The veterinary practice dispensary – part 1 In the dispensary
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Dispensing includes everything between the act of prescribing and a medicine being issued to the owner or administered to the patient. It is crucial 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. This learning module on dispensing is in two parts. Part 1 focuses on the physical aspects of the dispensary and its organisation. Part 2 will focus on the dispensing process. By doing this module you will:
understand who can prescribe and supply veterinary medicines
know who takes responsibility for dispensing in a veterinary practice
learn what constitutes a well set-up and well-run dispensary
know how to handle and store medicines correctly.
The legal classification of a veterinary medicine defines who is authorised to prescribe and supply it. Vets, pharmacists and Suitably Qualified Persons (SQPs), who are collectively known as Registered Qualified Persons, are entitled to prescribe and/or supply veterinary medicines. They may only prescribe and/or supply the products that fall within the scope of the qualification and the registration they hold:
A Prescription-only Medicine – Veterinarian (POM-V) may only be prescribed by a practising, registered vet. The prescribing vet may then administer the medicine to the animal, dispense it for the client or give the client a written prescription to obtain the product from another vet or a registered pharmacist (including online). Examples of POM-Vs include Osurnia ear gel (florfenicol/terbinafine/betamethasone) and Versican Plus L4 vaccine (leptospira).
A Prescription-only Medicine – Veterinarian, Pharmacist, SQP (POM-VPS) may be prescribed and dispensed by a vet, pharmacist or SQP. The prescriber may also give the client a written prescription to obtain the product from another vet, pharmacist or SQP. POM-VPS medicines mainly consist of products for food-producing animals. Examples include Dermisol Cream and Imaverol Concentrate for Cutaneous Emulsion (enilconazole).
Non-Food Animal – Veterinarian, Pharmacist, SQP (NFA-VPS) medicines can be supplied by a vet, pharmacist or SQP. They do not have to be prescribed unless they are supplied for use outside the terms of the marketing authorisation. NFA-VPS medicines mainly consist of parasiticides for companion animals. Advantage spot-on (imidacloprid) is one example. Pardale V tablets (paracetamol/codeine) for short-term pain relief in dogs is another example.
Authorised Veterinary Medicine – General Sales List (AVM-GSL) medicines are considered to have a wide margin of safety and so may be supplied without any special advice, so there is no requirement for anyone selling AVM-GSL medicines to be qualified. Examples include Beaphar Cat Flea Spray (pyrethrins), Seleen Shampoo (selenium sulfide).
Besides authorised veterinary medicines, vets may prescribe medicines that are not authorised (unlicensed), for use in animals under the ‘prescribing cascade’, provided there is no UK-authorised product to treat a certain species or condition.
Dispensing includes everything between the act of prescribing and a medicine being issued to the owner or administered to the patient. In a veterinary practice, the prescribing vet (or SQP, as appropriate, for POM-VPS and NFA-VPS products) is the person who takes personal responsibility for the supply of the prescribed medicine. In practice, the person who actually does the dispensing varies from practice to practice. In some practices the prescribing vet also dispenses the medicine; in others dispensing is delegated to another member of staff. Importantly, if a person other than the vet does the dispensing, responsibility for the supply remains with the vet. Although there is no requirement for anyone dispensing veterinary medicines in a veterinary practice to have a specific qualification, staff should be trained in dispensing. The RCVS Practice Standards Scheme* states that at least one team member must have attended an appropriate dispensing course in the last 4 years. Vets must also ensure that any person handing out a medicine is competent to do so. There should be clear standard procedures for handling medicines in the practice.
*Clarification: RCVS Practice Standards Scheme Small Animal Veterinary Hospital Accreditation requires that at least one team member must have attended an appropriate dispensing course in the last 4 years. Additional Awards are available in the Small Animal scheme if a team member has recently attended further training in dispensing and medicines legislation, and if the practice has a designated person responsible for running the dispensary.
The dispensary should be clean, safe and well organised, and should not be accessible to the general public. There must be a schedule for cleaning the physical surroundings, shelves and used surfaces, defrosting fridges and removing waste. All items in the dispensary (that is, packaging materials, medicines and equipment) should be protected from dust, dirt and moisture. The room should be well lit and its temperature must be regulated and checked daily. Most medicines can be stored at room temperature up to 25OC. It is important to clean the floor regularly to make sure there are no medicinal products anywhere that a patient could potentially get to them, especially as many veterinary medicines have an inviting smell.
Products that must be refrigerated should be kept between 2OC and 8OC; they must never be allowed to freeze. Ideally, a pharmacy fridge should be used, not a domestic one. There should be an accurate monitoring probe in the fridge, and the temperature should be logged. Fridges should also be defrosted regularly. No item should touch any of the walls in the fridge, and medicines should not be stored in the fridge door. It is important to take care to separate products in the fridge. Limited space in fridges has led to vaccination errors such as cats being protected against distemper and dogs against feline influenza. A good practical tip is to separate medicines alphabetically in the fridge, but also to include a separate shelf for medicines that have been prepared for collection or have been dispensed for an inpatient. Pharmaceutical companies usually specify what to do if a medicine that should be stored in a fridge has been left outside. If you are unsure what to do, check the product’s summary of product characteristics (SPC) or data sheet, or contact the company directly.
Dispensing staff must wear a clean uniform and have good personal hygiene. Dispensers should be enabled to solely focus on dispensing medicines, and not be disturbed by other staff members or clients. If they have to stop dispensing and do a different task, they 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.
There should be absolutely no skin contact with dispensed medicines; staff should wear gloves whenever they could come into direct contact with medicines, and a face mask whenever working with powders. It is not advisable to use fans to control temperature in the dispensary. If they are used, they should be turned off when powders and uncoated tablets are being dispensed, or when medicines are being compounded or reconstituted. There must be a strict no food or drink policy in the dispensary and for fridges where medicines are stored. The related module Handling veterinary medicines and pregnancy also discusses safe handling of medicines.
A counting triangle, capsule counter, measure and scale are basic tools for busy and quieter practices. Separate equipment should be used for systemic and topical preparations. All equipment must be clean, regularly serviced and taken out of use if broken or faulty. Cross-contamination occurs when particles of a medicine are transferred to a different product, which can be dangerous if the contaminating substance is one to which a patient is sensitive (e.g. penicillin). In a veterinary practice, cross-contamination most easily occurs when using the same triangle for counting different (uncoated) tablets and when working with powdered medicines, such as antibiotic powders for reconstitution. Any equipment used for handling different products must be cleaned between use and daily. Wherever possible medicines should be kept and dispensed in the manufacturer’s original packaging. Loose tablets or capsules that need to be repackaged from bulk containers should be dispensed in child-resistant, crush-proof and moisture-proof containers. Preparations for external application should be dispensed in coloured fluted bottles, and oral liquids in plain amber glass bottles, with child-resistant closures.
A well-organised and a clearly-labelled dispensary can save time and costs, and prevent dispensing errors. The exact order in which the medicines are arranged depends on individual preference. Some dispensaries organise their medicines alphabetically, by the generic name of the drug, others by brand name. An alternative is to group products with similar actions together. Keeping dosage forms together can make it easier to find products: for example, having separate sections for tablets and capsules; oral solutions; topical medicines; eye and ear preparations; injectables; supplements; and wormers and flea products. Separating AVM-GSL products from NFA-VPS and POM-V from POM-VPS can also be helpful. All products in the dispensary should face so that the name and strength can be seen clearly.
Some veterinary medicines are defined as Controlled Drugs (CDs) under the Misuse of Drugs Regulations. The Regulations regulate the availability of controlled drugs by placing them in one of five Schedules to the Misuse of Drugs Regulations 2001. Generally, CDs containing substances under Schedule 2 (e.g. fentanyl, ketamine methadone) and some Schedule 3 CDs are subject to special rules on storage, prescribing, disposal and recording. Special care is needed for organising controlled drugs. If space is limited, staff should work together to ensure the amount of stock ordered is not excessive and be diligent in keeping the controlled drugs cupboard tidy and organised. All out-of-date controlled drugs must be clearly labelled and separated to prevent mix-ups with in-date stock. Dispensaries must carry out a full audit and reconciliation of all Schedule 2 Controlled Drugs. The RCVS Practice Standards Scheme expects practices to keep running totals and carry out checks against stock at least weekly.
The dispensary should follow either a ‘First in – First out’ or ‘First expired – First out’ protocol. Staff should do regular checks of expiry dates to ensure they are excluded from stock and disposed of promptly.
The batch number of products dispensed for administration to food-producing animals should be recorded on the case file for batch tracking purposes. For small animals, it is enough to record the date of first usage of each box or bottle.
Part 2 of the module will focus on the dispensing process and on avoiding dispensing errors.
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.
BSAVA (2018).Correct storage, dispensary management and standard operating procedures, [online] Available at: https://www.bsava.com/Resources/Veterinary-resources/Medicines-Guide/Storage-and-dispensary-management [Accessed 16 December 2018]
BSAVA (2018).Controlled drugs, [online] Available at: https://www.bsava.com/Resources/Veterinary-resources/Medicines-Guide/Controlled-drugs [Accessed 16 December 2018]
National Patient Safety Agency (2007). Design for patient safety. A guide to the design of the dispensing environment Edition 1 [online]. Available: file:///C:/Users/User/Downloads/NRLS-0586A-design-patient--environment-2007-v1.pdf [Accessed 16 December 2018]
Royal College of Veterinary Surgeons (2018) Practice Standards Scheme. Module and awards. Small animal. November Version 2.22 [online] Available at: file:///C:/Users/User/Downloads/small-animal-modules-and-awards-v2-22-november-2018-pdf.pdf [Accessed 16 December 2018]
Shilcock M, Stutchfield G. (2008). Veterinary Practice Management (Second Edition), WB Saunders pages: 207–13. Available at http://www.sciencedirect.com/science/article/pii/B9780702029202500248. [Accessed 16November 2018].
Veterinary Medicines Directorate (2018). Veterinary medicines guidance, [online]. Available at: https://www.gov.uk/government/collections/veterinary-medicines-guidance-notes-vmgns [Accessed 16 December 2018]
Veterinary Medicines Directorate (2018). The cascade: prescribing unauthorised medicines, [online]. Available at https://www.gov.uk/guidance/the-cascade-prescribing-unauthorised-medicines. [Accessed 9 January 2019]
World Health Organization, (2016). Ensuring good dispensing practices, [online] Available at:http://apps.who.int/medicinedocs/documents/s19607en/s19607en.pdf [Accessed 16 December 2018]