Good veterinary dispensing practice
Good veterinary dispensing practise
How it works
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Dispensing includes everything between the act of prescribing and a medicine being issued to the owner or administered to the patient. It is important to make sure that the right patient gets the effective form of the right medicine in the correct dosage and quantity, with the right instructions and packaging. If any of these steps fail, serious harm can be caused by medication errors (WHO, 2016; Vet Prescriber, 2017).
This module explores the practical aspects of dispensing medicines for veterinary use. It aims to help you put into place a safe and effective system in which you can dispense medicines safely and efficiently with minimal waste. By doing this module you will:
review the legal classification of medicines, including controlled drugs, and the prescribing cascade
learn what constitutes a well set-up and well-run dispensary, including how to organise medicines appropriately, about the staff and dispensing equipment needed, and safe practices
know how to handle and store medicines correctly
be aware of the general considerations to take into account when dispensing medicines
understand why dispensing errors occur and what to do when they happen.
This section outline the legal classification of veterinary medicines. The legal classification of a veterinary medicine defines who is authorised to prescribe and supply it. You can remind yourself about the four different classes of medicine and the rules on prescription and supply by reading table 1. The easiest and quickest way to find out the legal category of a specific medicine is to run a product search on the Veterinary Medicines Directorate (VMD) product information database.
Table 1 Medicine classification (VMD)
Besides authorised veterinary products, there are additional products that can be used under the ‘prescribing cascade’ provided there is no suitable UK-authorised product to treat a certain species or condition (VMD, 2018b; Veterinary Prescriber, 2018). Only practising vets registered with the Royal College of Veterinary Surgeons (RCVS) may prescribe medicines under the cascade. Look at table 2 to remind yourself of the rules for cascade prescribing.
Table 2 The prescribing cascade (VMD, 2018; Vet Prescriber, 2017; Vet Prescriber, 2018a)
Some veterinary medicines are defined as Controlled Drugs (CDs) under the Misuse of Drugs Regulations. The Regulations regulate the availability of controlled drugs by placing them in one of five Schedules to the Regulations (Misuse of Drugs Regulations 2001). The Schedule primarily dictates the extent to which it is lawful to import, export, produce, supply, administer and possess the drug and also imposes requirements around prescription writing, record keeping, labelling and safe custody. Generally, CDs containing substances under Schedule 2 (and some Schedule 3 CDs) are subject to additional storage, prescribing, disposal and recording requirements. See table 3 for an outline of the CD schedules.
Table 3 Controlled drugs (VMD)
A dispensary must be operated in accordance with the Veterinary Medicines Regulations. (RCVS, 2018) This section discusses the physical dispensary.
The dispensary should be clean, safe and well organised, and should not be accessible to the general public. There must be a schedule for cleaning the physical surroundings, shelves and used surfaces, defrosting fridges and removing waste. All items in the dispensary (that is, packaging materials, medicines and equipment) should be protected from dust, dirt and moisture. The room should be well lit and its temperature must be regulated and checked daily. Most medicines can be stored at room temperature up to 250C. It is important to clean the floor regularly to make sure there are no medicinal products anywhere that a patient could potentially get to them, especially as many veterinary medicines have an inviting smell. (WHO, 2016; NPSA, 2007)
Refrigerated products should be kept between 2OC and 8OC and must never be allowed to freeze. Ideally, a pharmacy fridge should be used, not a domestic one. There should be an accurate monitoring probe in the fridge, and the temperature should be logged. Fridges should also be defrosted regularly. No item should touch any of the walls in the fridge, and medicines should not be stored in the fridge door. A good practical tip is to separate medicines alphabetically in the fridge, but also include a separate shelf for medicines that have been prepared for collection or have been dispensed for an inpatient. (Shilcock, 2008) Pharmaceutical companies usually specify what to do if a medicine that should be stored in a fridge has been left outside. If you are unsure what to do, check the product’s summary of product characteristics (SPC), or contact the company directly. it is important to take care to separate products in the fridge. Limited space in fridges has led to vaccination errors such as cats being protected against distemper and dogs against feline influenza (Stanford 2016).
Most injectable medicines can be stored and used for up to 28 days after the seal has been breached (e.g. maropitant [Cerenia] injection). However, some injections must be discarded immediately after opening (e.g. pimobendan [Vetmedin] injection) and some are stable for longer than 28 days (e.g. desoxycortone pivalate [Zycortal] injection – 120 days). (Noah, 2018)
Although there is no requirement for anyone dispensing veterinary medicines in a veterinary practice to have a specific qualification, staff should be trained in dispensing. The RCVS Practice Standards Scheme* states that at least one team member must have attended an appropriate dispensing course in the last 4 years (RCVS 2018) They must wear a clean uniform and have good personal hygiene. (BSAVA 2018a; WHO, 2016) It is crucial that dispensers should be enabled to solely focus on dispensing medicines, and not be disturbed by other staff members or clients. If they have to stop dispensing and do a different task, they should try to stop between two completed acts of dispensing, and never leave half-dispensed medicines on the counter unattended. Best practice when dispensing is strictly no talking and keeping all disruptions to a minimum.
*Clarification: RCVS Practice Standards Scheme Small Animal Veterinary Hospital Accreditation requires that at least one team member must have attended an appropriate dispensing course in the last 4 years. Additional Awards are available in the Small Animal scheme if a team member has recently attended further training in dispensing and medicines legislation, and if the practice has a designated person responsible for running the dispensary.
Safety of dispensary staff
There should be absolutely no skin contact with dispensed medicines; staff should wear gloves whenever they could come into direct contact with medicines, and a face mask whenever working with powders (BSAVA, 2018a; RCVS, 2018). It is not advisable to use fans to control temperature in the dispensary. If they are used, they should be turned off when powders and uncoated tablets are being dispensed, or when medicines are being compounded or reconstituted. There must be a strict no food or drink policy in the dispensary and for fridges where medicines are stored. There should be Control of Substances Hazardous to Health (COSHH) regulations assessments in place and available to staff members at all times (BSAVA, 2018a). There is more on safe handling of medicines in the related module Handling veterinary medicines and pregnancy. (Vet Prescriber, 2018b)
A counting triangle, capsule counter, measure and scale are basic tools for busy and quieter practices. Separate equipment should be used for systemic and topical preparations. All equipment must be clean, regularly serviced and taken out of use if broken or faulty. Cross-contamination occurs when particles of a medicine are transferred to a different product, which can be dangerous if the contaminating substance is one to which a patient is sensitive (e.g. penicillin). In a veterinary practice, cross-contamination most easily occurs when using the same triangle for counting different (uncoated) tablets and when working with powdered medicines, such as antibiotic powders for reconstitution. Any equipment used for handling different products must be cleaned between use and daily. (WHO, 2016) The British Small Animal Veterinary Association (BSAVA) recommends that medicines are kept and dispensed in the manufacturer’s original packaging (BSAVA, 2018a). Loose tablets or capsules that need to be repackaged from bulk containers should be dispensed in child-resistant, crush-proof and moisture-proof containers. (RCVS, 2018) Preparations for external application should be dispensed in coloured fluted bottles, and oral liquids in plain amber glass bottles, with child-resistant closures.
A well-organised and a clearly-labelled dispensary can save time and costs, and prevent dispensing errors. The BSAVA advises that products should be stored in their original packaging in a logical order (BSAVA, 2018a), but the exact arrangement of medicines depends on individual preference. Some dispensaries organise their medicines alphabetically, by the generic name of the drug, others by brand name. An alternative is to group products with similar actions together (e.g. NSAIDs), and to put drugs with potentially serious side effects together (Stanford, 2016). However, clearly separating dosage forms from each other, for example, tablets and capsules, oral solutions, topical medicines, eye and ear preparations, injectables, supplements, wormers and flea products can help new staff members quickly find their way round. Separating AVM-GSL products from NFA-VPS and POM-V from POM-VPS can also be helpful. All products in the dispensary should face so that the name and strength can be seen clearly.
Narrow therapeutic range drugs
Regardless of how the products in the dispensary are ordered, different strengths of the same medicine should preferably not stand next to each other, especially if they look alike and/or there is a risk of a mix-up. They may be separated by an object or a different product, or a sticker applied to the shelf as a visual alert. This is particularly important for medicines with a narrow therapeutic range (that is, when the difference between therapeutic and toxic dose is relatively small, for example amikacin, digoxin, gentamicin, lithium, phenobarbital, rifampicin and theophylline) because even small changes in dose can cause harm (Blix, 2010). Medicines that have a narrow therapeutic range should also never be split and compounded in-house, but rather reformulated by a compounding laboratory or specials company. For more on compounding and special formulations see the module on Specials.
Special care is needed for organising controlled drugs. If space is limited, staff should work together to ensure the amount of stock ordered is not excessive and be diligent in keeping the controlled drugs’ cupboard tidy and organised. All out-of-date controlled drugs must be clearly labelled and separated to prevent mix-ups with in-date stock. (BSAVA 2018b) Dispensaries must conduct a full audit and reconciliation of all Schedule 2 Controlled Drugs. The RCVS Practice Standards Scheme expects practices to keep running totals and carry out checks against stock at least weekly. (RCVS 2018)
The dispensary should follow either a ‘First in – First out’ or ‘First expired – First out’ protocol, and staff should do regular checks of expiry dates to ensure they are excluded from stock and disposed of promptly.
The batch number of products dispensed for administration to food-producing animals should be recorded on the case file for batch-tracking purposes. For small animals, it is enough to record the date of first usage of each box or bottle. (RCVS, 2018)
The section discusses the physical aspects of medicines and how they might be affected.
Stability of medicines
Most medicines are protected by primary and secondary packaging. Primary packaging is that which is in direct physical contact with the product (e.g. ampoule, blister, tube) whereas the secondary packaging is not (e.g. cardboard box). The main roles of packaging are product containment and protection, to make sure the medicine is safe and stable. Pre-splitting packs of tablets in advance is not advisable because stability can be compromised. Another important role of both packaging types is to provide information; important information should never be obscured.
Humidity and light-sensitive oral preparations
Tablets and capsules should not be taken out of their primary packaging (e.g. blisters) because they may be sensitive to light or humidity. Examples of common moisture-sensitive medicines in veterinary practice are aspirin, piroxicam, ranitidine, selegiline and telmisartan. Soluble and dispersible tablets should be used as soon as taken out of the blister. Examples of light-sensitive oral medicines are erythromycin, ketoprofen, metronidazole and vitamin K1 (phytomenadione). (NOAH 2018; Church, 2006) You can check the humidity and light-sensitivity of a product by looking at the summary of product characteristics (SPC).
Light-sensitive injectable preparations
Light-sensitive injectable solutions must always be stored in their secondary packaging. (University of Illinois, 2014) Examples of light-sensitive injectables that vets use are: buprenorphine, butorphanol, carprofen, delmadinone, diazepam, dopamine, furosemide, ketamine, methadone, metronidazole, morphine, naloxone, neostigmine, ondansetron, procaine benzylpenicillin, ranitidine, robenacoxib, terbutaline and vitamin K1 (phytomenadione). (VMD product database 2018; Church C. et al, 2006) This list is not exhaustive so always refer to a product’s SPC, which will state whether a product needs to be protected from light during storage, and if necessary, during use (that is, when used as described in the SPC). Use of a product outside the terms of the product licence (e.g. dilution, or use over longer periods than recommended) might affect the stability of the product.
Modifying a product (e.g. crushing tablets)
If a product needs to be modified, identify any potential problems with stability, safety, or palatability that a might arise as a result (e.g. because of cytotoxicity, teratogenicity, irritancy or bitterness). If a tablet is sugar- or film- coated, check why, before crushing it. (Royal Pharm Soc, 2011) The Colchester NHS Medicines Information service has published a helpful guide on crushing tablets. Click here to get to it. Proper data on the bioavailability of such manipulated forms is lacking, so patients having reformulated medicines should be carefully monitored. Generally, modified-release tablets should not be crushed or split and modified-release capsules should not be opened. (Royal Pharm Soc, 2011) Be aware that modified-release formulations can have different names, including controlled release (CR), enteric coated (EC/EN), long acting (LA), modified release (MR/Retard), sustained action (SA), sustained release (SR/DUR/Dural), extended release (XL).
Sources of further information
More information about the stability of injectable medicines and mofidied oral medicines may be found in the following sources:
Handbook of Injectable Drugs. 20th edition (2018). American Society of Health-System Pharmacists, Bethesda, Maryland.
Injectable Drugs Guide. Gray A et al, 1st edition (2011). Pharmaceutical Press.
Trissel’s Handbook of Compounded Formulations. 6th edition (2018).
Handbook of Drug Administration via Enteral Feeeding Tubes. White R, Bradnam V. 3rd edition (2015). Pharmaceutical Press.
The section outlines the key principles of dispensing medicines. There are some questions that a dispenser needs to be able to answer during the dispensing process:
Is the dosage in the normal range for this species?
Is the medicine appropriate for use in this species?
If a POM-V, has it been prescribed by a vet?
If under the cascade, is the label appropriate?
Is the dosing regimen owner-friendly?
Is it OK for these tablets be split or crushed?
How long is the shelf life of the product after opening?
Are there any special instructions for the owner?
Steps in dispensing
There is no legal requirement to label authorised veterinary medicines that are dispensed in their original packaging for an authorised use. However, both the VMD and the RCVS consider it good practice for all POM-V medicines to have a dispensing label attached. As soon as the label has been generated, place it on the container in which the medicine is being dispensed. Take care to ensure that labels do not obscure any information (e.g. batch numbers or expiry dates) on the packaging. It is an offence to cover this information. (BSAVA, 2018b; RCVS, 2018) If the medicine is being removed from its original pack, the label should be attached to the new container before medicine selection because medicines should never be transferred to unlabelled containers or syringes.
The label should be checked three times:
1. First check against the product you are selecting from the shelf. Do not base product selection on the location, or colour or shape of the box. Read the name of the active ingredient(s) in the medicine (the generic name(s)) as well as the brand name. Remember, the brain may see what it expects to see, not what is really there. This is also the time to do a quality assessment of the product and ensure it is in date.
2. The second check should be done when dispensing from the selected container. When pouring liquids, they should be held face up so that any spilled medicine does not damage the label.
3. Check the label and what you are holding in your hand when putting the product back on the shelf. (Saskatchewan Veterinary Medical Association, 2015)
Dispensed items should be double-checked by another person whenever possible. When pouring liquids and dispensing tablets into tubs, the original container should stay with the labelled one so that the checker can see what was used. Some dispensaries use baskets to help keep related items together. If the double-checking is done by the person who did the dispensing, there should be a mental break between dispensing and checking. The label should be signed by everyone involved in the process.
When preparing instructions for owners
Avoid using medical abbreviations on the labels.
Use words rather than numbers. For example, ‘every 2-4 hours’ could easily be misread as ‘every 24 hours’; ‘2i.u.’ or ‘2IU’could be misunderstood as 21 units.
Owners might need additional information on appropriate use and storage of a medicine, especially if it is unlicensed. (The module on “What pet owners need to know about medicines” has more on this). For example, suspensions and emulsions must be shaken well before using, so a noticeable ‘SHAKE WELL BEFORE USE’ label on the container is a good reminder to owners each time they pick up the medicine container. Suspensions should never be dispensed in syringes but in tubs with enough room for vigorous shaking.
When dispensing a human medicine, for example, Maxitrol eye ointment, it is advisable to label the primary as well as the secondary packaging. This is to make sure it will not be mixed up if a human in the household is using the same product. If a container is too small for a full label, make sure the warnings that are attached to it include at least ‘For veterinary use only’, ‘Keep out of reach of children’ and, for example, ‘For the eye’ (Saskatchewan Veterinary Medical Association, 2015). When dispensing medicines in a tub, for example, a compounded ointment in a jar, always make sure the label is placed on the jar and not the lid. This way, information about what the jar contains will not be lost if the lid is misplaced.
The final section discusses dispensing errors, what to do about them and how to prevent them. A dispensing error is a discrepancy between the medicine a patient received and what the patient was supposed to receive. A near miss is a dispensing error that was noticed and corrected before the medicine was given to the patient or client. Even though not harmful, a near miss is judged to have the potential to be harmful to the patient.
Why do errors happen?
Dispensing errors can occur when the wrong drug, or dosage or formulation of the drug, is given out. They can happen because the wrong label has been applied, for example giving instructions about a wrong dosage or route of administration or for the wrong drug or patient. Providing a wrong dosing item with the correct medicine is also a dispensing error with potentially serious consequences, for example, supplying the wrong syringes with insulin. Dispensing errors are normally considered ‘action-based errors’ or ‘slips’, and are most likely to occur because of attention slips during routine dispensing or drug administration. No working environment can completely eliminate these slips because our brains often see what they expect to see rather than what really is there. (Aronson, 2009; Hannbeck, 2015)
The shape, size and colour of medicines is an excellent opportunity for drug companies to make their products stand out. They might even regularly change the look of products to make them more appealing. This means that look-alike medicine branding is now widely recognised as a potential risk in medicine dispensing. For example, eight NSAID overdoses in cats, which mainly resulted in death, were due to packaging that was similar for both an NSAID and an antibiotic marketed by the same company; this resulted in the cats being accidentally given an NSAID instead of an antibiotic. These incidents were reported to the VMD and the brand name of the NSAID was subsequently changed (Diesel, 2015)
A major cause of medication errors across all healthcare settings is time pressure, as well as exhaustion because of working overtime, inadequate resources, and distraction and disturbances during the workflow process. In any dispensary, accuracy is more important than speed. (Hannbeck, 2015)
Internal and external reporting
When medication errors happen, they should be acknowledged and resolved immediately, and reported and evaluated retrospectively. An important part of evaluation is seeking to understand why the error happened, and taking steps to prevent such errors recurring in the future. Monitoring and regularly assessing medication errors should be incorporated into the workflow of any veterinary practice. Reporting errors, including near-misses, should be encouraged by creating a blame-free environment. An internal error-reporting system should be readily accessible and followed up with feedback. For example, you could have a ‘Dispensing error and near miss logbook’ in the dispensary, for staff to fill out. Click here to see an example of a near-miss log. Any practice should have an estimate of their dispensing and medication error rate. This is the number of dispensing errors observed divided by the number of opportunities for errors and multiplied by 100. Practice staff should also regularly discuss errors that have happened and possible reasons for them. Reporting any errors and potential adverse reactions resulting from errors to drug companies and the VMD is important. This is because it enables them to monitor potential problems with similarities in products packaging or product names and make changes. (Hannbeck, 2015)
If you prefer, you can listen to the whole audio presentation of this module using the following podcast. Don't forget that you can also download the podcast to your iPod, music player, tablet or smartphone using the Download link on the right of the audio player.
How we produced this module
Our modules start with a detailed outline and electronic literature search. The collaborating author on this module was veterinary pharmacist Spela Oberstar MRPharmS. The draft is circulated unsigned to a wide range of commentators, including practising first-opinion vets, topic specialists, the companies that market any mentioned drugs and other organisations and individuals, as appropriate. They can raise points about the interpretation of evidence, ask questions that are important to clinical practice, and present alternative viewpoints. There is a rigorous editing and checking process and the result is a module that is evidence-based, impartial and relevant to clinical practice. The final module is unsigned because it is the result of collaboration.
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