Ensuring Therapeutic Appropriateness for New and Refill Prescriptions


Recent practice assessments have highlighted the importance of establishing a workflow that ensures that therapeutic checks are being done for both new and refill prescriptions at the pharmacy. Both pharmacy technicians and pharmacists must be aware of their accountabilities for a prescription prior to its release to the patient.


PATIENT ASSESSMENTS ARE CRITICAL FOR OPTIMAL HEALTH OUTCOMES

For every prescription that is dispensed, pharmacists must ask whether the prescription is therapeutically appropriate. This means that the pharmacist must have assessed the patient and authorized that drug ‘x’ is the appropriate medication for the patient.

When performed in an efficient, structured manner, patient assessment allows the pharmacist to gather the necessary information to make informed decisions that will help resolve their patient’s primary issue and meet their patient’s desired health outcomes. Pharmacists are expected to gather relevant information through dialogue with the patient, and review the patient profile. Note that patient profiles need to be maintained; a patient’s health is not static and their profile should be reviewed on a regular basis.

An example of a systematic approach to identify problems related to the patient’s drug therapy is Alberta College of Pharmacy's Chat, Check, Chart method. Use the "Check" method of four questions to identify potential drug therapy problems and evaluate the appropriateness of therapy for a patient:

I: Is the therapy indicated? Understand the indication and if it is still valid (for example, has anything changed with their health status? Was the medication meant for short term use?)

E: Is the therapy effective? Understand if the goals of the therapy are being met (for example, are the medications supporting changes in blood sugar?)

S: Is the therapy safe? Understand if there are changes in medications or conditions, if monitoring is needed (i.e. blood work), if there are potentially other untreated conditions or if additional therapies could be instituted.

U: Is the patient willing to use/adhere to the therapy? Understand the patient’s compliance with the drug regimen and schedule.

CASE EXAMPLE:

Patient A has been on pantoprazole for the past 12 months and has presented at the pharmacy requesting a refill on her prescription. The patient has expressed that she is in a hurry as she has an appointment to get to but she just needs this refill. The refill is processed and filled by an assistant. The assistant asks the pharmacy technician to check the prescription as the pharmacist is in the counselling room administering a flu shot to another patient. The pharmacy technician checks the technical aspects of the refill prescription and notes that the patient is on time for this refill. Is this prescription ready for release to patient A?

Answer: No. A therapeutic check by the pharmacist must be completed prior to release to the patient.

Using the Check method to approach patient assessment in this case, the pharmacist would consider:

I = The indication for the pantoprazole and the ongoing appropriateness of continuing therapy. For example, was the patient initially prescribed the pantoprazole along with an NSAID which has since been discontinued?

E = What is the current status of symptoms and has the pantoprazole been effective?

S = What are the risks of continuing the pantoprazole (for example, lower calcium and B12 absorption) versus the benefits (for example, would a lowering of the dose or deprescribing be an appropriate recommendation?)

U = How has the patient actually been using the pantoprazole regardless of how it was prescribed (for example, has the patient been taking it regularly? At what dose? Has the prescriber discussed long term use?)

UNDERSTANDING THE RESPONSIBILITIES OF PHARMACISTS AND PHARMACY TECHNICIANS FOR THERAPEUTIC AND TECHNICAL CHECKS

Under the Standards of Practice for the profession, pharmacy technicians are responsible and accountable for the technical aspects of all prescriptions that they check, both new and refill (i.e. the correct patient, product and prescriber in accordance with the prescription). Pharmacists remain responsible and accountable for the therapeutic/clinical appropriateness of all prescriptions.

Under the Standards of Practice, prior to releasing any medication to a patient, it is the responsibility of the pharmacy technician to ensure that the prescription has been reviewed for therapeutic appropriateness by a pharmacist; a pharmacy technician cannot release the product, including for refills, until that therapeutic check is complete. A therapeutic check is required regardless of whether an issue is identified or not. There must be an established process in place at the pharmacy to ensure that the pharmacist’s authorization, which can be digital or handwritten, has occurred.

The Designated Manager of the pharmacy must establish a method for identifying the pharmacist and technician responsible for each prescription (new and refill). Although signatures are the traditional method of accepting or declaring responsibility, pharmacy teams may wish to utilize other mechanisms within clearly defined and understood policies and procedures. Electronic and/or paperless workflow processes should consider this requirement.

The pharmacy team is encouraged to develop policies to ensure clear accountability when the pharmacy technician is independently authorizing prescriptions (for example, in reference to compliance packaging using a structured/defined review process.) This can support the therapeutic check authorization process and ensure both a technical and therapeutic authorization is in place for prescriptions prior to the medication being released to the patient.

It is important to note that when the act of dispensing is shared between the pharmacist and a pharmacy technician, each individual must be aware of their own scope as well as the others’. In order to have a collaborative approach when dispensing, a well thought-out process will ensure that the independent functions of the technical check and the therapeutic check are completed and documented by the right individuals each time to optimize patient outcomes. See the Legal Authority for Scope of Practice/Authorized Act chart for specific authorized acts for each profession.