Additional information | Patient safety and quality assurance

Issues that require pharmacist intervention

Drug utilization review (DUR)

A comprehensive review of a patient’s medical condition(s) and medication use history. A pharmacist typically does it. The goal of DUR is to optimize medical therapy. It is an ongoing quality assurance process with reviews done multiple times a year, especially when new medications are introduced, or there are dose changes. DUR helps to prevent adverse drug reactions, avoid harmful drug-drug and drug-food interactions, reduce cost, increase patient adherence to therapy, and increase efficiency. As part of DUR, the pharmacist can also collaborate with prescribers to optimize drug therapy.

DUR can be classified as prospective, retrospective, or concurrent.

Prospective DUR: It is done before the medication is dispensed. Examples include evaluating drug abuse or misuse potential, e.g., while prescribing opioid analgesics, generic substitutions, etc. If a patient taking warfarin is prescribed another blood thinner like heparin, it may cause internal bleeding. During DUR, the pharmacist notices that and contacts the prescriber to alter the therapy, even before initiating treatment.

Retrospective DUR: It is done after the medication is dispensed. This helps in identifying patterns of under or overtreatment. For example, the pharmacist may notice that a patient with asthma needs an inhaled steroid or a step-up in their therapy and inform the physician accordingly.

Concurrent DUR: It is done during the course of current medical therapy. For example, hospitalized patients receive multiple medications, which the pharmacist can review, notice duplication of therapy or drug interactions, and inform the physician.

OTC recommendation

OTC or over-the-counter drugs can be bought without a prescription. Sometimes, when a prescription drug is out of stock, the pharmacist can make an OTC substitution, depending on availability. Like any other drug, OTC drugs can also cause adverse effects, and some, like dextromethorphan, loperamide, etc., are associated with drug abuse. The patient’s age, drug allergies, medical history, and drug-drug interactions are essential factors that affect OTC recommendations.

Therapeutic substitution

Therapeutic substitution replaces the initially prescribed drug with an alternative molecule with therapeutic equivalence. The alternative drug may be within the same class or from another class with assumed therapeutic equivalence. Therapeutic substitution is done to lower drug costs, prevent adverse effects, or due to the unavailability of prescribed medication. Consulting the prescriber is always recommended before making a therapeutic substitution.

Generic substitution

Generic substitution occurs when a different formulation of the same drug is substituted. The licensing authority considers all generic versions of a drug equivalent to each other and the original drug. Generic drugs are cheaper than brand-name drugs. Unless the prescriber ticks the “dispense as written” box, the pharmacist can make a generic substitution.

For example, Rosuvastatin is a generic substitution for Crestor (brand name). A therapeutic substitution for Crestor can be Simvastatin, which is in the same class of drugs as Crestor.

Post-immunization follow-up

Pharmacists and, in some cases, pharmacy technicians are trained to administer vaccinations. Follow-ups to immunizations are related to adverse events related to vaccinations or medical errors, such as injecting at the wrong site, loss of potency, injection site reactions like swelling and pain, general symptoms like fever, or allergies to vaccine components like egg, polyethylene glycol (PEG), etc.

Apart from the discussed functions, the pharmacist is also responsible for monitoring and preventing adverse drug events, identifying drug abuse or misuse, drug interactions and allergies, and actively promoting adherence to medical therapy.

Hygiene and cleaning standards

Maintaining cleanliness and hygiene is very important in the pharmacy. The following methods help to keep the pharmacy clean and hygienic and allow safe drug dispensing.

All pharmacy professionals must keep their hands clean by handwashing with soap and water and using gloves when appropriate, such as when counting and packing drugs or administering immunizations. Hand sanitizers are an add-on to handwashing. Liquid soaps are preferred over bar soaps.
Pharmacy countertops, workstations, and equipment like counting trays should be disinfected daily with alcohol-based products.
The pharmacy countertops and floor should be frequently dusted, including vacuum cleaning carpets and floors.
Storage areas should be kept clean, organized, and properly labeled.
Personal protective equipment (PPE) like gloves and masks is recommended to avoid contamination during immunization, COVID testing, and compounding medications for immunocompromised patients. PPE is also used for disposing of hazardous drugs.
Pill counting trays should be cleaned with isopropyl alcohol after each use. Hazardous drugs like chemotherapy drugs, warfarin, penicillin, etc., should have separate pill counting trays.
Pharmacies that compound injectables, infusions, and eye drops need sterile compounding areas where apart from PPE use and disinfection of surroundings, proper ventilation and building design are vital to maintain decontamination.
Color-coded disposal bins must be used to separate medications and sharps from general pharmacy waste.