The prescription

11/13/2024 1
 Prescription
• It is an order for medication issued by a
physician, or other properly licensed medical
practitioner.

• The prescription order is a part of the

professional relationship among the prescriber,
the pharmacist and the patient.

• It is the pharmacist’s responsibiity in this

relationship to provide quality pharmceutical care
that meets the medication needs of the patient.
11/13/2024 2
• Pharmacists should also:

– Advice the prescriber of drug hypersensitivity the

patient may have
– Previous adverse drug reactions
– Medications that the patient may be taking that
may alter the effectiveness or safety of the newly
or previously prescribed medications
– Antacids and antibiotics (ciprofloxacin)

11/13/2024 3
• For this:

– Pharmacists should maintain a high level of

practice competence
– Should keep appropriate records on the health
status and medication history of his patients
– Develops professional working relationships with
other health professionals

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 Paper based prescription

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• Prescription
- is a legal document
-clinical document

11/13/2024 10
Minimum information in a Prescription
• Name and signature of the prescribers
• Date of the prescription
• Name of the medicine (with strength and
dosage form, if relevant)
• Total amount to be dispensed or length of
treatment line
• Directions for use
• Name and address of the patient
11/13/2024 11
 Common terms
• Dosage form
• Strength
• Dose
• Dosage regimen (the schedule of doses of a medicine,
including the time between doses, the duration
of treatment and the amount to be taken each time.)

• Total daily dose

• Total amount to be supplied
• Generic name
• Proprietary name
• Length of treatment

11/13/2024 12
 Dispensing
• dispense - Derived from Latin dispendere,
"weigh out.“

• dis·pense (d-spns) v. dis·pensed, dis·pens·ing,

dis·pens·es
1. To deal out in parts or portions; distribute.
2. To prepare and give out (medicines).

11/13/2024 13
• dispenser [dɪˈspɛnsə] n
1. a device, such as a vending machine, that
automatically dispenses a single item or a measured
quantity

2. a person or thing that dispenses

• Collins English Dictionary – Complete and Unabridged © HarperCollins Publishers 1991, 1994, 1998, 2000, 2003

11/13/2024 14
 Why good dispensing practice?

11/13/2024 15
 Dispensing
Good dispensing practice ensures that an effective
form of the correct medicine is delivered to the
right person, in the correct dosage and quantity
with clear instructions and in a package that
maintains potency of the medicine.

Dispensing include all activities that occur between

the time the prescription is presented and the time
the medicine or other prescribed items are issue to
the patient.
11/13/2024 16
 Dispensing
According to Drug act 1978
 Dispensing is the issuing of the drug in a
suitable container, appropriately labeled and
compounded for the subsequent
administration to the patient.

 It has failed to include the duty of a dispenser

about the prescription and counseling to the
patient.

11/13/2024 17
 Aim of dispensing
• The aim of dispensing is to ensure that the
right patient receives the appropriate
medicine in the correct dose and form.
The requisites are:
• The right patient gets the right medicine
• Possible interactions are avoided
• The quality and integrity of the medicine are
maintained throughout the indicated shelf life
11/13/2024 18
 Aim of dispensing
• Correct and clear instructions are given to the
patient: (Why?)

• To ensure correct and safe use of the

medicine (suppository, vaginal tablets,
inhalers)

• To achieve optimal benefit of patient in line

with objective of the treatment
11/13/2024 19
 Aim of dispensing
• The patient is given at the least basic information:

• Regarding special instructions for use

• Warnings if applicable
• Possible adverse/side effect
• Action to take in the event of certain events
occurring
• (e.g Budesonide inhaler - white patches, redness
and soreness in mouth)

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 Aim of dispensing
• As far as possible the basic information should be
given in the written form:

– When to take (T. Paracetamol 500mg TDS for 5 days

and then SOS)
– How to take
– Certain precautions

Written materials may provide the answer or encourage

the patient to know if the patient has forgotten or is
unclear about what the pharmacist said.

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 Dispensing error
• A dispensing error is a discrepancy between a
prescription and the medicine that the
pharmacy:
– Delivers to the patient or
– Distributes to the ward on the basis of this
prescription

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 Categories of dispensing error
• Dispensing an incorrectly • Incorrect instruction
compounded medicine (including incorrect dosage)
(compounding in pharmacy) • Incorrect drug quantity
• Dispensing with the wrong • Incorrect dosage form
information on the label • Incorrect expiry date
• Incorrect patient name • Omission of additional
warning(s)
• Incorrect drug name • Incorrect pharmacy address
• Incorrect drug strength • Other labelling errors
• Dispensing with the wrong
verbal information to the
patient or representative

11/13/2024 23
 Importance of proper dispensing
• Dispensing is one of the vital elements to ensure
rational prescribing of medicines

• Rational medicine use looks into:

– Rational prescribing habits
– Appropriate dispensing
– Patient’s use of medicines

• All efforts and resources involved in patient care may

be wasted if dispensing does not result in named
patient receiving an effective form of correct drug in
appropriate packaging with correct dose and advice.
11/13/2024 24
 Importance of proper dispensing
• Dispensing done in an appropriate way can
prevent the mistakes done by the prescriber and
also prevents the medication error due to the
dispenser.

• It can assure that the patient leaves the counter

comfortably with correct information.

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11/13/2024 26
Prescription Checking
Name: XXXXX XX Sex:F Age:29 yrs Wt:50 kg
Liver: Normal Kidney: Normal Pregnancy: None
Allergy: NKDA (No known Drug Allergy)

#Hypertension for 2 years (managed by Atenolol 50 mg).

Not well controlled
#Symptoms of respiratory distress and UTI
#occasional GI discomfort and burning

Rx Atenolol 200 mg x 1 x 30 days

Norfloxacin 400mg x 2 x 7 days
Aminophylline 100mg x 3 x 15 days
Antacid syp 10mL x 3 x PRN
11/13/2024 27
Problems include:
 Maximum dose of atenolol for hypertension is 100 mg per
day.

 Atenolol causing acute respiratory distress syndrome

(ARDS) is a serious lung condition that causes low blood
oxygen

 Life threatening interaction between norfloxacin and

aminophylline

Aminophylline is a bronchodilator consisting of theophylline

that is used for the treatment of bronchospasm due to
asthma and chronic bronchitis.

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Problems include:
 Metabolism of Aminophylline can be decreased when
combined with Norfloxacin.

 ADR of Aminophylline

• Nausea
• Vomiting
• Headache
• Insomnia
• Irritability
• Intractable seizures
• Fast, slow, or irregular heartbeat
• CNS depression

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 Atenolol-aminophylline combination use is irrational.
Atenolol may decrease the bronchodilator activities
of Aminophylline

 Physical interaction between antacid and norfloxacin

 Antacids containing aluminum and magnesium salts and

calcium carbonate should be avoided by patients taking
norfloxacin. (At least 2 hours difference)

 May cause markedly reduced bioavailability  may lead to

therapeutic failures.

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 Prescription checking for
• Unit dose above limit
• Maximum daily dose above maximum limit
• Minimum daily dose below minimum limit
• Frequency above maximum allowable frequency
• Non-PRN medicines given on PRN (pro re nata) basis
(As needed)
• Route of administration

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 Prescription checking for
• Injection-Injection Incompatibility
 Meropenem (continuous infusion) + Pantoprazole (bolus) 
Precipitation
 Precipitate can lead to therapeutic failures due to:
 Drug inactivation
 catheter occlusions
 varying levels of harm due to particulate embolization, ranging from
thrombophlebitis to multi-organ failure or even death

• Injection-IV fluid Incompatibility

 Piperacillin/tazobactam is not compatible with lactated Ringer's
(Hartmann's) solution (electrolyte solution – Sodium chloride, sodium
lactate etc.)

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 Prescription checking for
• Drug-drug interactions

• Drug-disease interactions
 Worsening of urinary retention in men who have benign
prostatic hypertrophy when an anticholinergic medication is
prescribed (decrease bladder detrusor muscle contraction)

• Drug-Lab interactions
 Cephalosporins may alter urine glucose and ketone tests (false
positive result)

• Pregnancy contraindicated drugs (Isotretinoin, ACEI etc.)

• Breast-feeding precautions
• Kidney impairment precautions (NSAIDs, Digoxin)
• Liver impairment precautions (Morphine, Theophylline)
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 Parts of Prescription
Followings are the core parts of prescription:
1. Prescriber information
2. Patient information
3. Date
4. Superscription
5. Inscription
6. Subscription
7. Signatura
8. Prescriber signature

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Physicians prescription showing typical
form and content
1 . Dhulikhel Hospital
Dhulikhel
2. Patient name : ……… 3 . Date: ………
Address: ……
Diagnosis:
4.5 Rx ampicillin 250 mg
6. Disp 40
7. Sig: one qid
8. Label
Refill 1 2 3 4
PRN
9. ____________________________________________

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 Parts of Prescription
1. Prescribers office information
2. Patient information
3. date
4. Rx symbol or superscription
5. Medication prescribed or inscription
6. Dispensing directions to pharmacist or subscription
7. Directions for patient or signa (to be placed on label)
8. Refill, special labeling, and other instructions
9. Prescriber’s signature and license

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 Parts of Prescription
Superscription
• Consists of the heading where the symbol Rx is found
• Derived from the Latin word recipe or “recipere”which
means to take.

Inscription
Body of the prescription
Provides names and quantities of main ingredients of
prescription
Dose and dosage form, such as tablet, suspension,
capsule, syrup are present

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 Parts of Prescription
Subscription
Gives specific directions for the pharmacist on how
to compound the medication.

Signatura
Gives instructions to the patient on how, how
much, when and how long the drug is to be taken.

These instructions are preceded by the symbol “S”

or “Sig.” from the Latin meaning "mark.“

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 Examples of subscription
• M ft caps dtd no xxiv (Mix and make capsules.
Dispense 24 such doses)
• Ft supp No xii (make 12 suppositories)
• M ft ung (Mix and make an ointment)
• Disp tabs No c (Dipense 100 tablets).

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 Examples of signatura
• Tabs ii q4h (take 2 tablets every four hours)
• Caps I 4xd pc and hs (take one capsules four
times a day after meals and at bedtime)
• Instill gtts ii od (Instill two drops into the right
eye).

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 Parts of Prescription
Below the Signatura a special room should be
present for the signature of the prescriber.

It is the legal requirement of prescription that it

should contain prescriber signature for its validity

Prescriber information includes the name, address,

qualification, telephone no and license number,
these information are usually printed.

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 Parts of Prescription
If these information is written by hand it should be
written clearly on the top of the prescription form.

Date is the important part of the prescription which

confirm that when the prescription was written

The date is important for keeping medication record of

patient.

It tells about oldness of prescription.

In some countries prescription older than 3 to 6 months

does not dispensed by the pharmacist
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 Parts of Prescription
Full name and address of patient are
compulsory for identification of patient. It
should be written clearly

Weight and age should be mentioned on

prescription for children and elderly patient. It
helps the pharmacist to check the dose of
medicine

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Prescription Need of this Part in What Happened if Missed?
part Prescription
Prescriber To authenticate the The pharmacist are unable to understand
information prescription before whether the prescription is genuine or not
dispensing.

The prescription is a legal

document.
Patient For proper identification of a If the name is absent patient cannot be
information patient and to determine its contacted in case of dispensing error
age group. It is also essential
for follow-up of patient or to
get in touch with the patient
in case of prescribing or
dispensing errors
Date To know the validity of The Pharmacist cannot identify an old
prescription and to avoid prescription brought for refill and in many
unnecessary refilling of the cases not advisable
prescription
Superscription It is a sign of practice If it is not present then the written piece of
paper does not be consider as a prescription
by law.
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Prescription Need of this Part in Prescription What Happened if Missed?
part

Inscription Includes the drug name, concentration and Chances of errors being
type of preparation increased during dispensing
the drugs by pharmacist.

Subscription For dispensing of correct and proper Medication errors results

medication to the patient

Signatura Patient needs to know the quantity of Patient is confused what dose
tablets/cap/ liquid & number of times the to take and how often.
medicine needs to be taken. So, Medication errors results.

Oral instructions to patients are most of the

times forgotten.
The pharmacist can also counsel the patient.

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Prescription Need of this Part in What Happened if Missed?
part Prescription

Prescriber To confirm authenticity of Misuse of blank prescription cannot be

signature prescription and to avoid detected
misuse of blank prescription
pads.

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11/13/2024 47
11/13/2024 48
 Routine procedure
for
dispensing
prescriptions
or
Filling prescription
11/13/2024 49
 Stages involved
• Receiving the prescription
• Clinical and legal checking of the prescription
• Assembly of the product and labelling
• Accuracy checking the product against the
prescription
• Delivery of the product to the patient with the
appropriate advice about the product

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11/13/2024 51
 Step 1: Receive and validate the
prescription
• Upon receiving the prescription, staff responsible should
confirm name of the patient

• Whether the prescription is presented by the client

himself/herself or by someone on the client’s behalf.

• This step is particularly important when there is large

crowd and there is any risk that staffs or patients may mix
up prescriptions

• Cross-checking name and identity of the patient must also

be done when issuing medication

11/13/2024 52
 Step 2: Understand and interpret the
prescription
• Interpreting a prescription must be done by a staff
member who can –

– Read the prescription

– Correctly interpret any abbreviations used by prescriber
– Confirm that the doses prescribed are in normal range for
the patient (noting gender and age)
– Correctly perform any calculations of dose and issue
quantity
– Identify any drug-drug interactions
– Double check all calculations or counter-check by another
staff member

11/13/2024 53
 Step 2: Understand and interpret the
prescription
The client may be politely requested to wait
while the prescription is reviewed for:
a. Therapeutic aspects (pharmaceutical &
pharmacological)
b. Appropriateness for an individual
c. Legality and completeness of prescription

11/13/2024 54
 Step 2: Understand and interpret the
prescription
Prescription should be considered as incomplete if any of
the following information is missing:
a. Name of the prescriber, his/her address and
council registration number
b. Name, address, age, gender of the patient
c. Name(s) of the medicine(s), potency, dosage,
total amount of the medicines to be supplied
d. Instructions to the patient
e. Refill information if any
f. Prescribers’ signature and date

11/13/2024 55
 Step 2: Understand and interpret the
prescription
Mnemonics : IDEAL CASE
• I - nteractions
• D –ose
• E - vidence of harm/benefit
• A- ppropriate
• L- egal and complete
• C – ost-effective
• A – cceptable to the patient
• S – afe
• E - ffective

11/13/2024 56
 Step 2: Understand and interpret the
prescription
• Any incompleteness, ambiguities, confusions,
shortcomings or anomalies (deviation from
standard) in the prescription should be
brought to notice of the prescriber.

11/13/2024 57
 Step 2: Understand and interpret the
prescription
Correctness of prescribed medicines:

The prescription should be checked for the following things:

• Dosage regimen:
Whether the dosage prescribed is within the standard
minimum or maximum dosage range.

• Double medication (same medicine or different medicine with

same pharmaco-therapeutic effect) concurrently prescribed
by the same prescriber or by two or more prescribers to the
same patient.

11/13/2024 58
 Step 2: Understand and interpret the
prescription
• Interactions between currently prescribed medicines with :

• Other medicines being taken by the patient like Over the

Counter medicines (OTC)

• Medicines from any past prescriptions (record of which may

be available in the Patient’s Medication Records), vitamins,
tonics, or any other herbal medicines

• Any medicine interactions likely to render the therapy

ineffective or cause undesirable effects to the patient should
be brought to notice of the prescriber.

 Aspirin with the anticoagulant warfarin can increase the

risk of abnormal bleeding
11/13/2024 59
 Step 2: Understand and interpret the
prescription

 Contraindications/Precautions: Age, gender, disease(s),

conditions or other characteristic of a patient that may
cause certain prescribed medicines to be contraindicated
or need precaution.

• History of overuse, under use, or misuse of

medicines by the patient.

• Any of the above as well as handwriting legibility

problems should be brought to the notice of the
prescriber.
11/13/2024 60
 Step 2: Understand and interpret the
prescription
• Any necessary changes made by the prescriber should be
recorded on the prescription, with the words "Changes made
over the telephone in consultation with the prescriber
(name) at (time) on (date)" and should be signed and
stamped by the pharmacist.

• This exercise necessitates a trust based professional

relationship with the prescriber. In case of any doubt, the
prescription should be suitably amended from the prescriber.

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 Step 3:Prepare and label items for
issue
• Preparing items for issue is the central part of
dispensing process and it must include
procedures for self-checking or counter
checking to ensure accuracy

• This part begins after prescription is clearly

understood and the quantity has been
calculated

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 Step 3:Prepare and label items for
issue
Select the item

A good dispenser selects the item by reading the

label and cross-matching the product name and
strength against the prescription

Dispenser should check the stock to make sure that

it has not expired and choose the oldest stock (first-
in, first-out) or first expiry depending on the stock
rotation used

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 Step 3:Prepare and label items for
issue
Select the item

Most well-trained staff members read the container

label at least twice during dispensing process

Selecting according to color or location of container

without consciously reading the label is poor
dispensing practice and may have fatal
consequences

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 Step 3:Prepare and label items for issue

Appropriate medicine should be taken out,

labeled and dispensed.

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 Step 4: Make final check

• Dispensed preparation should be checked

against the prescription prior to dispensing

11/13/2024 66
 Step 5: Issue medicine to patient with clear
instructions and advice
• Medicine should be given to the named patient or
patient’s representative with clear instructions and any
appropriate advice about the medicine

• Verbal advice is important due to illiteracy or poor

labeling might be problems

• Pictograms can be used for counseling such patients

• Information on dose, length of treatment, duration of

treatment, route of administration

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 Step 5: Issue medicine to patient with clear
instructions and advice
Advice should concentrate on :

– When to take medicine (particularly in relation to food or

other medicines)
– How to take the medicine (chewed, swallowed whole etc)
– How to store the medicine
Warnings on possible side effects should be given

Common, harmless side effects should be mentioned

(nausea, mild diarrhea, urine color change) should be
mentioned to prevent a frightened patient from stopping
the treatment.
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 Step 5: Issue medicine to patient with clear
instructions and advice
Dispenser should ensure that patient completely understands
how to take drug.

By making patient to repeat how to take drug a dispenser can

ensure that patient really understands.

If special counseling is required patient should be taken to a

counseling room.

After filling the prescription, the patient should be provided

with a bill in which the batch no, manufactured date and the
expiry date of the dispensed medicines should be clearly
written
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 Labeling of dispensed medicines

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 Definition of Label as per drug act
• "Label" means the name and the description
of the drug written on the same container of
the drug.

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 Standard labeling requirements
Warning or advisory labels
• Printed : for legibility A batch number (extemporaneous
preparation)

• Proper font size An expiry date or shelf life for a

diluted preparation
Labelling requirements Storage conditions

1. The name of the preparation, strength and form

2. Quantity
3. Instructions for use
4. Precautions relating to the use of the product Additional
5. The patient’s name labelling
6. The date of dispensing requirements
7. The name and address of the pharmacy
8. ‘keep out of the reach and sight of children’
9. The phrase ‘for external use’ for certain
formulations
11/13/2024 72
 1. As same as the one which appears on the
prescription

3. RPSGB : use of active verbs ; active verbs are more

1. The name of the preparation, easily understood and remembered than passive verbs
strength and form (if more than
Tablets (Correct)
one available)
2. Quantity 3.1. avoid: take two three times daily
Numbers which are part of an instruction
3. Instructions for use
must always be written as words except in
4. Precautions relating to the use
the case of 5 mL
of the product
5. The patient’s name 5. A First full name e.g.
6. The date of dispensing Mr. Ganga Thapa
7. The name and address of the instead of G . Thapa
pharmacy
8. ‘keep out of the reach and sight
of children’
9. The phrase ‘for external use’ for
certain formulations

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 Contents of Label
i. Patient name, identification number, location
ii.Medicine name, dosage form, batch and
expiry date
iii.Quantity to dispense
iv.Route of administration, dosing method (Unit
dose, dosing interval, duration of use)
v.Precautions, warnings related to medicine
vi.Hospital name

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 National Good Pharmacy Practice
Guidelines
Nepal Pharmacy Council, 2005

Good Pharmacy Practice guideline is a reference for the

pharmacy professionals offering the pharmaceutical services to
the patients in the different service settings.

In accordance with this guideline, National Good Pharmacy

Practice guidelines (NGPPG) draft have been formulated, by the
Nepal Pharmacy Council (NPC), which establishes certain
standards of practice for community pharmacies in Nepal.

11/13/2024 75
 National Good Pharmacy Practice
Guidelines
Nepal’s National Regulatory Authority, the Department of Drug
Administration (DDA) has revised the Codes on Sale and
Distribution of Drugs (CSD) and prepared Nepal’s first Good
Pharmacy Practices (GPP) and Good Storage and Distribution
Practices (GSDP) guidelines (2024)

11/13/2024 76
 Patient Information (NGPPG)

● Pharmacist should provide oral as well as written

information

● All dispensed medicines should be provided with a label

● Dosage and usage information must be given verbally to

the patients along with demonstrations and pictograms
where ever required

● It must be ensured that information and advice given is

correct

11/13/2024 77
• NPA GPP Model
● Outpatient: Verbal +
Dispensing label
● Inpatient: Dispensing
label
● Discharge patient:
Verbal + Dispensing
label

11/13/2024 78
 Outpatient Labeling

11/13/2024 79
 Inpatient Labeling

11/13/2024 80
 Labeling sample

11/13/2024 81
11/13/2024 82
 Benefits of Dispensing Label
● Fast and accurate counseling.
● Uniformity in counseling
● Information read immediately before administration
● Reduces dispensing errors

11/13/2024 83
 Dispensing Label
•The labels can be printed on
i. paper envelopes
ii. paper stickers.

11/13/2024 84
 The purpose of a label for a prescribed medicine is:
• To describe and identify it

• To contribute to optimal therapeutic outcome and to avoid

medication errors

• To achieve appropriate handling and storage

• To allow the product to be traced if there are problems

with either the manufacturing, prescribing or dispensing
process

• Label information for prescribed medicines should be

considered to supplement and reinforce oral
communication between the patient and healthcare
provider.
11/13/2024 85
 Minimum Labelling - GSD
• In many countries, there is no legislation on product
labelling

• Therefore, FIP considers it necessary to define an absolute

minimum of information for labels of prescribed medicines
as follows:

*Generic name
*Strength of medicine
*Individual Dosage Instructions

• The route of administration should be stated if other than

oral. This absolute minimum of information is termed GSD.
11/13/2024 86
 Information sources
• Nepalese National Formulary
• National guidelines
• DDA bulletins
• BNF
• Martindale

11/13/2024 87
11/13/2024 88
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 Nimesulide 100

Alprazolam 0.25

11/13/2024 90
 Strength missing

11/13/2024 91
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