Order entry may also provide input into other systems. For example, entering the prescription/medication order into a computerized patient profile may simultaneously generate a prescription label, update the drug inventory record, create an entry into an electronic inventory ordering system, and update or change information in other databases. When entering new prescription/medication information, follow these steps:

a. Verify the patient’s name and/or identification number. If the patient already has an existing profile, confirm that the patient information on the new order matches the patient information on the profile. If you do not find an existing patient profile, you will need to create a new profile. Chapter 5 contains more information on creating patient profiles.

b. Compare the new order with the patient profile. Look for medication duplication, drug class duplication, or other possible problems. If you discover problems, notify the pharmacist immediately before proceeding. Problems that may require a pharmacist’s intervention include a potential adverse drug event, new prescription or nonprescription medication, and suspected drug misuse or nonadherence.

c. Enter the date, drug name, dosage form, dispensing quantity, directions for use, and number of refills, if any.

d. Enter the prescriber information and the initials of the technician and supervising pharmacist dispensing the medication. How this information gets entered may vary from pharmacy to pharmacy.

e. Enter the reimbursement mechanism or third-party payer information.

f. Enter other information as required by the pharmacy’s policies and procedures.

B. DUR alerts

1. Pharmacy computer systems include automated DUR or DUE alerts to signal pharmacists and technicians to potential medication errors or problems, such as drug-drug interactions or adverse drug reactions.
   
   A DUR alert may appear during the order-entry process or when a prescription claim gets submitted electronically. Technicians should watch for DUR alerts and let the pharmacist know when one arises to ensure patient safety and appropriate medication use.

C. Verifying prescription validity

1. Technicians should watch for forged or invalid prescriptions, which happen most commonly with controlled substances. A forged prescription may:
   
   a. have an altered quantity, or
   b. be written on altered, invalid, or stolen prescription blanks
   
2. A prescription for a controlled substance must contain the prescriber’s name, address, and Drug Enforcement Administration (DEA) number. The patient’s name and address must also appear on the prescription.
   
3. If you question the validity of a prescription, verify the prescriber’s DEA number. However, a prescription may still be invalid or forged even if the DEA number is valid.
   
   To verify a DEA number, use the following formula:
   
   Step 1: Add the 1st, 3rd, and 5th digits.
   Step 2: Add the 2nd, 4th, and 6th digits. Multiple this number by 2.
   Step 3: Add the two totals together.
   Step 4: The second digit in that total should equal the last digit in the DEA number (referred to as the “check digit”).
   
   Here is an example for DEA Number BG6125341:
   
   Step 1: Add the 1st, 3rd, and 5th digits: 6 + 2 + 3 = 11
   Step 2: Add the 2nd, 4th, and 6th digits, then multiple this number by 2: 1 + 5 + 4 = 10 x 2 = 20
   Step 3: Add the two totals together: 20 + 11 = 31
   Step 4: The second digit in that total should equal the last digit in the DEA number: The second digit in that total is “1,” which equals the last digit in the DEA number, so this DEA number is valid.
   
   If you suspect that a prescription is altered or invalid, alert the pharmacist and follow the pharmacy’s policies and procedures. You may also need to notify the local narcotics office.

D. Processing investigational drug orders

1. Investigational drugs are prepared by pharmacists and technicians, following protocols for dispensing, recordkeeping, storage, and preparation. Investigational Drug Services, provided by pharmacy departments, oversees all of these activities. Chapter 3 contains additional information on investigational drugs.

III. Selecting Appropriate Product(s) to Be Dispensed

A. Selecting the appropriate drug for a prescription or medication order

1. To minimize errors, you should fill prescriptions and medication orders from the original order. While filling the order, carefully check the information in the patient profile and on the prescription label to verify its accuracy against the original prescription/medication order. If you note a discrepancy or question, let the pharmacist know.

B. Selecting the product(s) to be dispensed. Prescriptions and medication orders may be written in two ways:

1. Generic drug name (drug’s chemical name)
   
   a. When a pharmaceutical manufacturer’s patent expires for a proprietary or brand-name drug, other companies may obtain approval from the Food and Drug Administration (FDA) to manufacture and market a generic product. Each pharmacy has different preferred manufacturing sources for generic drugs based on pricing and contracts.
   
   When a prescription or medication order is written generically, selecting which product to dispense usually depends on the preferred manufacturing source. Chapter 1 details therapeutic equivalence, the process used to certify that a generic drug is equivalent to its brand counterpart.
   
2. Trade or brand name
   
   a. Appropriate methods for processing prescriptions and medication orders written as brand-name drugs depend on state laws, third-party payers, individual pharmacies or institutions, and other factors. In most cases, if a therapeutically equivalent generic product is available, it will be substituted for the brand-name drug.
   
   
   
   (1) Hospitals, health systems, and institutions. The Pharmacy and Therapeutics Committee usually develops the policies related to drug product use within the institution and creates formularies based on these decisions. A formulary or preferred drug list contains preferred or acceptable medications set by a payer or a specific institution.
   
   Formulary decisions may be driven by cost, drug effectiveness, or safety. The formulary restricts which drugs a physician may prescribe and gives the pharmacy department authority to substitute a generic equivalent for a trade-name product if available. As a result, when a medication order is written in trade-name terminology, the order is usually filled with the preferred generic equivalent. If no generic equivalent exists and the drug is on the formulary, the order is filled with the trade-name product.
   
   
   
   
   (2) Community and ambulatory pharmacies. Each pharmacy may set its own policies and procedures in addition to the preferred generics mentioned above. Most commonly, third-party payers dictate whether the prescription will be filled (some medications are not covered on a payer’s formulary) and how they will be filled (trade name or generic). Most payers require generic substitution when available. If a generic equivalent is available, the technician or pharmacist will usually ask the patient or the patient’s representative if he or she will accept a generic substitute. If the patient or patient’s representative prefers the trade-name version not approved by his or her particular health insurance company, the patient will usually have to pay the price difference to the pharmacy.

C. Obtaining medications or devices from inventory. After determining the manufacturing source of the product(s) to be dispensed, obtain the medications or devices from inventory.

D. Calibrating equipment for preparing or compounding the prescription or medication order. As an important quality control measure and to ensure accuracy, pharmacies should regularly calibrate the equipment used for measuring or compounding prescriptions and medication orders. Each pharmacy department has policies and procedures that describe calibration methods and schedules to follow to ensure that equipment stays maintained on a routine basis.

IV. Preparing and Dispensing Medications to Fill Prescriptions and Medication Orders

A. Dispensing finished dosage forms

1. Measure or count finished dosage forms according to instructions on the original prescription or medication order. Chapter 11 contains more information on avoiding medication errors in the dispensing process.

B. Calculations

1. At the direction of the pharmacist, the technician may help perform and/or verify pharmaceutical calculations. Section VII includes a thorough discussion of calculations.

C. Preparing intravenous admixtures and other sterile products

1. Preparation procedures for intravenous admixtures and other sterile products can be found in a variety of sources. Sections IV and VII provide more detail on these procedures.

D. Compounding medications for dispensing according to prescription formula or instructions

1. At the pharmacist’s direction, technicians may help with the compounding function. Sections IV and VII contain more information on compounding.

E. Using appropriate computer-related technology to dispense medications

Some pharmacies or health systems use automated equipment to help prepare, deliver, and administer medication orders. For example, Baker cell systems can be programmed to count quantities of frequently dispensed medications stored in bulk. Other commonly used technology includes robotics, automated total parenteral nutrition preparation equipment, automated dispensing cabinets, and drug infusion pumps.

Technicians routinely use the following computer-related technology to assist in dispensing medications:

1. Automated prescription-dispensing machines. Technicians fill bins and program these machines to count quantities of frequently dispensed medications stored in bulk.
   
2. Automated cart-fill machines. These machines have cart drawers called cassettes that contain medications for a set time period (e.g., 24 hours) for a given patient. Technicians fill medication bins and the automated cart-fill machine fills the cassettes by pulling medication from the bins.
   
3. Automated point-of-care dispensing machines (e.g., Pyxis^® machines). Nursing staff use these machines in the point-of-care area to obtain needed medications directly from the Pyxis^® machine for administration to patients.
   
4. Robots or robotic technology devices. These devices also directly assist in delivering medications to patient-care areas in some institutions.

F. Recording preparation of medication in various dosage forms

1. Document information describing how the prescription was prepared on the prescription or medication order and on the patient profile.

G. Recording preparation of controlled substances for dispensing

1. By law, controlled substances require strict inventory control and documentation to record the dispensing of both established dosage forms and as ingredients of compounded preparations. Chapter 3 details the recordkeeping requirements of controlled substances.
   
   The following information may be required to document the dispensing or use of controlled substances in preparing compounded products:
   
   a. Date the drug was removed from inventory
   
   b. Amount of drug that was removed from inventory
   
   c. How the drug was used (e.g., in the preparation of a cough syrup)
   
   d. Patient and auxiliary information
   
   e. Technician and pharmacist initials

V. Packaging Medications

A. Prescriptions

1. Prescription preparations are usually packaged according to the requirements of the specific drug and/or dosage form. Most preparations, regardless of dosage form, are packaged and dispensed in containers that protect the drug from light, which can hasten the degradation of drug products.
   
2. Certain drug products must be dispensed with special packaging requirements or in their original container. For example, some medications must be packaged from the manufacturer as unit-dose products to prevent accidental ingestion and poisoning, and must be dispensed in approved unit-dose packaging.
   
3. The Poison Prevention Packaging Act of 1970 required most prescription and nonprescription drugs to be packaged in child-resistant containers.

B. Medication orders

1. Unit-dose packaging
   
   a. Unit-dose packaging is used for medications packaged individually (e.g., blister packing). This includes most drugs dispensed in the institutional setting. Unit-dose packaging may also be used to fill orders dispensed to other types of institutions, such as long-term care facilities or dialysis centers.
   
   
   
   When not commercially available, the pharmacy department may use special equipment to package “bulk” medications into unit-dose forms.
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