Part I: Policy and economic issues
Part II: Pharmaceutical management
Selection
Procurement
Distribution
Use
27 Managing for rational medicine use
28 Investigating medicine use
29 Promoting rational prescribing
30 Ensuring good dispensing practices
31 Community-based participation and initiatives
32 Drug seller initiatives
33 Encouraging appropriate medicine use by consumers
34 Medicine and therapeutics information
35 Pharmacovigilance
Part III: Management support systems
chap ter 30
Ensuring good dispensing practices
Summary
30.2
30.1 Introduction
30.2
30.2 Dispensing environment
30.2
30.3 Dispensing person
30.3
30.4 Dispensing process
30.5
Step 1. Receive and validate the prescription “tep 2. Understand and interpret the prescription “tep 3. Prepare and label items for issue tep 4. Make a
final check tep 5. Record action taken tep 6. Issue
medicine to the patient with clear instructions and advice
30.5 Promoting efficient management
in dispensing
30.10
30.6 Packaging and labeling of dispensed
medicines
30.11
Containers for dispensed medicine abeling of
dispensed medicine
illustrations
Figure 30-1 Illustration of a stock container label
30.3
Figure 30-2 The dispensing cycle
30.5
Figure 30-3 Writing medicine labels
30.6
Figure 30-4 Selection from a shelf: read the label every
time
30.6
Figure 30-5 Position label upward when pouring
liquids
30.7
Figure 30-6 Counting methods
30.7
Figure 30-7 Ensuring understanding
30.10
Figure 30-8 Check routines, prevent mistakes
30.10
Figure 30-9 Dispensed medicine label
30.13
Figure 30-10 Pictorial labeling
30.13
Figure 30-11 Tablet counter in use
30.14
Table 30-1 Packaging materials for medicine
dispensing
30.8
30.7 Course-of-therapy prepackaging
of medicines
30.13
b oxes
Box 30-1
Box 30-2
Box 30-3
30.8 Aids in counting tablets and capsules
c ountry studies
CS 30-1
Improving dispensing and counseling practices for
antiretroviral therapy in Kenya
30.4
CS 30-2
The quality of medication counseling in three
pharmaceutical service sectors
30.9
Benefits of course-of-therapy prepackaging mportance
of controls in prepackaging process recautions and
quality checks
30.14
Tablet counter an weighing scales lectronic tablet
counter
30.9 Pharmacy personnel
30.14
Pharmacists harmacy technicians uxiliary or
assistant pharmacy staff ntrained medicine sellers
References and further readings
Assessment guide
30.17
30.16
copyright -anagement sciences for health 2012
Dispensing errors cost lives
30.6
Sample inspection checklist
30.11
Factors that influence dispenser behavior
30.12
30.2
U SE
SUMMARY
Good dispensing practices ensure that an effective form
of the correct medicine is delivered to the right patient,
in the correct dosage and quantity, with clear instructions, and in a package that maintains the potency of
the medicine. Dispensing includes all the activities that
occur between the time the prescription is presented
and the time the medicine or other prescribed items are
issued to the patient.
A safe, clean, and organized working environment
provides a basis for good practice. Dispensing must be
performed accurately and should be done in an orderly
manner, with disciplined use of effective procedures.
Care should be taken to read labels accurately. The
dispenser must count and measure carefully and guard
against contamination of medicines by using clean
equipment and never allowing skin contact with the
medicines.
Staff members who dispense must be trained in the
knowledge, skills, and practices necessary to dispense
the range of medicines prescribed at the facility. Their
performance should be regularly monitored.
Prepackaging medicines can improve efficiency in dispensing. Dispensing can also be improved by routine
procedures for safety checking before issuing medicines
to patients.
Cost factors inevitably lead to the use of packaging that is
less than ideal. The packaging used must be the best compromise between cost and the risk of waste, with regard
to maintaining standards of cleanliness.
Labeling is also affected by cost. Labels should contain
information about the medicine and its correct use. The
style and language of labeling should be appropriate to
the needs of the patient.
Ensuring patients5nderstanding of how to take their
medicines is a primary responsibility of dispensers.
Dispensers should check understanding by asking each
patient to repeat instructions.
Good records, though sometimes neglected, are an
essential part of dispensing; they facilitate good management and monitoring of services provided.
30.1 Introduction
30.2 Dispensing environment
Dispensing refers to the process of preparing and giving
medicine to a named person on the basis of a prescription. It
involves the correct interpretation of the wishes of the prescriber and the accurate preparation and labeling of medicine for use by the patient. This process may take place in a
public or private clinic, health center, hospital, or in a shop
or community pharmacy setting. It is carried out by many
different kinds of people with a variety of training and backgrounds. No matter where dispensing is done or who does
it, any error or failure in the dispensing process can seriously
affect the care of the patient.
Dispensing is one of the vital elements of the rational use
of medicines. Programs to improve rational use have often
been concentrated on ensuring rational prescribing habits,
overlooking dispensing and the patientàuse of medicines.
Dispensing is commonly assumed to be a simple, routine
process that cannot go wrong. Yet all the resources involved
in patient care prior to dispensing may be wasted if dispensing does not result in the named patient receiving an effective form of the correct drug, in appropriate packaging, and
with the correct dose and advice.
This chapter considers the factors that influence the process of dispensing and therefore are important in ensuring
ïrrectly dispensed-edicine.
Dispensing environments must be clean, because most
medicinal products are for internal use, making it important that they be hygienic and uncontaminated. The environment must also be organized so that dispensing can be
performed accurately and efficiently. The dispensing environment includes• Staff
hysical surroundings
helving and storage areas
urfaces used during work
quipment and packaging materials
Staff members involved in dispensing must maintain
good personal hygiene and should wear a uniform or other
clean clothing.
The physical surroundings must be kept as free of dust
and dirt as possible. Although the dispensary must be
accessible to patients, care should be taken to locate it in a
protected place and not beside, or open to, a road or other
area where dust, dirt, and pollution are commonly present.
Ideally, the dispensary should be designed so that access to
the dispensing area itself is restricted to authorized personnel only.
30 / Ensuring good dispensing practices
Figure 30-1
Illustration of a stock container label
Tablets
PARACETAMOL
500 mg
Batch no. 9312101
Date of Manufacture: 12/06
Expiry Date: 11/09
Maintaining a clean environment requires a regular routine of cleaning shelves, daily cleaning of floors and working surfaces, and daily removal of waste (garbage). A regular
schedule should be in place for checking, cleaning, and
defrosting the refrigerator. Spills should be wiped up immediately, especially if the liquid spilled is sticky, sweet, or
attractive to insects and flies. Food and drink must be kept
out of the dispensing area, and the refrigerator used strictly
for medicines. Regular monitoring of the refrigerator temperature should be an established procedure, together with
detailed actions to be taken to promptly repair the refrigerator if temperatures fall outside of acceptable limits (usually
+20C).
Dispensing equipment is used for measuring liquids,
weighing solids, or counting tablets or capsules. Uncoated
tablets normally leave a layer of powder on any surface they
touch, which can easily be transferred to other tablets or
capsules counted on the same surface. This process is called
cross-contamination and can be dangerous if the contaminating substance (for example, aspirin or penicillin) is one
to which a patient is sensitive. Cleaning any equipment used
for handling different products, both between uses and at
the end of the day, is essential.
The dispensing environment must be organized to create
a safe and efficient working area. Space should be sufficient
to allow for movement by staff members during the dispensing process. However, the distance that a dispenser must
cover during the dispensing process should be minimized
to maintain efficiency.
Stock containers and prepacked medicines must be stored
in an organized way on shelves, preferably according to dosage forms (for example, tablets and capsules, syrups and
mixtures) and in alphabetical order. All stock containers in
use must be clearly and accurately labeled to ensure the safe
selection of the correct preparation and to minimize the risk
of error (see Figure 30-1).
In addition, a system of stock rotation should determine
which items are to be used first, on either a first-in/firstout (FIFO) or first-expiry/first-out (FEFO) basis. Regular
checking of expiry dates and removal of expired stock facilitates stock rotation, as does placing stock to be used first
at the front of the shelf. Recommended storage conditions
in terms of temperature, light, and moisture should be followed as closely as possible to maintain product quality.
Stock bottles must be kept closed except when in use.
A limited range of preparations will be used with the
greatest frequency, and these ¡st movers-ay be placed in
the most accessible areas for the convenience of dispensers.
30.3 Dispensing person
A superficial look at dispensing suggests that it is a process of
supplying goods to a patient on the basis of a written order,
and that it can be done successfully by anyone who can read
the prescription, count, and pour. As a result, dispensing is
often delegated to any staff member who has nothing else to
do, who then performs this function without any training or
supervision. This situation is irrational and dangerous.
One major difference between supplying medicines or
medical supplies and supplying other goods is that, with
medicines or medical supplies, the recipient/patient usually does not know the correct use and is unable to judge
the quality of the product he or she receives. Therefore,
responsibility for the correctness and quality of medicines
or products supplied lies entirely with the person dispensing them, and the patient must rely on the dispenseràability. Consequently, in most countries, laws mandate that the
distribution of medicines and important medical supplies to
the general public be carried out by professional pharmacists. In many countries, however, where a shortage of qualified pharmacists or trained dispensers makes it difficult to
achieve this level of service, medicines and related products
are supplied by individuals who have no training in medicines and no knowledge about their safe use.
In addition to reading, writing, counting, and pouring,
the dispenser or dispensing team needs specific additional
knowledge, skills, and attitudes to complete the dispensing
process. These include• Knowledge about the medicines being dispensed
(common use, correct dose, precautions about the
method of use, common side effects, common interactions with other medicines or food, storage needs)
ood calculation and arithmetic skills
kills in assessing the quality of preparations
ttributes of cleanliness, accuracy, and honesty
ttitudes and skills required to communicate effectively with patients
The level of training needed for any particular dispensing
task is determined by the range of medicines dispensed and
the extent to which calculation and preparation are required.
Dispensing personnel must receive an appropriate level
of training, which will enable them to correctly dispense the
30.3
30.4
U SE
range of medicines prescribed in their facilities. This is true
in both the private and the public sectors. At a basic health
facility, where a limited range of medicines is used and the
number of patients is small, dispenser training may be basic,
highly structured, and built on the traineeàprevious health
care training. Dispensing assistants with this level of training may be employed at higher levels (for example, a district
hospital) but should work under the guidance and supervision of trained pharmacy staff, such as a pharmacy technician or technologist. Dispensers in community pharmacy
shops should also be trained in the basics of good dispensing
practices and the handling of medicines. Dispenser training
in medication counseling and adherence is especially important to the success of programs providing antiretroviral therapy for HIV/AIDS patients, which are rapidly increasing in
resource-limited settings (see Country Study 30-1).
In areas where graduate pharmacists are scarce, they
are more effectively employed as trainers and supervisors
rather than as technicians performing the routine tasks of
dispensing.
Country Study 30-1
Improving dispensing and counseling practices for antiretroviral therapy in Kenya
Starting in 2003, the government of Kenya initiated antiretroviral therapy (ART) for HIV/AIDS patients at four
health facilities serving the Coast Province, including the
Port Reitz District Hospital in Mombasa. Management
Sciences for HealthàRational Pharmaceutical Management (RPM) Plus Program performed a facility assessment and identified several factors related to dispensing
that needed to be addressed before the ART program was
initiated• Prescriptions were written on unofficial pieces of
paper, difficult to read, and often incomplete.
ablet counters were available, but staff used their
hands to count.
abeling of medicines was inadequate.
he facility was extremely hot and no fans were
available.
nly one dispensing window was availableccess
to the second window was restricted.
atients crowded at the windows, which was distracting to the dispensing staff and made confidential counseling impossible.
verage length of a medication counseling session
was twenty-two seconds.
o reference books or guidelines of any type were
available.
he dispensary was used to store nonpharmacy
items (for example, staff members had to maneuver
around a wheelbarrow).
Before the ART program began, the newly appointed
head pharmacist attended an RPM Plus Promoting
Rational Drug Use course. Upon returning to the hospital, the pharmacist shared the results of the RPM
Plus assessment with the dispensary staff, and the team
worked to identify the underlying causes of problems
and develop strategies to address each issue. The staff
team• Prepared a code of good dispensing practice and
hung it on the dispensary wall
ollaborated with the medical staff to design an official prescription form that specified patient information
ommitted to using tablet countersõpportive
supervision by the pharmacist in charge encouraged
the behavior change
esigned a preprinted stamp to clearly label medication envelopes
nstalled fans in the pharmacy
mproved dispensing conditions and confidentiality
by arranging for the installation of private counseling booths and freeing access to the second dispensing window
orked to apply their training in good dispensing practice and medication counseling for ART to
improve the quality of dispensing and patient care
for all medicines dispensed

ade use of a set of key resource materials and
national guidelines that were made available to them
leared nonpharmacy items from the dispensary
In a review conducted one year later, staff members commented that reorganizing patient flow was key in facilitating the improvements in dispensing and that one of their
greatest achievements was improving medication counseling for all patients. The new private booths at pharmacy
windows provided a welcoming and secure atmosphere.
The staff members saw the confidential nature of the
booths as a valuable addition: ¥fore when I was dispensing pessaries to a patient there would be four heads listening. n addition, several of the dispensing staff members
reported that they were applying their training on ART
medication counseling to those patients taking medicines
for the treatment of diabetes or hypertension.
Source: Pharmacist, Port Reitz District Hospital, personal
communication.
30 / Ensuring good dispensing practices
Figure 30-2
The dispensing cycle
1. Receive and validate prescription
6. Issue medicine to
patient with clear
instructions and
advice
2. Understand and interpret
prescription
patient ?
medicine ?
dose ?
Dispensing cycle
5. Record
action taken
4. Make a final check
30.4 Dispensing process
The consistent, repeated use of good dispensing procedures
is vital in ensuring that errors are detected and corrected
at all stages of the dispensing process. The term dispensing
process covers all activities involved, from receiving the prescription to issuing the prescribed medicine to the patient.
The development and use of written standard operating
procedures (SOPs) for the dispensing process will improve
consistency and quality of work and can be used for training
and reference. The framework for such SOPs may be based
on the six major areas of activity (see Figure 30-2)±. Receive and validate the prescription
2. Understand and interpret the prescription
3. Prepare and label items for issue
4. Make a final check
5. Record the action taken
6. Issue medicine to the patient with clear instructions
and advice
Step 1. Receive and validate the prescription
Upon receiving a prescription, the staff member responsible should confirm the name of the patient. This action
is particularly important when the clinic is dealing with a
large crowd of people and when there is any risk that staff
3. Prepare and label items for issue
or patients may mix up prescriptions. Cross-checking the
name and identity of the patient must also be done when
issuing the medicines. (The use of matching numbers or
symbolsîe attached to the prescription and one given
to the patientán also contribute to making sure the right
patient gets the right medicines and is especially helpful in
situations where many people share the same surname.)
Step 2. Understand and interpret the prescription
Interpreting a prescription must be done by a staff member
who can• Read the prescription
orrectly interpret any abbreviations used by the
prescriber
onfirm that the doses prescribed are in the normal
range for the patient (noting sex and age)
orrectly perform any calculations of dose and issue
quantity
dentify any common drug-drug interactions
It is assumed that the prescription will be in written form.
Verbal orders for medications should be given only in exceptional and emergency situations. In such cases, the order
should be repeated back to the prescriber to ensure accuracy, and written confirmation should be supplied within
30.5
30.6
U SE
an agreed-upon period. Computerized prescribing and dispensing systems are becoming more widespread, especially
in large hospitals (see Chapter 45). If the person dispensing
the medicine has any doubt about what is required by the
prescriber, he or she must check with the prescriber. Illegible
writing by prescribers has serious implications when many
product names are confusingly similar. Checking a prescription may save a life (see Box 30-1).
All calculations should be double checked by the dispenser or counter-checked by another staff member. An
arithmetical error could be fatal.
Step 3. Prepare and label items for issue
Preparation of items for issue is the central part of the dispensing process, and it must include procedures for selfchecking or counter-checking to ensure accuracy. This part
of the process begins after the prescription is clearly understood and the quantity has been calculated. It is good practice to write the label at this point as a form of self-check (see
Figure 30-3).
Select stock container or prepack. A good dispenser
selects the item by reading the label and cross-matching the
product name and strength against the prescription. The
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 method used.
Most well-trained staff members deliberately read the container label at least twice during the dispensing process (see
Figure 30-4). Selecting according to the color or location of
Figure 30-3
Writing medicine labels
Box 30-1
Dispensing errors cost lives
A patient had been given a prescription for an antacidïmething beginning with and ending in
. he prescription was poorly written, but the dosage of two tablets taken four times a day was clear.
The dispenser at the shop was not sure about the drug
name but knew of a product on the market with a trade
name that began with and ended with ,!nd
so dispensed it. That was how glibenclamide tablets
(brand name Daonil) were dispensed at a level eight
times the recommended daily dose, and the patient
died of hypoglycemia. The prescriber who wrote out
the prescription had the antacid Diovol in mind, but
the handwriting was unclear. Although it is easy to
see how this tragedy occurred, the fact remains that it
should not have happened.
the container, without consciously reading the label, is poor
dispensing practice and may have fatal consequences.
Another dangerous practice that should be discouraged is
having many stock containers open at the same time. In this
situation, product selection is frequently made only according to appearance, which could lead to errors. In addition,
medicines continuously exposed to the air eventually deteriorate in quality. It is important to open and close containers one at a time.
Figure 30-4
every time
Selection from a shelf: Read the label
30 / Ensuring good dispensing practices
Figure 30-5
Position label upward when pouring liquids
RIGHT
Figure 30-6
Counting methods
WRONG
Measure or count quantity from stock containers.
Liquids must be measured in a clean vessel and should be
poured from the stock bottle with the label kept upward.
Using this technique avoids damage to the label from any
spilled or dripping liquid (see Figure 30-5).
Tablets and capsules can be counted with or without
the assistance of a counting device (see Figure 30-6). The
most important rule to follow is that the dispenseràhands
must not be in direct contact with the medicine. Using
the hands is bad practice for both hygienic and product
quality reasons. Counting should be done using one of the
following• Clean piece of paper and clean knife or spatula
lean tablet-counting device
id of the stock container in use
ny other clean, dust-free surface
Immediately after measuring or counting, the stock container lid should be replaced and the stock container label
should be rechecked for drug name and strength.
Pack and label medicine. Tablets or capsules should be
packed into a clean, dry container, such as a bottle, plastic
envelope, cardboard box, or paper envelope. Any of these
containers are satisfactory in a dry climate. During the rainy
season or in a humid climate, however, cardboard or paper
will not protect tablets and capsules from moisture in the
air, which can quickly ruin medicines and make them unfit
for use. Capsules and sugar-coated tablets are the most vulnerable to moisture. Section 30.6 and Table 30-1 cover packing and labeling in more detail.
Step 4. Make a final check
At this point, the dispensed preparation should be checked
against the prescription and against the stock containers
used. Although this step can be done as a self-check, it is
valuable to have the final check done by another staff member. The final check should include reading and interpreting
the prescription before looking at the dispensed medicines; checking the appropriateness of doses prescribed and
checking for drug interactions; checking the identity of
the medicine dispensed; checking the labels; and finally
countersigning the prescription.
Step 5. Record action taken
Records of issues to patients are essential in an efficiently
run dispensary. Such records can be used to verify the stocks
used in dispensing, and they will be required if a need arises
to trace any problems with medicines issued to patients.
Three different methods can be used to keep a record of
medicines dispensed. When the prescription is retained, the
dispenser should initial and annotate the prescription with
strength and quantities dispensed and either file it or enter
the details into a record book as soon as time is available.
When the prescription is returned to the patient, details
of the medicines dispensed must be entered into a record
book before the items are issued to the patient. The date, the
patientàname and age, the medicine name and strength, the
amount issued, and the dispenseràname should be entered
into the register. When dispensers use computers to record
the dispensing details, the computer program should retain
30.7
30.8
U SE
Table 30-1
Packaging materials for medicine dispensing
Category of packaging*
Package characteristics
Examples
Desirable
Clean, dry, plastic or glass container with tightfitting cap or seal
Blister packages, plastic sachets, tightly sealing
plastic or glass containers with screw or snap cap
Acceptable
Clean, dry container that provides protection from
dirt and moisture
Zipper-lock plastic bags, glycine paper, tin with
tight-fitting lid
Undesirable
Unclean absorbent paper, cotton, cardboard
containers with no provision for closure
Unsealed plastic bags, paper bags, newspaper or
other printed paper
Desirable
Clean, dry, light-resistant glass container with tightfitting cap
Amber or opaque bottle with screw cap
Acceptable
Clean, dry plastic or glass container with tight-fitting
cap
Glass or plastic bottle with tight-fitting cap
Undesirable
Unclean paper, cardboard, metal, or plastic (not
formed) container with no provision for closure
Previously used liquid-containing cartons, plasticlined paper bags, plastic bags
Desirable
Clean (preferably sterile), light-resistant glass or
plastic container with a dropper incorporated into a
tight-fitting cap or a top fitted with a dropper with
a protective sleeve
Amber dropper bottle, opaque plastic dropper
bottle
Acceptable
Clean, dry plastic or glass container with tight-fitting
cap and a clean plastic/glass dropper (separate)
Glass or plastic bottle with tight-fitting cap, glass
or plastic dropper with protective container
(cardboard, zipper-lock, plastic, or paper)
Undesirable
Anything other than above
Anything else
Desirable
Clean glass or porcelain wide-mouth jar with tightfitting lid or collapsible plastic or metal tube
Wide-mouth jar with tight-fitting lid, cream or
ointment tube with cap
Acceptable
Clean glass or porcelain jar with lid
Glass or porcelain jar
Undesirable
Anything other than above
Anything else
Tablets/capsules
Liquids (oral and topical)
Liquids (otic and ophthalmic)
Creams/ointments
* Desirable: Packaging should meet listed requirements for a period greater than 30 days.
Acceptable: Packaging should meet listed requirements for up to 30 days.
Undesirable: Packaging provides no protection from dirt, moisture, or other contaminants, thus permitting rapid deterioration or contamination.
the information, which can then be recalled to generate
summary reports.
Step 6. Issue medicine to the patient with clear
instructions and advice
The medicine must be given to the named patient, or the
patientàrepresentative, with clear instructions and any
appropriate advice about the medicine. The appopriate level
of informational detail about possible side effects varies
from patient to patient. Verbal advice is important, because
illiteracy and poor labeling may both be problems. Country
Study 30-2 shows data collected on how well dispensers
instructed patients on medication use in six different countries.
Apart from information on the dose, frequency, length of
treatment, and route of administration, priority should be
given to providing information that will maximize the effect
of the treatment. Advice should therefore concentrate on• When to take the medicine (particularly in relation to
food and other medicines)
ow to take the medicine (chewed, swallowed whole,
taken with plenty of water, etc.)
ow to store the medicine
Warnings about possible side effects should be given cautiously. Common but harmless side effects (nausea, mild
diarrhea, urine changing color) should be mentioned to
prevent a frightened patient from stopping the treatment.
More serious side effects should be mentioned only with the
agreement of the prescriber, who needs to take those risks
into account when prescribing the medicine.
Every effort must be made to confirm that the patient
understands the instructions and advice. This can be difficult to do if someone other than the patient is collecting
items for the patient or for several patients, particularly
when the same medicines are prescribed in different dosages. Whenever possible, the staff member dispensing
30 / Ensuring good dispensing practices
Country Study 30-2
The quality of medication counseling in three pharmaceutical service sectors
As part of an overall assessment of pharmaceutical management in six resource-limited countries, Management
Sciences for HealthàStrategies for Enhancing Access
to Medicines (SEAM) Program used standard indicators to measure the quality of pharmaceutical services,
including dispensing. The data on patients+nowledge
of how to take their medicine came from interviews with
patients exiting public and nongovernmental organization (NGO) facilities and from simulat