C3.2 R3: Prepare and dispense medications according to organizational policies and procedures

Throughout the rotation, I had the opportunity to be involved with handling orders for non-formulary medications. (For excluded medications, the majority of them are able to be auto-subbed as per the policy: automatic-therapeutic-interchange-adult-patients).

Non-formulary medications are medications where no decision has been made on whether it should be on the formulary, or are restricted drugs that have not met the restriction criteria. For non-formulary and excluded drugs to be started/continued in the hospital, they need to meet the following criteria based on the policy:

  • Efficacy and safety is supported by evidence
  • Drug is clinically appropriate for patient
  • No acceptable formulary alternatives
  • For excluded drugs, use should be limited to exceptional circumstances around patient-specific factors only

If patients were on a non-formulary medication PTA and the above criteria are met, pharmacy will try to coordinate so that patient can use patient’s own medications (POM). For POMs that are scheduled daily and not OTCs, they will be flagged and pharmacy technicians will follow up and check if patients have their own supply. If they have their own supply, it will be brought back to the pharmacy for identification and verification.

If patients cannot supply or supply is not considered usable (e.g. a low hazardous drug, blister packed medications) and cannot be held during hospital stay, the pharmacist will fill out a “Non-Formulary and Excluded Drug Approval Form”. If cost per day < $100, the dispensary supervisor can approve it and if >$100, the clinical coordinator can approve it. Ordering the supply of non-formulary drugs is the same process for formulary drugs.


C3.2 R3: Prepare and dispense medications according to organizational policies and procedures

ID: 45 weeks + 3 days (post-menstrual age) 4.9kg female (considered paediatrics) with Klebsiella bacteremia

  • Microbiologist recommended cefotaxime IV for coverage and the pediatrician wanted to use the meningitis dose
  • Order was written for cefotaxime 375mg IV Q6H

For all neonatal + pediatric medications, pharmacists have to check the dose

  • As per C&W online formulary and progress notes, the dose is appropriate

In order to select the correct set (LK-), it is important to refer to the pediatric PDTM (45 wks post-menstrual [gestational age + chronological age] to 17yo). The Alaris Pump has a drug library based on the PDTM, with different profiles such as Adult, Critical Care, Maternity, etc.

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  • Dose is < 920mg – therefore, it would be in a syringe
    → selected kit: Peds Cefotaxime IV 40mg/mL (up to 920mg)


For the Alaris pump, there needs to be a minimum of 2mL extra to prime the line. When the syringe is programmed for the dose, it will prime the line and then only dispense the volume of drug ordered (any remaining volume in the syringe will be discarded).

  • syringes can only be drawn up to 75% of maximum volume
  • when entering the order, select the smallest appropriate size syringe
    → volume of drug + priming required ~ 11mL → syringe: 20mL

After the order is verified, it proceeds to the filling station where 4 labels are printed out (for 4 syringes) and goes to be made.

For pediatric orders, there are “recipe” sets that the IV tech has to follow when mixing:

  • For this order, the cefotaxime 1g vial (200mg/mL) has to be diluted to 40mg/mL and the recipe provides steps on how to do that

The following policy has to be followed for compounding sterile preparations: compounded-sterile-preps-aseptic-technique. Prior to going in the IV room, the IV tech alcohol wipes all the supplies (syringes, vials, etc.) and places it in an alcohol-wiped bin. This bin is placed in a designated sterile area near the window into the IV mixing room.

I was able to follow the IV tech into the mixing room, and had to follow the garbing procedure as FH policy: garbing-poster. After wearing all the protective equipment, we step over to the “clean” area where the laminar hood and extra mixing supplies are kept and are not able to step back into the ante room unless we are planning to de-garb. The laminar hood needs to be alcohol-wiped prior to mixing. As well, all the hard or plastic supplies placed into the laminar hood have to be alcohol-wiped and mixing occurs 6 inches into the laminar hood where it is considered sterile. It is important to avoid blocking the air flow (flowing from the back of the hood towards the mixer) from the product to ensure sterility, as well as, to avoid contacting critical sites (like the syringe plunger). 2 really cool things in the LMH IV room was that there was a “product/vial-shaking” machine and an intercom for techs to use if they needed supplies from outside! 😮 Some things to keep in mind when mixing are that the expiry date on vials are actually “best used” dates – so even if a drug was expiring today, as long as it was reconstituted and injected into the bag, the stability of the full product is extended to the stated expiry of the stability chart – an example: civa-recon-and-stability-chart-adult-aug-2014, as well as, that all syringes are only good for 24 hours after mixing. So for this order, we mixed 4 luer-locked syringes which will help cover the next 24 hours. The preparations are wiped and passed back to the IV prep room through the window to be checked. After exiting the IV room, IV tech wear a white coat to protect their environment from their contaminated scrubs.

Useful resources:

C3.2 R3: Prepare and dispense medications according to organizational policies and procedures

During my rotation, I had the opportunity to be involved in the different steps of drug distribution. At Langley Memorial Hospital, orders are prepared via a pharm tech order entry and pharmacist verification system (pharmacists are also able to do both order entry and verify). Drugs are distributed as automated unit doses (AUD) and if it is not a bulk item, wardstock or excluded drug, scheduled drugs are packaged by the Langley Pharmacy Drug Distribution Centre (PDDC). Fill lists run at 6:30pm daily (Pharmacy closes at 6pm) and the rolls are ready by 4:30am. Rolls arrive in the morning (with the patient’s name header on the top, followed by the patient’s scheduled meds) and pharmacy technicians sort the rolls and deliver them to the ward by 800hr. When delivering, they also collect the previous day bins and any pharmacy returns (incl. fridge items) which are sorted for recycling in the morning. For orders that are faxed throughout the day – pharmacy has to prepare and deliver an interim supply of scheduled and PRN meds until the rolls can come in from PDDC the next morning. If later during the hospital stay, the patient requires more PRN meds – the ward will send down a prescription refill request form (has patient’s name and medication) and pharmacy will check Rx Audit (to see previous debits/refills and assess quantity to send) and debit the quantity, print a label and send the supply to the ward.

When verifying new orders, pharmacists highlight the orders that require an interim supply and the order goes to the filling station where it has to either be filled and checked by 2 separate pharmacy technicians or 1 pharmacist (who would have to initial on the order and on the label). One difference between checking in community and hospital is that the label does not contain the DIN and brands are generally interchangeable, so there is no double check with the DIN. If they are not stat orders, the interim supplies are placed into their ward-specific bin to be delivered throughout the day. If it is a stat, the supply is delivered as soon as possible by the pharmacy technician and is either placed into the pharmacy bin, given directly to the clinical pharmacist or given directly to the nurse taking care of the patient. If it is a fridge item, it will be placed in the fridge in the room-specific bin. For extended care, drivers come by to pick up the interim supplies and patient profiles documenting the changes at certain times of the day.

C3.2 R4(b): Accurately transcribe a medication order onto the medication profile or health record #4

Order written on chart:

  • Risperidone 0.5mg hs if confused and disruptive, repeat x 1 if not effective in 1 hour
  • Haloperidol 2mg IM PO if all else fails

Entered and verified:

  1. Risperidone 0.5mg tablet – 1 tablet
    Order Type: MEDM; Route: PO; Frequency: HS PRN; Schedule; PRN
    Start date: 17/01/17; Start time: 1245 (could be any time, does not matter since PRN); no stop date
    Inventory: LM;  Charge Type: INP
    QTY: 2 (in case need to repeat x 1)
    If confused and disruptive
    Repeat x 1 dose if not effective in 1 hour
    Hazardous Drug – wear 1 pair of nitrile gloves; do not crush or split
  2. Haloperidol 2mg tablet – 1 tablet
    Order type: MEDM; Route: PO; Frequency: PRN; Schedule: PRN
    Start date: 17/01/17; Start time: 1245 (could be any time, does not matter since PRN); no stop date
    Inventory: LM; Charge Type: INP
    QTY: 1
    If risperidone is not effective
    Or see alternate IM order on MAR (F5 LMAY)
  3. Haloperidol 5mg/mL amp – 2mg (0.4 mL per dose)
    Order type: MEDM; Route: IM; Frequency: PRN; Schedule: PRN
    Start date: 17/01/17; Start time: 1245 (could be any time, does not matter since PRN)
    Inventory: LM-4SC; Charge type: WS
    QTY: 0 (as ward stock)
    If risperidone is not effective
    Or see alternate PO order on MAR


  • Important to ensure that the order type matches the order
    • MEDM: wardstock, PRNs or narcotics
      • BUT…if wardstock that is regularly scheduled, it will be a MED
  • Important to ensure that if it is a PRN that is not wardstock, to send to the ward 1-2 days of supply

C3.2 R4(c): Clarify a medication order with a prescriber

ID: 82 yo male admitted with sepsis, secondary to infected diabetic feet.
NKDA, PMHx – Parkinson disease with dementia, atrial fibrillation, previous CVA, ischemic heart disease, orthostatic hypotension, frequent falls, hypothyroidism and depression

Order by Family Nurse Practitioner:

  • Stop metformin
  • Decrease gliclazide MR to 15mg po qam

Progress notes:

  • eGFR ~51, borderline kidney function
  • Hypoglycemia twice 3.7 in am in last 10 days – range 4.5-6.7 in am fasting
  • A/P: at risk for hypo due to age, on metformin – stop today given kidney function, decrease gliclazide MR


  • metformin 500mg PO BID since Jul 2016
  • gliclazide 30mg MR PO daily (was on 80mg IR AM and 160mg IR PM)
  • discharged with insuln glargine from Sept 2016 admission for diabetes foot cellulitis – not on insulin during current admission
Labs HbA1c: Jul 16: 7.6%; Apr 16: 8.8%; Jan 16: 11.6%
eGFR: stable ~ 50


  • Lowest dose of gliclazide MR = 30mg – unable to split dose of MR
    • Dose given at 800hr
  • Nurse was concerned re: hypoglycemia and renal dysfunction with metformin, but:
    • At his current renal function (stable), metformin is safe (nurse practitioner unaware of any tolerability issues with metformin).
    • Metformin has a very low risk for hypoglycemia, and as a result, is considered quite safe in the elderly


  • Called ward to let them know to hold the morning dose until I was able to speak to the prescriber
    • I had spoken to the unit clerk instead of the nurse taking care of the patient – in the future, will ask to speak to the nurse and inquire when the nurse practitioner (prescriber) is on the ward
  • Discussed with nurse practitioner on above issues – NP to reassess, and plans to continue metformin and discontinue gliclazide (patient to be discharged tomorrow). Nurse to fax new order. Aware that last HbA1c was ~6 months ago.
  • Document on order that order for stop metformin and decrease gliclazide was not entered and copied to clinical as an FYI that issue has been discussed with NP and NP to R/A

FYI Metformin in renal dysfunction:

  • Lexicomp:
    • eGFR 30-45: initiation is not recommended. may consider dose reduction by 50% (e.g. of current dose or max dose) and monitor renal function q 3 mos
    • eGFR <30: use is contraindicated
  • CCS HF Compendium guidelines: Metformin may be considered a first-line agent for diabetes treatment if the eGFR is greater than 30 mL/min. However, care should be taken to temporarily discontinue metformin if renal function worsens significantly.
  • Diabetes Care 2011:
    • eGFR 45-60: continue but monitor renal function q 3-6 mos
    • eGFR 30-45: use lower dose (e.g. 50% or half maximal dose) and monitor renal function q 3 most, and don’t start new patients on metformin
  • Renal impairment – increases risk of lactic acidosis with metformin
    • Lactic acidosis
      • symptoms: malaise, myalgias, respiratory distress, increased somnolence, abdominal distress
      • signs: low pH, increased anion gap, elevated blood lactate

My summary:

  • eGFR < 30: contraindicated
  • eGFR 30-45: do not initiate and for patients currently on metformin, use lower doses (e.g. 50% reduction or half maximal dose), monitor renal function q 3 mos
  • eGFR 45-60: ok to continue but monitor renal function q 3-6 mos
  • eGFR >60: no issue


C3.2 R4(b): Accurately transcribe a medication order onto the medication profile or health record #3


  1. d/c Pip/Tazo
  2. Flagyl 500mg TID x 1/52 (no route specified)

Progress notes step down: Abx step down PO

Current orders entered but not verified:

  • Pip/Taz IV – already discontinued
  • Flagyl 500mg IV TID x 7 days
  • Previous order of Flagyl 500mg IV TID started on Jan 15 was still active

Progress notes step down: Abx step down PO


  • Discontinued previous Flagyl IV order
  • Cancelled entered Flagyl IV order
  • Enter metronidazole 500mg PO TID x 7 days order
    • Comments: x 7 days
    • Queries: Put N on Stop Date Report
    • Not copied to clinical re: slightly shorter duration for C. diff treatment as discussed with preceptor as medication will show up on clinical pharmacist’s target drug report
    • Documented on order that PO was inferred from progress notes


  • Important to check for duplicate orders
  • For orders with set duration – ensure that start and stop date are accurate and that a comment is placed on the MAR so that nurse and team is aware of stop date

C3.2 R4(b): Accurately transcribe a medication order onto the medication profile or health record #2

Order was faxed ~ 1000hr on Jan 11/17 for:

  • Order written on Jan 10/17:
    Furosemide 40mg IV in the ER tonight then 40mg IV at 800hr
  • On the same order: also written Furosemide 40mg IV, Carvediolol 37.5mg and Bisoprolol 10mg
    • No frequency written for all
    • Med Rec was filled out with no orders ticked off
    • Med Rec only had carvedilol and bisoprolol, but no furosemide doses given previously

Discussed with preceptor and entered:

  • Furosemide 40mg IV x 1 dose at 800hr today
  • In comments: wrote ON JAN 11/17
  • As it is wardstock, nothing will be charged out of Langley Main and no labels would be printed out.


  • Although dose is given, putting furosemide IV x 1 dose on the med profile will provide a record of the furosemide dose so that the team (e.g. nurse, physician, pharmacist) is aware
  • Would help to prompt the physician to reassess the furosemide as only 1 dose is written on the med profile for Jan 11

C3.2 R4(b): Accurately transcribe a medication order onto the medication profile or health record #1

ID: 11 month old female (13.3kg) admitted to pediatrics ward for pneumonia

Orders for dimenhydrinate were completed on an adult admission PPO and entered as:

  • Dimenhydrinate 12.5mg PO Q6H PRN – oral tablets
  • Dimenhydrinate 12.5mg PR Q6H PRN – 1/4 of adult gravol suppositories (50mg)
  • Dimenhydrinate 12.5mg IV Q6H PRN – 10mg/mL solution

(1) Verified that the doses above are appropriate for her age and weight with C&W formulary
(2) Cancelled the above orders and entered the medication orders as following:

  • Dimenhydrinate 12.5mg PO Q6H PRN
    • Filled as 10mg/mL solution as 11 month old unable to swallow tablets
  • Dimenhydrinate 12.5mg PR Q6H PRN
    • Filled as 1/2 of pediatric gravol suppositories (25mg) as also available as wardstock on pediatric ward
  • Dimenhydrinate 12.5mg IV Q6H PRN
    • Filled as 50mg/mL amp
    • LM is the only site that stocks 10mg/mL solution – but when entering, charge type: WS but is coming from LM
    • Pediatric PDTM was made off the pediatric profile on the Alaris IV pump; therefore, the solution that needs to be used is the 50mg/mL amp

FYI, as per pediatric PDTM:



  • For pediatric patients, make sure that there is a weight provided
  • Consider the formulations and whether it is appropriate for the population you are dispensing it to
  • Check *Order Type (e.g. MED vs. MEDM), *Inventory (e.g. LM vs. LM-WARD), *Charge Type (e.g. WS) and see if they match up accordingly. Investigate if not.

Learning Objectives – Distribution

I am excited to be heading to LMH for my drug distribution rotation. The following are my learning objectives:

  • Develop a systematic approach to interpreting, assessing, checking, preparing and dispensing medication orders, according to organizational policies and procedures
    • E.g. use medication profile, medical conditions, allergy history, relevant patient information, drug interaction checkers
  • Be able to describe the automation technologies, medication use system and safe medication practices used in LMH

Procedure Logs I aim to complete:

  • *3 x C3.2 R4(b): Accurately transcribe a medication order onto the medication profile or health record
  • *3 x  C3.2 R3: Prepare and dispense medications according to organizational policies and procedures
  • 3 x: C3.2 R4(c): Clarify a medication order with a prescriber

The following are the learning objectives listed in the manual:

  1. Demonstrate the ability to locate source documentation outlining the legal requirements and professional standards that pertain to the distribution and control of drugs in health care organizations.
    1. Describe all legal requirements and professional standards that pertain to the distribution and control of drug sin health care organizations
  2. Demonstrate the ability to find and interpret 3 assigned FH policy and/or procedure documents relating to drug distribution and administration.
  3. Name 3 different types of drug distribution systems in place within FH. Describe the key principles of each system and list 3 advantages and 3 disadvantages of each of these systems.
  4. Describe 3 roles of the drug distribution process as a component of the provision of pharmaceutical care.
  5. Identify 3 potential drug-related problems that could occur within FH’s distribution system and identify 3 ways to prevent their occurrence.
  6. Describe 3 roles of pharmacy technicians and 3 roles of two other support personnel in the functioning of the drug distribution system. (e.g. tech, tech supervisor, nursing, unit clerk)
  7. Identify 10 patient-specific, real or potential, drug-related problems through the use of medication profiles and document the appropriate action taken to resolve these problems.
  8. State 3 benefits and 3 limitations of using a profile for pharmacotherapy monitoring and drug distribution.
  9. Demonstrate at least one process of medication incident reporting & analysis.
  10. Demonstrate the basic principles of aseptic technique under direct observation.
  11. Describe 3 advantages and 3 limitations of a pharmacy-based intravenous admixture service.
  12. Describe 3 specialized equipment used in an intravenous admixture service, including TPN, and describe 3 techniques and 2 aspects of the technology that may be used to increase efficiency and productivity of the service.
  13. Describe all precautions that are unique to cytotoxic drug admixture and delivery.
  14. Describe 3 other types of parenteral drug delivery systems and programs (e.g., PCA, home IV therapy, etc.)

Reference for CHPRB Level and Ranges: