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Pharmacy technicians are counting machines! OK, not literally counting machines (which some stores are actually lucky enough to have), but they do count a variety of items throughout the day. How many customers were in the drive-through before opening? How many refills in the queue? And perhaps the most important…how many minutes until closing time? Counting counts for so much, and there are certain reminders that are worth revisiting, starting at the beginning…with zero.

Zero In On This Idea

Believe it or not, there are many ways to express the number zero! The British use the term "naught" but in the United States other options include aught, cipher, goose egg, nil, nothing, zilch, and zip. However one chooses to describe zero around the world, pharmacy personnel must honor the concept of "leading" and "trailing" zeroes. A leading zero is a zero preceding a decimal point, such as Risperdal 0.5 mg PO daily. Leading zeroes must always be used when writing prescriptions for quantities of drugs that are fractions of a unit to avoid dosing confusion. For example, if the prescription above is written without the leading zero, i.e. Risperdal .5 mg PO daily, the result may be a tenfold dosing error! Pharmacy technicians that encounter a prescription written incorrectly should notify their supervisor of the need to clarify the drug strength.

On the other side of this concept is a "trailing" zero. A trailing zero refers to a zero that follows a decimal point, such as Clonidine 1.0 mg PO TID. Using a zero after a decimal point can also result in a tenfold dosing error if the decimal point is illegible or not noticed. For this reason, the Joint Commission on the Accreditation of Hospitals has included trailing zeroes on their official "Do Not Use" list.

Other Number Confusion – Where to Start?

Another topic in pharmacy where confusion may come up are with starter packs. A starter pack refers to a unique manufacturing package size for medication regimens with quantities that may increase during the first few days or weeks of use. Examples of starter packs include the following regimens:

• Chantix (Varenicline): The patient should take one 0.5 mg tablet PO for 3 days, then one 0.5 mg tablet PO BID for 4 days. Continued treatment is 1 mg PO BID. The dose is started slowly to reduce adverse effects with varenicline, including strange dreams and trouble sleeping.
• Namenda (Memantine):
  • Week 1 (day 1-7): The patient should take one 5 mg tablet PO daily for 7 days.
  • Week 2 (day 8-14): The patient should take one 10 mg tablet per day for 7 days.
  • Week 3 (day 15-21): The patient should take one 15 mg tablet per day for 7 days.
  • Week 4 (day 22-28): The patient should take one 20 mg tablet per day for 7 days.
  • The maintenance dose is 20 mg per day. Each tablet strength is a different color, and starting with lower doses reduces the risk of side effects such as headache and sleepiness.
• Xarelto (Rivaroxaban): This starter pack is designed for the first 30 day supply. The patient should take 15 mg PO BID for 21 days, then the dose is reduced to 20 mg PO daily. Higher doses are given at the start of treatment when the patient is most vulnerable to a clotting event such as deep vein thrombosis (DVT) or pulmonary embolism (PE).
• Lamictal (Lamotrigine): This medication has not one, but THREE different types of starter kits, each based upon other medications taken by the patient. The starter kits help minimize drug interactions, including life-threatening rashes.
  • Blue starter kit: for patients taking valproate
  • Green starter kit: for patients taking carbamazepine, phenytoin, phenobarbital, or primidone
  • Orange starter kit: for patients NOT TAKING carbamazepine, phenytoin, phenobarbital, primidone, or valproate

Take extra precaution when entering prescriptions for starter kits and ensure that you pick the right packaging and kit choice, and confirm the patient has received counseling from the pharmacist on how to use these kits to prevent errors related to patients who do not take these items as prescribed.

RELATED: 3 Ways Pharmacy Technicians Are Vital for Patient Care

Billing and Other Considerations

A final consideration when entering and filling prescriptions are errors related to the package size itself and how these items are billed to insurance. Stock bottles often come in quantities of 90 or 100, but there are some exceptions. Tizanidine products, for example, often contain 150 tablets per stock bottle (not 100) which can increase the risk of error when pouring an entire bottle into a vial. Other examples include testosterone gel packets supplied in boxes of 30 packets but billed for a quantity of 150 grams, and birth control packets which may have 21, 28, or 91 tablets.

The bottom line is take your time and focus on the details!

Dr. Michelle Lamb

Dr. Michelle Lamb currently works full-time as a Senior Care/Geriatric Pharmacy Consultant based out of Tulsa, OK. She is the Founder of LTC Pharmacist Connection, a forum of over 3500 current and future LTC consultants and dispensing pharmacists. She is also the CEO/Owner of Foxglove Pharmacy Consulting. Dr. Lamb provides inspection services and medication therapy management for nursing homes, assisted living facilities, and group homes in the GREAT state of Oklahoma. This role allows her to promote safe medication use by residents in long-term care settings focusing upon reducing the use of anti-psychotic medications.

Let's face it, folks, no matter how you look at it 2020 has been a tough year. Much about the pandemic is unknown and may remain that way for quite some time, but one certainty is the impact that wearing a mask and social distancing can have upon transmission of COVID-19. What is less clear is the impact masks and physical separation have on effective communication within the pharmacy. Keep reading for some real-world tips to improve these situations.

The pharmacy environment is a bustling and often stressful workplace, and in current times customers may be in an even bigger hurry to grab their medications and hit the road. Despite this, it remains important for the pharmacy technician to communicate with patients and customers in a clear and precise manner even while wearing a mask and social distancing. Being mindful of certain tips and tricks can help reduce communication errors, clarify nonverbal messages, and avoid facial irritation or "maskne" caused by long shifts wearing a mask.

RELATED: Working as a Pharmacy Technician

"Excuse Me, But What Did You Just Say?"

Since masks can muffle sound, and speech becomes quieter with distance, it is tougher than ever for pharmacy technicians to effectively relay prescription or health information to customers. For example, technicians providing price quotes to customers for a medication or co-pay may use the word "fifteen" as in, "Your new prescription has a $15 co-pay." This amount may be misheard as "fifty" instead, which would certainly cause some stress for all involved. One tip when sharing numerical information with a customer is to use multiple ways to state a quantity, such as "That will be fifteen dollars, one-five" or "Your prescription's instructions read forty units of insulin, four-zero." Pharmacy technicians can further improve communication by facing the customer directly, speaking louder and slower, and moving to a quiet counseling area if possible.

The Eyebrows Tell a Story

Masks affect our ability to see each other's facial expressions and can impact our understanding of what we are hearing. On the other hand, thoughtful use of hand gestures and body language can send a strong message of customer service and empathy. For example, pharmacy technicians should aim to relax their shoulders (not always easy), try not to cross their arms in front of their body, and nod to acknowledge listening and understanding of pharmacy customer concerns. In addition, eyebrows tell the story! Raised eyebrows imply happiness, pinched eyebrows can mean sadness, and "V" shaped eyebrows often connote anger or frustration. In addition to careful nonverbal communication, the pharmacy team should consider removing physical barriers that could impede the travel of sound or block customer view, such as over the counter (OTC) item displays or other signage. The Hearing, Speech, and Deaf Center even provides options for making or purchasing clear masks, an excellent option for team members working with deaf or hard of hearing customers who may rely on lip-reading.

2020 and Beyond…What's Next?

Some jobs just aren't meant for working from home, and most pharmacy personnel will not have the option to work in pajamas and forgo makeup or deodorant for a day. If working retail during a pandemic wasn't stressful enough, now pharmacy technicians must also deal with a certain type of acne associated with facial coverings, affectionately known as "maskne." That's right, there's even a nickname for this condition brought to us by 2020. This type of skin outbreak is actually called "acne mechanica," and it is caused by pores that become blocked by sweat, makeup, dirt, or oil. Before the pandemic, this condition was commonly found among athletes who were required to wear sports gear with helmets or straps, or on the armpits of patients using crutches.

These days, the friction of wearing a mask for long periods of time can clog pores, and the mask itself can lead to increased humidity and further exacerbate outbreaks. Strategies to help reduce the risk or severity of acne associated with wearing a mask include washing cloth masks daily and replacing disposable masks often. If an outbreak should occur, it is not uncommon to scrub excessively or too hard, which can actually worsen an outbreak. Instead, it is recommended to wash with a gentle facial cleanser and avoid products that are overly drying. Lotions that contain hyaluronic acid can also help keep skin moist, and products containing ceramides may provide a healthy protective barrier between the mask and the skin.

Don't forget to give your face a rest and remove your mask when it’s safe to do so, such as while driving or at home, unless taking care of a loved one and needing to take precautions. Take care of your face, and yourself! We can do this together.

Dr. Michelle Lamb

Dr. Michelle Lamb currently works full-time as a Senior Care/Geriatric Pharmacy Consultant based out of Tulsa, OK. She is the Founder of LTC Pharmacist Connection, a forum of over 3500 current and future LTC consultants and dispensing pharmacists. She is also the CEO/Owner of Foxglove Pharmacy Consulting. Dr. Lamb provides inspection services and medication therapy management for nursing homes, assisted living facilities, and group homes in the GREAT state of Oklahoma. This role allows her to promote safe medication use by residents in long-term care settings focusing upon reducing the use of anti-psychotic medications.

Without the help of pharmacy technicians, patient care would be compromised and the pharmacy profession would crumble. This may sound like a bold statement, but the vital importance of pharmacy technicians can't be understated. Read on to find out why pharmacy techs are needed more than ever.

1. Pharmacy Techs Save Lives With Their Compounding Expertise

Nowadays, pharmacy technicians are mainly the ones who compound medications for patients, especially IV medications. They have the dexterity and adaptability in this working environment. They are mostly on their feet while they are working in the IV room. Due to the critical nature of the drugs, they must be made in a sterile environment and per protocol for certain drugs.

For example, with the COVID-19 pandemic, technicians prepare a novel COVID-19 medication, named Remdesivir, and it has short stability; hence, they have to communicate with both the nurse and pharmacist before making it. Some technicians work to make specialized hazardous medications, such as chemotherapy agents. These medications can be toxic if accidentally spilled on the preparer or incorrectly made, as it could harm or delay recovery. Many precautions are taken to avoid accidents from occurring in this arena. In addition, these medications tend to be high cost, upwards of thousands of dollars per vial, which require extra attention to avoid waste. Oftentimes, most patients know the nurses that administer the medications or the doctor that they see but may not think about other critical staff members who are behind the scenes. Hence, it is important to know that we have pharmacy technicians to thank and recognize for making it possible to get medications to patients.

2. Pharmacy Techs Prevent Medication Errors by Retrieving Appropriate Medication History

One of the advanced pharmacy tech roles is a medication history pharmacy technician in a hospital setting. When patients arrive at a hospital, most patients are either incoherent or unprepared to provide their full medical and medication history to the healthcare team. In addition, there are circumstances where doctors and nurses don't have time to take a full, complete medication history. This could lead to medication errors, delays in care, or adverse health outcomes from inappropriate treatment due to lack of information.

A medication history pharmacy technician is a dedicated healthcare team member who takes the necessary time to talk with the patient and their family members to retrieve an accurate medication history. Patients may be upset with a pharmacy technician if they have to repeat themselves if they have already talked to a nurse or a doctor. However, for one's safety, it is worth the effort – especially if the technician deems the information to be incomplete. Sometimes, a call to the patient's home pharmacy may be needed to retrieve the information, as the patient may not recall the actual dose or name of the medication, or it may have been entered incorrectly.

By getting the medication history right at admission, it will help with the discharge process of going home as well, where doctors can either safely resume home medications or change them depending on the patient’s therapy. When healthcare records are not shared between the health system institutions, doctor's office, and pharmacy, it is paramount to get a complete medication history to provide effective care. Having a medication history technician in the Emergency Department (ED) is a crucial decision to prevent medication errors and improve patient safety.

3. Pharmacy Techs Ensure Medications Are Available Despite Supply Chain Disruptions

Another advanced pharmacy tech role is the inventory specialist, who manages the purchasing of the medications. Due to natural disasters and other unforeseen circumstances, medication supply may be limited, which impacts patient care and the ways doctors treat patients.

For example, with Hurricane Maria, 80 manufacturing industries were located in Puerto Rico, which disrupted chain supply to hospitals in the US. In 2018, during the flu season, basic IV fluid such as sodium chloride was in short supply. In these situations, the inventory specialists collaborate with pharmacy leadership and the healthcare team to alleviate the stress on patient care. When a commercial product becomes unavailable, it falls back on pharmacy technicians to compound these items in bulk, which creates extra stress as it is an additional workload to their already hectic workflow. The inventory specialist serves as an important gatekeeper for inventory management and acts as a leader in the drug supply chain to ensure patients get their medications when they are needed.

Being a pharmacy technician is a very stimulating and challenging, yet rewarding role. Overall, pharmacy technicians are the lifelines to the industry of the pharmacy, as they help pharmacists to practice at the top of their profession. Without pharmacy technicians, patients would suffer by not having their treatment when they need it. The bottom line is that pharmacy technicians play a vital role in delivering effective care while maintaining patient safety. Let's recognize them each day and not just on #RxTechDay!

Phuoc Anne Nguyen, PharmD, MS, BCPS

Phuoc Anne Nguyen is a passionate pharmacy leader who wants to enhance the pharmacy profession and financial literacy. She has had a wide range of experiences including community independent pharmacy, clinical pharmacy, hospital pharmacy leadership, and academia.

Yes. Pharmacy technicians are trained to prepare, package, mix, and distribute medications, among other duties. Dispensing a drug, according to the North Carolina Public Health department, means to prepare and package a prescribed medication in a container and label the container with information that is required by state or federal law. Dispensing also includes the process of filling or refilling drug containers with prescribed medications for use by patients.

How Pharm Techs Dispense Medications

The process of dispensing medications to a patient is a detailed one that involves checks and double-checks by the pharmacist and the pharmacy technician. The first step is to enter the prescription information into the computer system (tech) including the patient name, prescribing doctor's information, medication, dose, and instructions to the patient as well as the number of medications. Most pharmacy management systems will automatically check the new medication order against any previous orders to identify contraindications or adverse drug-to-drug interactions. This information is then verified by a pharmacist, including the appropriateness of the medication for the patient.

RELATED: Pharmacy Technician vs Pharmacist

The technician or the pharmacy management system creates a label for the order and secures it to the container. The pharmacy technician then fills the container with the prescribed quantity of the medication and the pharmacist verifies the medication in the container. Medication information sheets are also printed for each dispensed medication.

What About Medication Counseling?

When the patient presents to purchase the medication, a pharmacy technician may conduct the sale of the medication, although that is not required in most states. If the medication is new to the patient, or even if it's a refill, the pharmacist will provide counseling to patients regarding the specific medication. Pharmacy technicians are not trained nor certified to provide medication counseling or information that is not pre-printed by the pharmacy management system.

Phuoc Anne Nguyen, PharmD, MS, BCPS

Phuoc Anne Nguyen is a passionate pharmacy leader who wants to enhance the pharmacy profession and financial literacy. She has had a wide range of experiences including community independent pharmacy, clinical pharmacy, hospital pharmacy leadership, and academia.