ‘per os’ won’t be understood by most people. And it’s clearer to use the words ‘by mouth’ rather than ‘orally’.

  • Use words rather than numbers. For example, ‘every 2-4 hours’ could easily be misread as ‘every 24 hours’; ‘2i.u.’ or ‘2IU’could be misunderstood as 21 units. In these examples it is clearer to write ‘every two to four hours’, or ‘every 2 to 4 hours’; and ‘two units’ or ‘2 units’

  • Owners might need additional information on appropriate use and storage of medicines, especially if it is unlicensed. For example, suspensions and emulsions must be shaken well before using, so a noticeable ‘SHAKE WELL BEFORE USE’ label on the container is a good reminder to owners each time they pick up the medicine container. Suspensions should never be dispensed in syringes but in tubs with enough room for vigorous shaking.

  • When dispensing a human medicine, for example Maxitrol eye ointment, it is advisable to label the primary packaging (the tube) as well as the secondary packaging (the cardboard carton). This is to make sure it will not be mixed up if a human in the household happens to be using the same product. 

  • If a container is too small for a full label, make sure the warnings that are attached to it include at least ‘For veterinary use only’, ‘Keep out of reach of children’ and, for example, ‘For the eye’. 

  • When dispensing medicines in a tub, for example, a compounded ointment in a jar, always make sure the label is placed on the jar and not the lid. This way, information about what the jar contains will not be lost if, for example, a lid is misplaced.

It is important for the client to have written information on how to use the medicine correctly. Most medicines have an information leaflet for the client inside the package. If the medicine is dispensed in a different container, by law enough information must be supplied to ensure the product will be used safely. For example, if parasiticide products are split for supplying or administering single doses in the veterinary practice (e.g. at puppy parties), pet owners must be given a copy of the package leaflet. This can be achieved by providing a copy of the package insert or the summary of product characteristics (SPC) or datasheet. If spare copies are not available, it should usually be possible to print the information. SPCs for all veterinary medicines can be found on the VMD product database; datasheets for many products are in the NOAH online Compendium. Some package leaflets can be found on company websites. To read more about medicines information, including how SPCs, datasheets and package leaflets relate to each other, see the module Sources of information on licensed veterinary medicines

A dispensing error is a discrepancy between the medicine a patient received and what the patient was supposed to receive. A near miss is a dispensing error that was noticed and corrected before the medicine was given to the patient or client. Even though not actually harmful, a near miss is judged to have the potential to be harmful to the patient.

Dispensing errors can occur because the wrong drug, or dose or formulation of the drug, is given out. Or they can happen because the wrong label is applied (e.g. a label intended for a different patient) or because the label contains the wrong details about the medicine, such as a wrong dosage or route of administration. Providing a wrong dosing item with the correct medicine is also a dispensing error with potentially serious consequences; for example, supplying the wrong syringes with insulin.

Dispensing errors are normally considered ‘action-based errors’ or ‘slips’, and are most likely to occur because of attention slips during routine dispensing or drug administration. No working environment can completely eliminate these slips because our brains often see what they expect to see rather than what really is there. 

Drug companies use the shape, size and colour of medicines packaging to help their products stand out. They might even regularly change the look of a product to make it more appealing. This means that look-alike medicine branding is now widely recognised as a potential risk in medicine dispensing. For example, several reported cat deaths due to overdoses of an anti-inflammatory drug were the result of accidentally giving the cats an anti-inflammatory instead of an antibiotic because the two products had similar brand names. The company subsequently changed the brand name of the anti-inflammatory drug. 

A major cause of medication errors across all healthcare settings is time pressure, as well as exhaustion because of working overtime, inadequate resources, and distraction and disturbances during the workflow process. In any dispensary, accuracy is more important than speed. 

When medication errors happen, they should be acknowledged and resolved immediately, and reported and evaluated retrospectively. An important part of evaluation is seeking to understand why the error happened, and taking steps to prevent such errors recurring in the future. Monitoring and regularly assessing medication errors should be incorporated into the workflow of any veterinary practice. Reporting errors, including near-misses, should be encouraged by creating a blame-free environment. An internal error-reporting system should be readily accessible and followed up with feedback. For example, you could have a ‘Dispensing error and near miss logbook’ available in the dispensary, to be filled out by staff. Click here to see an example. Practice staff should also regularly discuss errors that have happened and possible reasons for them. Reporting any errors and potential adverse reactions resulting from errors to drug companies and the VMD is important. This is because it enables them to monitor possible issues with similarities in packaging or product names. The example of the two very different products with similar names discussed earlier shows that reporting errors like this to the VMD can result in important safety improvements.

Podcast

You can listen to a complete podcast of the module by using the play button below or use the download link on the right-hand side of the player to download the podcast to your mobile device.

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References

Aronson J. Medication errors: what they are, how they happen, and how to avoid them. QJM: An International Journal of Medicine 2009; 102: 513–21. [Accessed 16 December 2018]

BSAVA (2018). Correct storage, dispensary management and standard operating procedures, [online] [Accessed 16 December 2018]

BSAVA (2018). Prescribing, supplying, dispensing and labelling procedures [online] Available at: https://www.bsava.com/Resources/Veterinary-resources/Medicines-Guide/Supplying-and-dispensing-procedures [Accessed 16 December 2018]

Diesel, G., Giles, D. (2015). Adverse events relating to dispensing errors. Veterinary Record, [online] pages 360-2. [Accessed 16 December 2018]

Hannbeck, L. et al. (2015). Common dispensing errors and how to avoid? [online] NPA. Available at: https://www.npa.co.uk/wp-content/uploads/2015/11/Common-dispensing-errors-webinar.pdf [Accessed 16 December 2018]

Shilcock M, Stutchfield G. (2008). Veterinary Practice Management (Second Edition), WB Saunders pages: 207–13. [Accessed 16November 2018].

Stanford M. Claims, complaints and consent in the small animal dispensary. Companion Animal 2016; 21: 43–9.

World Health Organization, (2016).Ensuring good dispensing practices, [online] [Accessed 16 December 2018]