Final Exam - Lectures Flashcards
1
Q
Verbal Orders are ______________________ by the RPh or RPhT, and then used to process as a regular prescription.
A
handwritten
2
Q
Verbal Orders are a ________________ act.
A
Protected
3
Q
RPhTs can only take verbal prescriptions for regular prescriptions. True or False?
A
True
4
Q
Name the 6 requirements for a legal prescription that must be included in a written verbal prescription.
A
- Date
- Patient Name
- Drug
- Dosing Instructions
- Quantity/Duration
- Prescriber Signature
5
Q
What information/leading questions should we be giving/asking when first taking a verbal prescription over the phone?
A
- Identify ourselves (Name and title)
- Identify if medication is regular Pr or T/C, C or N
- Ask if the patient has been to our pharmacy before (if not get extra info)
6
Q
What drug related information should we be checking for when receiving a verbal prescription?
A
- Drug name
- Drug strength
- Dosage form
- SIG
- Quantity
- Repeats
7
Q
What prescriber related details should be confirming when receiving a verbal order?
A
- Name
- CPSO #
- Phone
- Fax
8
Q
What patient information should we double checking when receiving a verbal order?
A
- DOB
- Allergies
- Weight (Pediatric patients)
9
Q
When repeating back the verbal prescription information to the prescriber, do we need to repeat back the prescibers information?
A
No, unless you are think you made an error
10
Q
What two things should we do to finish up with a verbal prescription before handing it off to the entry station?
A
- Re-write if the prescription is illegible/messy
- Sign prescription (V/O name, registration #)
11
Q
What is MAiD?
A
A medical practitioner, at an individual’s request, a) administers a substance that causes an individual’s death, or b) prescribes a substance for an individual to self-administer to cause their own death
12
Q
On Feb. 6, 2015—through the Carter v. Canada decision—the Supreme Court of Canada (SCC) ruled that all provinces and territories in Canada must permit some form of _______________________.
A
Physician assisted death
13
Q
June 17, 2016 - the federal government enacted amendments to the Criminal Code of Canada (the “Criminal Code”) to include circumstances under which _____________________________________ is permitted.
A
Medical assistance in dying
14
Q
On September 11, 2019, the Superior Court of Québec declared that it is unconstitutional for the federal Medical Assistance in Dying legislation to require that ___________________ be reasonably foreseeable to be eligible for MAiD.
A
Natural death
15
Q
What is the eligibility criteria for MAiD (2021)?
A
- Have a grievous and irremediable medical condition
- Natural death does NOT need to be reasonably foreseeable - there are two different sets of safeguards/consent requirements depending on whether death is foreseeable or not
- Eligibility for those with ONLY mental illness is on hold until March 2024 (possibly)
16
Q
What impact do legislative changes included in Bill C-7 have on pharmacies?
A
- Self-administered MAiD patients can arrange to have their doctor/NP administer a back-up dose in the case of a failed dose - pharmacists should discuss/confirm with providers so everyone is on the same page regarding this option
- RPhTs are now required to also notify Health Canada within 30 days of dispensing a MAiD prescription. (These regulations are not currently in force - another amendment needs to be made)
17
Q
What are we legally allowed to tell a patient who is inquiring about MAiD?
A
- Always refer to a medical/nurse practitioner
- Do not give any impression that we are involved in any decision-making regarding MAiD processes
- Giving anyone information on how they can take direct action to end their life outside of MAiD is a crime
18
Q
Are RPhTs involved in the assessment of patient eligibility for MAiD?
A
NO - that is not our domain
19
Q
Can RPhTs receive/fill a MAiD prescription?
A
- Yes
20
Q
What considerations should we be aware of when dispensing a MAiD prescription?
A
- MAiD kits should never be dispensed “office use”
- Two kits are prepared to bring bedside (back-up)
21
Q
What are the requirements for documenting a MAiD prescription?
A
RPhTs& RPhs who have dispensed a substance in connection with MAiD must report to Health Canada via MAID Data Collection Portal within 30 days after the day of dispensing.
22
Q
Are RPh or RPhTs allowed to refuse to fill a MAiD prescription on ethical/religious grounds?
A
Yes, but…
- the refusal cannot impede a patient’s access to care
- must made an effective referral to an alternate provider
- make reasonable efforts to ensure continuity of patient care
- must provide care in an emergency, even if the care conflicts with beliefs
- must communicate in sensitive and respectful way without promoting religious beliefs
23
Q
What is a BPMH?
A
Best Possible Medication History: A systematic process of interviewing the patient/family and at least one other reliable source of information to obtain and verify all of a patient’s medication use (Pr and OTC) - Medication Reconciliation
24
Q
Complete documentation for a BPMH includes the following:
A
- Drug name
- Dosage
- Route
- Frequency
25
A BPMH is less comprehensive then a primary medication history. True or False?
False - A routine primary med history if often quick and may not include multiple sources of information
26
What is the ultimate goal of medication reconciliation?
- Prevent adverse drug events (ADE)
- Eliminate undocumented intentional and unintentional discrepancies by reconciling all medications, at all interfaces of care
27
What actions are inappropriate when errors (Medication incidents/discrepancies) occur?
- Avoidance
- Shifting blame
- Rationalizing importance of error
- Putting responsibility on patient to call the pharmacy if there is a problem
28
What are the three types of discrepancies to look out for when preforming a BPMH?
1. Intentional (Prescriber meant to add, change or discontinue a medication prior to admission)
2. Undocumented Intentional (Same as above, but this intention is not clearly documented in the patient's profile)
3. Unintentional (Prescriber unintentionally changes, adds or omits medication the patient was taking prior to admission)
29
Medication history requests are commonly requested when preforming a BPMH. The RPhT will usually ask for the last ____ months of medication records.
Six
30
What is meant by maintaining a "clean" profile with regards to patient medication records and BPMH?
- Proper documentation of discontinued drugs, changes in treatment plan, OTC medications the patient takes
- Helps the RPhT have accurate information to work with when preforming a BPMH
31
When is a BPHM usually preformed?
When there is a transition in care
- Home to hospital, hospital to home, home to LTC, hospital to LTC
32
What are PINs or Pseudo-DINs used for?
- Compounded products (methadone)
- Products without DINs (glucometers, aerochambers)
- Sometimes insurer will assign a specific PIN
- Billing professional services
33
When billing a professional service in Kroll, what should be entered for the presciber, SIG, dispensing quantity and days supply?
Prescriber: Pharmacist
SIG: (Pharmacy Service) provided by: (Pharmacist name)
Dispensing Quantity: 1
Days Supply: 1
34
Annual MedsCheck
- One per year
- 3 or more prescription meds for chronic condition
- $60 a year
- PIN: 79
35
MedsCheck Follow Up
- Already had an annual MedsCheck
- Required due to complexities in drug therapy
- Criteria: Prescriber referral, Admission/discharge, Pharmacist's decision
- $25 per follow up
Discharge: 81, RPh: 82, Doctor: 83, Admission: 84
36
MedsCheck Diabetes
- Type 1 or Type 2
- No min number of meds
- RPh must have knowledge of diabetes
- $75 a year
- PIN: 88
37
MedsCheck Home
Same as annual BUT also cannot physically come in to the pharmacy
- includes a medicine cabinet clean-up
- $150 a year
- PIN: 87
38
When can a RPh submit a claim for payment for a pharmaceutical opinion?
- Identification
- Prescriber contacted
- Patient communication
- Documentation complete
39
What intervention codes must be used when billing for a pharmaceutical opinion?
- PS
- Must include pharmacist ID code
40
Forgery Confirmed / Not Filled
Prescription not filled as prescribed due to a clinical issue or it was confirmed as a falsified prescription
PIN: 91
41
No Change to Rx
Pharmacist’s recommendation was made to the prescriber and resulted in no change to the prescription; prescription was filled as originally prescribed.
PIN: 92
42
Change to Rx
Pharmacist’s recommendation was made to the prescriber and resulted in a change to the prescription which was subsequently filled as per prescribed change.
PIN: 93
43
Smoking Cessation: First Consultation
- Once per year
- $40
PIN: 41
44
Smoking Cessation: Primary follow up (1-3)
- 3 times per year
- $45 total
PIN: 42
45
Smoking Cessation: Secondary follow up (4-7)
- 4 times per year
- $40 total
PIN: 43
46
When can a claim for Smoking Cessation be made?
A claim for payment is made after documentation is complete and the respective smoking cessation meeting / session has occurred using the appropriate PIN; claim to be submitted on the date of service
47
Smoking Cessation: program tracking and evaluation
1. Successful Quit (PIN: 44)
2. Un-Sucessful Quit (PIN: 45)
3. Unknown status (PIN: 46)
48
When can a claim for Smoking Cessation: Program evaluation be made?
A claim for evaluation is made after documentation is completed and pharmacist is made aware of the program quit status using the appropriate PIN; claim to be submitted on the date the pharmacist is made aware of the program quit status. Once a program evaluation PIN is claimed, no further meetings are billable for that program period.
49
Pharmacies must be approved by Ministry to participate in the UIIP. True or False?
True
50
How old does a patient need to be in order to receive the flu shot from the pharmacy?
2 years or older
51
All claims for flu shots must be submitted through the ministry's __________________ system.
Health Network
52
How much can the pharmacy claim per immunization?
$7.50
53
What questions might we ask a patient when demonstrating a glucometer?
1. Is this the first time using a glucometer?
2. If not, why did you switch?
54
What is the normal range and average fasting for blood glucose levels?
Normal: 4-7
Fasting: 5.5
55
How do we respond to a question about how many times a day to check blood glucose levels?
T1: as often as they use insulin
T2: depends on meds - 2x a day or few times a week
NOTE: always recommend a follow up w/ pharmacist for specific directions
56
What are the signs of HYPOglycemia?
1. Lower then 4mmol
2. hunger
3. shakiness
4. sweating
5. pale
6. nauseous
57
What are the signs of HYPERglycemia
1. Higher than 10mmol
2. frequent urination
3. increased thirst
4. headaches
5. not enough insulin/not effective enough
58
How much do glucometers usually cost?
Meters are usually free with purchase of test strips.
ODB can get on RX - limit on how many test strips are covered per year depending on how diabetes is treated
59
Where is the best site to test blood glucose?
Outside of fingertips - less nerve endings
- palm, forearm, upper arm are alternatives if bg is stable
60
What questions should we ask a patient we are demonstrating a blood pressure machine to?
1. Have you used a blood pressure machine before?
2. What are you using a blood pressure machine to monitor?
61
What are some best practices for getting consistent blood pressure readings?
- Resting for at least 5 minutes before taking BP
- Feet flat on ground, arm at rest (palm up)
- Taking a reading at the same time each day (morning/late afternoon)
62
Systolic VRS Diastolic?
Systolic: Upper number - pressure when heat beats
Diastolic: Lower number - pressure when heat rests
63
Normal blood pressure is Systolic _____________ and Diastolic _____________.
LESS than 120 upper and LESS than 80 lower
64
Elevated blood pressure is ____________ Systolic and ____________ Diastolic.
120-129 and LESS than 80
65
Stage 1 Hypertension ranges from __________ Systolic and __________ Diastolic.
130-139 OR 80-89
66
Stage 2 Hypertension ranges from __________ Systolic and __________ Diastolic.
140 + OR 90+
67
Hypertensive Crisis
Systolic above 180 and/or Diastolic above 120
68
What are some consequences of high blood pressure?
- Stroke
- Vision Loss
- Heart Failure
- Heat Attack
- Sexual dysfunction
- Kidney disease/failure
69
What drugs are in the general category of blood pressure lowering drugs?
- Thiazide diuretics (HCTZ)
- ACE-Inhibitors (PRIL)
- ARBs (SARTEN)
- CCBs (PINE)
70
What should we be checking for when confirming reason for use with EPIPEN patient?
- What type of allergic reaction did they experience?
- Do they understand the importance of carrying it with them all the time?
- What is their weight?
71
What helpful information can we pass on to EPIPEN patients regarding product expiry?
They can register their product online to have reminders sent when device is expiring soon
72
What is anaphylaxis?
Body overreacts to allergy triggers and releases chemicals to protect itself. This can produce anaphylactic shock.
73
EpiPens are used in the emergency treatment of anaphylaxis; following treatment, the patient must still call 911. True or False?
TRUE - medication could wear off or patient might have a second reaction
74
Patients should be informed that clothing will need to be removed before using EPIPEN to inject. True or False?
FALSE - needle will work through clothing
75
An EPIPEN patient can inject another dose ___________ minutes after the first dose.
5-15
76
"Blue to the _____, orange to the _______." for _______ full seconds.
Sky, Thigh, 3
77
EPIPENS are schedule _____ drugs and are available to purchase ______ a prescription.
II, without
78
What should we be asking/informing our patient when demonstrating a turbuhaler?
- Have you used an inhaler before?
- Dry powder, do not shake, turn upside down or drop
- Quick deep inhalation with firm lip seal
- Do not have to wait for second dose
- Always rinse mouth after use to avoid thrush
- can track doses left on device
79
What should we be asking/informing our patient when demonstrating a Diskus inhaler?
- Have you used a Diskus before?
- Dry powder, do not shake!
- Hold like a sandwich, firm mouth seal
- Quick deep inhalation
- Rinse mouth after use
- For COPD or Asthma
- Usually contains 60 doses
- Ages 6 and up
- Advair require LU code
80
What should we be asking/informing our patient when demonstrating a MDI?
- Have you used an inhaler before?
- Pressurized, must shake prior to use
- Slow deep inhalation
- Wait 30-60sec before second dose
- Rinse mouth after use
- Can use with a spacer
81
What are some important things to note about using a spacer with an MDI?
- Only use one spray in the chamber at a time
- Only use soap/water to clean
- for those without proper breath control
82
What items are required to for a patient using a vial for insulin delivery?
- Syringes, needle tips, alcohol swabs and sharps container
83
What are some critical questions to ask a patient when we are demonstrating an insulin delivery system?
- Are you a newly diagnosed diabetic?
- Are you switching insulin delivery systems?
84
What percentage of diabetics are type 1 vrs. type 2?
10% vrs. 90%
85
How should insulin be stored?
- unused insulin should be stored in the fridge
- Used/opened insulin is stored at room temp and shelf life varies depending on type.
VIALS: Novocain R, N, 70/30 and Levemir are 42 days, all others are 28 days
86
RAPID-ACTING
Apidra/Humalog - 15min, 1hr, 2-4hr
87
REGULAR (Short-acting)
Humulin R - 30min, 2-3hr, 3-6hr
88
INTERMEDIATE
2-4hr, 4-12hr, 12-18hr
89
LONG-ACTING
24hr reduction
90
ULTRA-LONG
6hr, no peak, 36hr or more
91
What important information/tips can we pass on to our insulin demonstration patients?
- Always have a backup of insulin on hand
- Sharps containers are free!
- Most insulin is 100u/mL, easy to figure out how long a fill of insulin will last
92
LIFESCAN: How is diabetes managed?
Nutrition
Physical Activity
Glucose monitoring
Medication
Healthcare Team
93
Why is it important for diabetes to monitor their blood glucose levels?
- Let you know if you are HYPO or HYPERglycemic
- Give you information on how your lifestyle or meds are impacting your blood glucose
- Help your healthcare team make decisions about treatment
94
TECHNICAL CHECK: Patient
- Name, address, phone
- DOB
- Allergies
- Gender
- Health Card #
95
TECHNICAL CHECK:
Billing
- Correct order?
- Correct intervention codes?
- Adjudication messages
- Brand name?
- ODB appropriate?
- Co-pay appropriate
- Deductible
- Not covered (note for patient)
96
TECHNICAL CHECK:
RX
- Drug (DIN)
- Drug strength
- Quantity and repeats
- Dosage form and pack size
- SIG and days supply
97
TECHNICAL CHECK: N, C and T/C
- VALID ID is written on prescription by prescriber
- Interval date is written on RX if repeats are given (fax and release as long as repeats are 0, can add them after)
- Early fill?
98
What is the NMS?
Narcotic Monitoring System - Centralized database that allows for monitoring of the dispensing of narcotics and controlled/targeted substances
99
What two things must a prescriber record on every prescription for a monitored drug product?
Patient ID and CPSO number
100
What should be doing when someone is picking up a monitored drug rx for someone else?
- need to show ID and name/address is recorded on patient file
- confirm patient they are picking up for has already provided ID for rx when it was written
101
When to monitored drugs not require NMS submission?
- Hospital in-patients
- Inmates
- Animals
102
MH
Double-doctor (Indicates that, including the current claim, the recipient has obtained monitored drugs prescribed by 3 or more different prescribers in the past 28 days.)
103
MI
Poly-pharmacy (Indicates that, including the current claim, the recipient has obtained monitored
drugs from 3 or more different dispensaries in the past 28 days.)
104
D7
Refill too soon (Indicates that, based on the days supply of the previous claim submitted to the NMS, a refill should not be required at this time. The patient may still have enough product available.)
105
DE
Fill/Refill too late (Indicates that, based on the days supply of the previous claim submitted to the NMS, a refill is overdue at this time.)
106
MY
Duplicate drug filled at other pharmacy (same patient, same DIN, same date, different pharmacy)
107
What other information does the NMS return along with the DUR code?
- transaction date of previous claim
- phone number of previous claim
- quantity of previous claim
- DIN of previous claim
108
When billing NMS-Monitored drugs, patient must have an ___________ plan in patient profile.
ODB
109
What extra codes are required if patient receiving NMS drugs does not have a health card?
ONG (Out of country, other ID)
ONO (Canadian residents, other ID)
ONX (Canadian resident, no ID, prescriber documented reason)
110
How would you input a dentist's licence number into Kroll?
DXXXXX (add 0 if not 5 digits)
111
What is Methadone?
Long-acting oral opioid that is used to replace a shorter-acting opioid reducing need to "use" 3-4 times a day. Considered a maintenance medication to treat opioid dependance.
112
=What are the benefits of MMT?
- Reduced illegal drug use & improved health
- Reduced transmission of HIV, Hep B&C
- Reduced illegal activity and increased employment
- Reduced cost to society
113
What are the risks of MMT?
- Improper use can be fatal
- Illegal diversion to street
114
The RPh prepares _________ labeled doses of methadone from a 10mg/mL solution, diluting with Tang (or other flavoured crystals) to produce 100mL at prescribed dosage.
individually
115
When the methadone is prepared, what three options does the RPh have when dispensing?
1. Dispense to patient in accredited pharmacy
2. Transfers securely to physician for patient administration
3. Takes does to patient at treatment location and observes ingestion
116
What happens if the pharmacy is not open 7 days a week?
Pharmacists can open the pharmacy for a restricted time or collaborate with hospital/other pharmacy to provide weekend access to patients requiring daily dosing.
117
What are the requirements for dispensing Methadone in a pharmacy?
1. Prescription written by physician
2. Proper preparation of Methadone
3. Appropriate final dosage form
118
What are the requirements for Methadone final dosage form?
1. Drink and carries must be prepared from a manufactured product (10 mg/mL solution) diluted to 100 mL of a vehicle that does not lend itself to injection (such as orange flavoured Tang®)
2. Methadone doses must be accurately measured using a device that is able to deliver 0.1mL increments.
3.Methadone carries must be dispensed with child-proof safety caps.
4. Labelling must be in accordance with DRPA 156
5. Proper transfer of custody
6. Proper observation of dose
7. Documentation of daily ingest (Name, date, time and place)
8. Dose change always requires a new prescription
9. Unused doses are properly managed
10. Daily reconciliation
11. Maintenance of patient privacy and confidentiality
119
What needs to be included when labelling a Methadone bottle?
- Total dose
- "Drink entire contents of bottle"
- Ingestion date for carries
- AUX labels (Keep in fridge, Methadone red label)
120
What must the prescriber document on the Methadone rx?
The full name of the dispensing pharmacy that the patient MUST go to
121
When must the pharmacy notify the prescriber if a dose is missed?
- Every time a dose is missed
- If 3 or more consecutive doses are missed, the prescription is cancelled and patient MUST see their physician
122
What behavioural expectations are required of the MMT patient?
- Patient must speak (verbally) to RPh after ingest and before leaving store
- Intoxicated patients will not be served their dose (contact prescriber)
- Must treat staff appropriately or will not be served dose
- Must submit regular urine tests to clinic for prescription to be issued
123
What training is required for a RPh to dispense Methadone legally?
- Familiar with CAMH and CPSO guidelines on MMT
- Designated manager must complete CAMH ODT core course within 6 months of starting MMT practice
- After start, within one year, at least one staff RPh must also complete training
- Must update training every 5 years
124
What reference materials must the pharmacy have in order to dispense Methadone legally?
- Opioid Agonist Maintenance Treatment: A Pharmacist’s Guide to Methadone and Buprenorphine for Opioid Use Disorder (CAMH)
- Methadone Maintenance Treatment: Program Standards and Clinical Guidelines (CPSO)
- Methadone Maintenance Treatment for Opioid Dependence (CPSO)
125
OCP-ECONNECT on Methadone Toxicity incident - what are the important takeaways from this article?
- Patient relapsed from Methadone treatment and was restarted after 10 weeks
- Starting dose was too high and patient died due to Methadone toxicity
- When restarting Methadone, starting dose needs to be very low and carefully monitored as patients can lose tolerance very quickly
- Families/patients need to be aware of overdose signs
126
Physcians do NOT have access to DUR alerts like RPh and RPhTs. True or False?
TRUE - Prescribers rely on pharmacy team to make them aware of NMS DUR alerts. We need to pay close attention, especially at the beginning of MMT.
127
NMS is designed to ________, not punish patients.
Protect
128
What is Suboxone?
Opioid-agonist therapy (no high) that consists of buprenorphine & naloxone, and administered via a SL tablet.
129
What are the advantages of Suboxone compared to Methadone?
- Less stigmatizing
- Can get to maintenance dose quicker
- Less likely to cause overdose
- Fewer side effects
130
What are the three goals of the OCP Crystal Meth Advisory?
1. Increase awareness of meth production and how chemicals can be diverted from legal products in to illegal production
2. Promote teamwork between retailers and law-enforcement
3. Reduce meth production without disrupting availability of legal products
131
ISMP - Deaths associated with overdose
- Increase in overdose deaths due to lack of knowledge (taking meds, symptoms of toxicity, high-alert meds)
- Need more understanding of risk associated with increasing dosage, interactions with OTC meds
- Encourage safe disposal of unused meds
- Counselling on importance of following medication directions on the labels (high-alert meds)
132
ISMP - Methadone in post partum patients
- 10-fold overdose due to change in supply from Methadone 1mg/mL to 10mg/mL
- Change in product not communicated, and put in dispensing cabinet
- lack of independent double check
- Use patient-specific doses rather than ward stock
- limit inventory and implement double checks
133
ISMP - Opioids in small community hospials
- LA/CR and IR Fentanyl were used inappropriately to treat acute patient pain. Patient symptoms of toxicity were ignored.
- Must have proper protocols for pain management
- Hospitals should have an experienced opioid prescriber and all RXs should be checked for appropriateness by RPh before dispensing (prescriber should not be on double-duty)
134
ISMP - Decimal point in hydromorph
New strength of Hydromophone (4.5mg) was confused with 45mg and given in conjunction with 9mg SC injection, resulting in overdose.
- BPMH could have avoided this result
- Recommendation to create drug strengths in whole numbers when possible
