Pharmacy Technician Certification: Review & Practice Exam, 3rd Edition

This chapter applies to Section I

of the PTCB exam, Assisting the

Pharmacist in Serving Patients.

Chapter 1

Learning Outcomes

After completing this chapter, the technician should

be able to:

Deﬁ ne the terms

medication order and prescription, and

list the common means by which they are received by the

pharmacy.

Deﬁ ne commonly used pharmacy terms and abbrevia-

tions used in medication orders and prescriptions.

List the required elements on a prescription or

medication order.

Deﬁ ne National Drug Code (NDC) numbers and put

into proper order for transmittal.

Verify correct Drug Enforcement Agency (DEA)

numbers.

Describe the steps required for proper prescription and

medication order processing.

Describe when a patient signature is required at the

point of sale.

Describe how prescriptions are transferred between

pharmacies.

Explain good compounding practices and aseptic

technique.

Give examples of drugs with Risk Evaluation and

Mitigation Strategy (REMS).

List and describe the equipment used in both sterile

and nonsterile compounding.

Describe the process utilized to prepare cytotoxic and

hazardous drugs.

Deﬁ ne laminar airﬂ ow workbenches (LAFW) and

biological safety cabinets (BSC).

Describe the types of questions that may be answered by a

pharmacy technician.

List common references found in many pharmacies and

what information might be found in each.

Medication Orders and

Prescriptions Deﬁ ned

Typically, the term medication order refers to a written

request on a physician’s order form or a transcribed ver-

bal or telephone order in an inpatient setting. This order

becomes part of the patient’s medical record. The term

prescription refers to a medication order on a prescrip-

tion blank to be ﬁ lled in an outpatient or ambulatory

care setting. The two serve essentially the same pur-

pose. They both represent a means of communication

for the prescriber to give instruction to the dispenser of

the medication or to those who will be administering the

medication.

Pharmacy Terms and Abbreviations

Pharmacy personnel use a number of terms in their work.

An understanding of these terms helps a technician to be

efﬁ cient and capable.

Some of these terms deﬁ ne classiﬁ cations of drugs.

For example, technicians must be able to differentiate

between generic and brand name drugs. A generic name

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

legibility is poor. These three abbreviations have been in-

cluded in the chapter because they are still widely used.

Receiving and Processing Medication

Orders in a Hospital

Medication orders come to the hospital pharmacy in vari-

ous ways. They can be delivered to the pharmacy or one

of its satellites in person or via some mechanical method,

such as fax transmission or a pneumatic tube system.

Orders may also be telephoned to the pharmacy by either

the prescriber or an intermediary, such as a nurse. There

are some legal restrictions on who may telephone in an

order or a prescription, and who may receive that infor-

mation in the pharmacy—particularly when controlled

substances are involved.

Ideally, every medication order should contain the

following elements:

Patient name, hospital identiﬁ cation number, and

room/bed location

Generic drug name (using generic drug names is

recommended, and many institutions have policies

to this effect)

Brand drug name (if a speciﬁ c product is required)

Route of administration (with some orders, the site

of administration should also be included)

Dosage form

Dose/strength

Frequency and duration of administration (if

duration is pertinent—may be open-ended)

Rate and time of administration, if applicable

Indication for use of the medication

Other instructions for the person administering the

medication, such as whether it should be given with

food or on an empty stomach

Prescriber’s name/signature and credentials (some

hospitals require a printed name, physician number,

or pager number in addition to the signature to

assist with identiﬁ cation)

Signature and credentials of person writing the

order if other than prescriber

Date and time of the order

When a new order is received, the ﬁ rst step is to ensure

that the order is clear and complete. If information is

missing—for example, the room number for the patient—

the technician may be able to clarify the order without phar-

macist intervention. Some clariﬁ cations, however, should

describes a unique chemical entity and can be applied to

that entity regardless of its manufacturer. A brand name

is trademarked by a manufacturer to identify its particu-

lar “brand” of that chemical entity. For example, Ancef

is a brand name product of the generic entity cefazolin.

Another pair of terms used to categorize drugs is leg-

end and over-the-counter. A legend drug, also called a

prescription drug, is one that may not be dispensed to the

public except on the order of a physician or other licensed

prescriber. The term comes from the federal legend that ap-

pears on the packaging: “Federal law prohibits dispensing

this medication without a prescription.” Over-the-counter

medications may be sold to the public without a prescrip-

tion as long as they are properly labeled for home use.

One last term, formulary, is used in slightly different

ways in institutional and retail settings. A formulary is a

listing of approved drugs available for use. In a hospital,

it refers to the drugs that are stocked by the pharmacy and

approved for use in the facility. In the retail setting, the

term is generally applied to an approved drug list associ-

ated with a particular beneﬁ t plan.

Pharmacy abbreviations are commonly used as a kind

of shorthand in prescriptions and medication orders to con-

vey information about directions for use. The abbreviations

are then “translated” on the prescription label. Appendix A

lists many commonly used pharmacy abbreviations.

The abbreviations for time and frequency of medi-

cation administration come from Latin phrases. Other

commonly used abbreviations include those for routes of

administration and those that designate units of measure.

Lowercase Roman numerals are often used to denote a

quantity, such as a number of tablets (i = one; ii = two).

(See Chapter 14 of Manual for Pharmacy Technicians

for a review of Roman numerals.)

Another subset of abbreviations is called x-substitu-

tions and includes the well-known and widely recognized

Rx symbol, meaning prescription. Other common x-

substitutions are dx for diagnosis and sx for symptoms.

Abbreviations in medical records and in prescrip-

tions are thought to be contributing factors in some medi-

cal errors. One important example is the use of the letter

U to abbreviate units. Because a U might be misread as

a zero if sloppily written—and could therefore result in

a tenfold dosing error—the Institute for Safe Medication

Practices recommends that it never be used as an abbre-

viation in prescriptions or medication orders; the word

units should always be written out in its entirety. Other

abbreviations that some consider unsafe are q., qid, and

qod, which may be indistinguishable from each other if

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Medication history (current and discontinued

medications; medications from a previous

admission in some instances)

Special considerations (eg, foreign language,

disability)

Clinical comments (eg, therapeutic monitoring,

counseling notes)

3. Enter the drug. Selecting the correct drug product

requires a working knowledge of both brand names

and generic names (although most computer systems

can search for either name) and a sensible approach

to interpreting orders when abbreviations are used.

When in doubt about a drug name or an abbrevia-

tion, however, it is always better to clarify the order

with the prescriber or the person who wrote the

order. Patient safety must be protected, and it is

dangerous to make assumptions when interpreting

orders. Most pharmacies take special precautions to

ensure accurate interpretation of prescriptions and

medication orders involving look-alike and sound-

alike drugs. With most pharmacy computer systems,

drug products can be reviewed by scrolling through

an alphabetical listing of the brand or generic names

or by entering a code or mnemonic that is associated

with the product name in the computer. Many com-

puter systems alert the operator if he or she attempts

to enter medications that interact with current orders,

conﬂ ict with the patient’s drug allergies, represent

therapeutic duplications, or are nonformulary drugs.

Many systems also check the dosage range and alert

the pharmacist or technician if he or she enters a

dose that exceeds the recommended dose for that

patient. Although these alert systems help prevent

errors, they are not always signiﬁ cant given the

patient’s unique situation. Therefore, the technician

must consult the pharmacist when the alert is posted.

Besides just choosing the “correct drug,” as has been

outlined in this section, some other related choices

are included in this step. For example, if an intrave-

nous (IV) medication is being entered, it might be

necessary to choose the correct diluent into which

the drug is to be mixed. Another decision involved in

choosing the correct drug is the choice of the pack-

age type and size—bulk or unit dose, 15 gram tube

or 30 gram tube, 100 ml bottle or 150 ml bottle.

4. Verify the dose to ensure that the correct amount

has been entered.

5. Enter the administration schedule. In institutions,

standard medication administration times are

involve the pharmacist. (See the discussion of which ques-

tions can be handled by a technician later in this chapter.)

Once orders are deemed clear and complete, they

must be prioritized so that the most urgent orders are

ﬁ lled ﬁ rst. Prioritizing orders means comparing the ur-

gency of new orders with the urgency of all the orders

requiring attention. This ensures that those orders needed

the most will be processed ﬁ rst. Technicians can priori-

tize orders by evaluating the route, time of administra-

tion, type of drug, intended use of the drug, and patient-

speciﬁ c circumstances.

A number of steps are involved in processing an or-

der in the computer. First, the patient must be positively

identiﬁ ed to avoid dispensing medication for the wrong

patient; many institutions are now using bar code tech-

nology and electronic charting to facilitate accuracy. Sec-

ond, the order is typically compared with the patient’s

existing medication proﬁ le, or a new proﬁ le is created for

the patient. Then, the technician takes a number of order

entry steps to update the patient’s medication proﬁ le.

The following step-by-step process outlines a fairly

typical medication order entry process. Systems vary

somewhat, however, and this is simply an example of

what the process ﬂ ow might look like.

1. Enter the patient’s name or medical record number

and verify them to ensure that the correct patient

record has been chosen.

2. Compare the order with the patient proﬁ le in detail to

look for duplications, other possible problems, or to

create the patient proﬁ le. Check for general appropri-

ateness of the order; it should make sense in regard

to patient proﬁ le information, such as the patient’s

age, allergies, and drugs currently being taken. The

following information is appropriately found in the

hospital pharmacy’s patient proﬁ le, although system

capabilities may limit access to some components:

Patient name and identiﬁ cation number

Date of birth, or age

Sex

Height and weight

Certain lab values, such as creatinine clearance

Admitting and secondary diagnoses (including

pregnancy and lactation status)

Name of parent or guardian, if applicable

Room and bed number

Names of admitting and consulting physicians

Medication allergies; latex allergy; pertinent

food allergies

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

information, such as date of birth, address, or phone

number should be obtained to conﬁ rm the patient’s iden-

tity. If the patient is bringing a prescription to you for the

ﬁ rst time, he or she needs to be registered by obtaining

the following information:

Correct spelling of name

Address and phone number(s)

Insurance information from patient’s insurance card

Date of birth

Any drug allergies

Other prescriptions or over-the-counter (OTC)

medications the patient takes regularly

Signiﬁ cant health conditions

Prescriptions may be received directly from the

patient or from the prescriber by telephone, fax, or

electronic transmission.

Many pharmacies also accept reﬁ ll requests over the

Internet through a pharmacy Web page.

Obtaining payer information is an important step in

receiving a prescription in the outpatient setting. This in-

formation is used for a number of purposes, including

establishing the primary payer for the prescription, the

patient’s portion of the reimbursement (copay), and in

some instances the drug formulary.

Reviewing a prescription for clarity and completeness

is similar in the outpatient and the inpatient setting. The

following prescription elements are typically present:

Patient name

Patient home address

Date the prescription was written

Drug name—either generic or brand

Drug strength and dose to be administered

Directions for use, including route of administra-

tion, frequency, and, as applicable, duration of use

(some durations are open-ended)

Quantity to be dispensed

Number of reﬁ lls to be allowed

Substitution authority or refusal

Signature and credentials of the prescriber, and

DEA number, if required

Reason for use, or indication (not generally required)

In an ambulatory practice, some special clarity and

completeness issues must be considered. Receiving a

prescription includes determining whether the prescrip-

tion will be ﬁ lled with generic or brand-name drugs. In

many states when a prescriber uses “Dispense as Written”

or DAW on a prescription blank, the brand name must be

generally set. These schedules are usually based

on therapeutic issues or nursing efﬁ ciency or are

designed to coordinate services, such as labora-

tory blood draws or therapy schedules. Standard

administration schedules and protocols are usually

agreed upon by pharmacy, nursing, and the hospi-

tal’s medical staff. Many pharmacies have a written

document, such as a policy, that staff can refer to

when the appropriate administration time is unclear.

6. Enter any comments in the clinical comments

ﬁ eld. The prescriber’s directions for proper use

of the medications must be conveyed clearly and

accurately. Additional instructions for the caregiver

are often entered into the pharmacy information

system for presentation on one of the many docu-

ments printed from the proﬁ le (or for the nurses’

use in an electronic system) or simply as additional

information for the pharmacists’ use at a later time.

These special instructions might include storage

information, such as the need to refrigerate, or spe-

cial instructions, such as for chemotherapy drugs.

Another example would be physician-speciﬁ ed

parameters for use, such as, “hold if systolic BP less

than 100 mm Hg,” or “repeat in one hour if ineffec-

tive.” These types of instructions would typically be

displayed on the medication administration record

(MAR) and also on the medication label.

7. Verify the prescriber name.

8. Fill and label the medication. Once the computer

entry has been completed and labeling materials

generated, the medication order must be ﬁ lled with

the correct quantity of the correct drug. During this

step, the technician should carefully review the

label against the order and the product to be used

to make sure the correct product has been chosen.

This is the ﬁ nal opportunity for the pharmacy to

catch an error before dispensing to a patient care

area. The medication order is then ﬁ lled and left

for the pharmacist to check. With few exceptions,

this pharmacist check is legally required before

dispensing any drug to a patient care area.

Receiving and Processing Prescriptions

in an Outpatient Pharmacy

When welcoming a patient to the pharmacy, it is impor-

tant to ﬁ rst identify him or her. If the patient has been

to your pharmacy before, another piece of identifying

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Prioritization of prescription processing in the outpa-

tient pharmacy is generally an issue of customer service

rather than patient care.

Prescription processing includes many of the same

steps as medication order processing in the inpatient

setting:

Identifying the patient: It is important to make sure

that prescriptions are ﬁ lled for and dispensed to the

correct patient. Proper attention needs to be paid to

similar or identical names to make sure the medica-

tion is proﬁ led on the right patient proﬁ le. Another

important concern for the outpatient staff at this

stage is to ensure that there is no forgery and that

the individuals obtaining controlled substances are

lawfully entitled to do so.

Creating, maintaining, and reviewing patient pro-

ﬁ les: A number of pieces of information are typical-

ly collected in the patient proﬁ le—some according

to law (which varies from state to state) and some

for efﬁ ciency and convenience purposes for both the

pharmacy and the patient. These pieces of informa-

tion include the following:

Patient’s name and identiﬁ cation number

Age or date of birth

Home address and telephone number

Allergies

Principle diagnoses of patient

Primary health care providers for patient

Third-party payer(s) and other billing

information

Over-the-counter medications and herbal

supplements used by the patient

Prescription and reﬁ ll history of the patient

Patient preferences (eg, child-resistant

packaging waiver, preference for receiving

prescriptions by mail)

Once the patient’s proﬁ le is located or created and

the existing information is veriﬁ ed, selecting the appro-

priate drug product is the next step in the order entry

process. Most outpatient computer systems, like inpa-

tient systems, allow drug product choice by typing in

a mnemonic or by accessing an alphabetical listing of

some sort. These are the typical prescription processing

steps:

1. Enter the patient’s medical record number or name

and verify them. This safety step ensures that the

drug is dispensed to the correct patient.

dispensed. The technician must know the requirements

of their state.

Pop Quiz!

If a prescription were ordered 1

tab qid, ac and hs, how would

you write the label?

tab

Assessing Order Authenticity

Screening prescriptions for potential forgeries, particularly

those for controlled substances, is part of routine prescrip-

tion processing. The technician should screen prescriptions

for anything that looks unusual, such as a dispense quantity

in excess of normal quantities or an unusual or unrecogniz-

able signature. Any suspicious prescription should be dis-

creetly presented to the pharmacist for further evaluation.

Prescription forgeries often take one of two forms:

(1) erasure or overwriting of the strength or dispensing

quantity of the drug (eg, changing a 3 to an 8), and (2)

theft of preprinted prescription pads that may result in

legitimate-looking prescriptions.

One thing a technician can do to help prevent pre-

scription forgery is determine if a DEA number on a

controlled substance prescription is valid. A valid DEA

number consists of two letters and seven numbers, such

as “BB 1 1 9 7 9 6 7.” If the holder of the DEA number is

a registrant, such as a physician or pharmacy, the ﬁ rst let-

ter is an “A” or “B.” If the holder of the DEA number is a

mid-level practitioner, such as a qualiﬁ ed nurse practitio-

ner, the ﬁ rst letter is an “M.” The second letter is related

to the registrant’s name. In the case of a physician, it is

the ﬁ rst letter of his or her last name.

The seven numbers are also used to determine a

legitimate DEA number. The odd group—the 1st, 3rd,

and 5th numbers in the sequence, and the even group—

the 2nd, 4th, and 6th numbers—are added in the follow-

ing manner so that the sum relates to the 7th number:

BB 1 1 9 7 9 6 7

Odd Group 1 + 9 + 9 = 19

Even Group 1 + 7 + 6 =14

Sum of odd (19) and 2 × even group (14 × 2)

= 19 + 28 = 47

The last digit of this odd/even group sum is the same as

the last digit of the DEA number.

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

a drug–drug or drug–allergy interaction

message should alert the pharmacist to the

problem.

Nonformulary/Not Covered:

Many third-party

payers have formularies (lists of covered drugs).

This message indicates that the drug is not

covered, and payment will not be made for that

drug. A technician who receives this message

should alert the pharmacist.

5. Fill and label the prescription. The following com-

ponents must generally appear on a prescription

label, whether typed or computer-generated (may

vary by state):

Patient’s name

Date the prescription is being ﬁ lled (or reﬁ lled)

Prescriber’s name

Sequential prescription number

Name of the drug (including manufacturer if

ﬁ lled generically)

Quantity to be dispensed

Directions for use

Number of reﬁ lls remaining (or associated reﬁ ll

period)

Labeling includes more than just the actual pre-

scription label. The inpatient section of this chapter

noted that labeling for inpatient use is often abbrevi-

ated or in a form of shorthand. For home use, however,

this practice is not acceptable. Beyond the prescription

label itself, auxiliary information is often included in

the form of special labels afﬁ xed to the container or

drug information leaﬂ ets for patients to read at home.

Instructions for home use must include the following at

a minimum:

Administration directions (eg, “Take,” “Insert,”

“Apply”)

Number of units constituting one dose and the

dosage form (eg, 2 tablets)

Route of administration (eg, “by mouth,”

“vaginally”)

How frequently or at what time (eg, “twice

daily,” “daily at 9 a.m.”)

Length of time to continue, if applicable (eg,

“for 10 days,” “until ﬁ nished”)

Indication of purpose, if applicable (eg, “for

pain,” “for blood pressure”)

At the time of dispensing, the pharmacist or technician

must be sure the patient fully understands how to use the

medication. This is also an appropriate time to consider

2. Enter or verify existing third-party billing informa-

tion to ensure correct billing and copayment.

3. Compare the order with the patient proﬁ le in detail

to identify duplications or other concerns.

4. Enter the prescription. A variety of information

must be entered into the computer at this point, and

systems vary as to the order in which it is entered.

The following are required elements:

Physician’s name

Directions for use, including special comments

Fill quantity

Initials of the pharmacist checking the

prescription

Number of reﬁ lls authorized

At the time of computer processing, an error mes-

sage may interrupt transmission of the prescription to the

third-party payer. The following are some common error

messages and their meanings:

Reﬁ ll Too Soon:

This message deals with reﬁ ll

prescriptions and the elapsed time between

ﬁ lling prescriptions. Typically, third parties

allow patients to receive a 30-day supply of

medications. If the patient attempts to reﬁ ll a

prescription within a signiﬁ cantly shorter period

(eg, 15 days after the last prescription), the

prescription cannot be processed without prior

approval from the third-party payer.

Missing/Invalid Patient ID:

This or a similar

message indicates that the patient who is

entered into the pharmacy computer does not

appear to be enrolled in the insurance program.

On receiving this message, the technician

should examine the patient information entered

for mistakes. Perhaps the name was misspelled,

identiﬁ cation number mistyped, or other

required information left out. Because many in-

surance plans use a Pharmacy Beneﬁ t Manager

(PBM) to manage their pharmacy services, the

prescription may need to be processed under

the name of the PBM instead of the name of the

third-party payer.

Drug–Drug or Drug–Allergy Interaction:

Most pharmacy software will screen the pa-

tient proﬁ le for drug and allergy information.

If interactions are detected, the program will

alert the user. Some software will not only

identify an interaction but also indicate its

potential severity. A technician who receives

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Assisting the Pharmacist

receives a message that the claim has been rejected,

resolving these third party issues becomes a time-

consuming part of the prescription process.

Collecting Payment and Patient

Counseling

Technicians are usually involved in point-of-sale (POS)

transactions, which involve checking out patients and col-

lecting payment when prescription orders are complete.

1. Verify the patient’s name and other identifying

information to ensure the medication is being given

to the correct patient.

2. Legal requirements regarding patient counseling

must be met; offer to have the pharmacist visit with

the patient if they would like counseling.

3. New patients must be given a copy of the phar-

macy’s patient privacy policy in compliance with

Health Insurance Portability and Accountability Act

(HIPAA) regulations.

4. The patients’ signature is required when they receive

the HIPAA information and by some states if they

refuse counseling and by some third party payers

when they take possession of the prescription.

Transferring Prescriptions

The laws regarding the transfer of prescriptions between

pharmacies vary among states and among different class-

es of drugs. However, the pharmacist is always ultimately

responsible for the information transferred. The transfer

of a prescription to another pharmacy is usually initiated

by a phone call from the pharmacy needing a transferred

prescription. A technician may pull the original prescrip-

tion from ﬁ les or pull up the data on the computer, but the

actual transfer of information is usually the responsibility

of the pharmacist.

The same is true for prescriptions being transferred

into the pharmacy. In this case, the process begins when

a patient requests to transfer the prescription from an-

other location. At that point, the technician must obtain

from the patient as much information as possible about

the prescription. At a minimum, the pharmacist needs

the patient’s name and the name of the pharmacy cur-

rently holding the prescription. If a patient brings in an

old container, it may be useful to troubleshoot the label.

For example, if the label indicates that there are no re-

ﬁ lls, the physician will have to be called to authorize the

reﬁ ll.

language barriers, such as illiteracy or a primary language

other than English.

NDC Numbers

NDC numbers are identiﬁ cation numbers used by drug

manufacturers to identify their product. Each number

is speciﬁ c for a speciﬁ c product. NDC numbers are

used for verifying the correct drug has been used to

ﬁ ll the prescription and for remittance to third party

companies.

First group of numbers: represent the manufacturer.

All products made by a speciﬁ c manufacturer will

have the same ﬁ rst number.

Second group of numbers: represent the speciﬁ c

product.

Third group of numbers: represent the package size.

In most cases, NDC numbers must be transmitted to

a third party in a 5-4-2 conﬁ guration, even though the

manufacturers do not always present them to us in that

conﬁ guration. If we do not bill the NDC # correctly, the

third party company’s computer cannot read it correctly,

and this could result in an error in payments, or no pay-

ment at all.

NDC Format Corrected to 5-4-2 Format

0536-3922-01 00536-3922-01

59930-1500-8 59930-1500-08

38245-196-72 38245-0196-72

The NDC format is very speciﬁ c, so placement of the

zeros to create a 5-4-2 format is also very speciﬁ c. The

zero is always placed at the beginning of the incorrect

group of numbers.

Pop Quiz!

What does the ﬁ rst letter of the

DEA number signify?

Communication with Third Party Payers

Most claims for third party payers are handled by phar-

macy beneﬁ ts managers (see Chapter 3 of the Pharmacy

Technician Certiﬁ cation Review) but if the pharmacy

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

in 1997, the Food and Drug Administration Moderniza-

tion Act (FDAMA) was passed. This legislation clearly

deﬁ ned the roles of both compounding pharmacies and

the FDA. In the summer of 2002, however, the legisla-

tion was declared unconstitutional because of advertis-

ing restrictions. Nonetheless, the guidelines of the 1997

FDAMA still offer a structure for compounding pharma-

cists to follow until future legislation addresses the issue.

The United States Pharmacopeia (USP 27) offers

guidelines for compounding. The following chapters of

the USP 27 review speciﬁ c areas of compounding:

Chapter 795 Pharmaceutical Compounding—

Nonsterile Preparations

Chapter 797 Pharmaceutical Compounding—Sterile

Preparations

Chapter 1075 Good Compounding Practices

The following are key areas of compounding:

1. Responsibility of the compounder

2. Compounding environment

3. Stability of compounded preparations

4. Ingredient selection

5. Compounded preparations

6. Compounding processes

7. Compounding records and documents

8. Material Safety Data Sheets (MSDS) ﬁ le

9. Quality control

10. Patient counseling

Pop Quiz!

NDC numbers are always

transmitted in what format?

Responsibility of the Compounder

The compounder is responsible for all aspects of the com-

pounding process, including, but not limited to, appropri-

ately trained personnel and the key areas of Chapter 795

that follow. Special training is required for all personnel

who prepare sterile products.

Compounding Environment

The compounding area should have adequate space for

equipment and support materials. Controlled tempera-

ture and lighting are needed for chemicals and ﬁ nished

Handling Restricted Use Medications

There are certain medications that can only be prescribed

and dispensed in a community or ambulatory care phar-

macy under speciﬁ c conditions due to special precautions

regarding their use. The FDA requires a Risk Evaluation

and Mitigation Strategy (REMS) when it determines

that a strategy is necessary to ensure the beneﬁ ts of using

the drug outweigh the potential risks. Examples of drugs

with REMS include: alosetron (Lotronex©), clozapine

(Clozaril©, Fazaclo©), isotretinoin (Accutane©, Amnest-

eem©, Claravis©, Sotret©), thalidomide (Thalomid©),

and dofetilide (Tikosyn©).

The FDA has designated other drugs that are required

to be dispensed with Medication Guides. A Medication

Guide is patient information approved by the FDA to

help patients avoid serious adverse events, inform them

about known serious side effects, and provide directions

for use to promote adherence to the treatment. These are

available for speciﬁ c drugs or classes of drugs and must

be dispensed with the prescription.

Common examples

dispensed in community and ambulatory care pharmacies

include nonsteroidal anti-inﬂ ammatory drugs (NSAID)

and antidepressants.

Investigational Drugs

Investigational Drug services may be a form of services

seen in a hospital or specialty pharmacy service. Before

a study is approved to be conducted, a study protocol is

developed, reviewed, and approved by the Institutional

Review Board of the facility. In order to carry out a suc-

cessful drug study there are speciﬁ c requirements and

procedures that must be followed. These include:

proper storage

record keeping

inventory control

preparation

dispensing

labeling of all investigational drugs

Good Compounding Practices

Chemicals for compounding are approved by the Food

and Drug Administration (FDA); however, the practice of

compounding is controlled by the individual state boards

of pharmacy. Certain aspects of compounding and the role

of the FDA were not clearly deﬁ ned in federal law until,

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Assisting the Pharmacist

list is a sample of areas to consider in the compounding

process:

Evaluation of the appropriateness of the prescription

Calculations of the amount of ingredients

Identiﬁ cation of equipment needed to properly com-

pound the prescription

Proper hand cleaning and gowning

Evaluation of the ﬁ nal medication for weight varia-

tion, proper mixing, and consistency

Proper notations in the compounding log

Appropriate labeling of the ﬁ nal medication

Properly clean and store all equipment

Compounding Records and Documents

USP Chapter 795 requires pharmacies to maintain a for-

mulation record (also known as the master formula)

and a compounding record for each compounded prep-

aration. The goal of record-keeping is to allow another

compounder to reproduce the same formulation at a later

date. Two parts of the records and documentation are

the formula, or formulation record, and the batch log, or

compounding record.

The formulation record is a ﬁ le of compounded prep-

arations, much like a recipe. It would include chemicals

in the formula, equipment needed to prepare the formula,

and mixing instructions for preparing the formula.

The compounding record is the log (or record) of

an actual batch being prepared. It would include manu-

facturers and lot numbers of chemicals used, the date of

preparation, an internal identiﬁ cation number (common-

ly called lot number), a beyond-use date, and any other

pertinent information regarding the preparation.

Quality Control

Quality control is a ﬁ nal check on the preparation to en-

sure safety and quality of the preparation. The compounder

should evaluate the ﬁ nished preparation both physically and

by reviewing the compounding procedure to be certain the

preparation is accurate. Discrepancies should be noted and

evaluated to determine if the preparation is acceptable.

Patient Counseling

With any prescription, the patient should be counseled on

the correct use of the medication. Compounded medica-

tions are often different in method of use or the type of

dispensing container used, so special care should be tak-

en to be certain the patient understands the proper use of

the medication.

medications. The area must be kept clean for sanitary

reasons and to prevent cross contamination. A sink with

hot and cold running water is essential for handwashing

and cleaning of equipment.

Stability of Compounded Preparations

Stability is deﬁ ned in USP-NF as “the extent to which

a preparation retains, within speciﬁ ed limits, and

throughout its period of storage and use, the same prop-

erties and characteristics that are possessed at the time of

compounding.”

Primary packaging of the ﬁ nished medication is of

utmost importance. The choice of container is guided by

the physical and chemical characteristics of the ﬁ nished

medication. Considerations such as light sensitivity and

the medication binding to the container are examples of

concern in maximizing stability.

Beyond-use labeling should be included on all medi-

cations (expiration dates apply to manufactured products).

Examples of considerations for determining beyond-use

dates include whether the medication is aqueous or non-

aqueous, expiration date of the ingredients used, storage

temperature, references documenting the stability of the

ﬁ nished medication, and the USP.

Ingredient Selection

Sources of ingredients vary widely. USP or National

Formulary (NF) chemicals are the preferred source of

chemicals for compounding. Other sources may be used,

but the compounder has a responsibility to be certain the

chemical meets purity and safety standards. Manufac-

tured medications are another acceptable source of in-

gredients. It would be inappropriate to use any chemical

withdrawn from use by the FDA.

Compounded Preparations

Preparations should contain at least 90%, but not more

than 110%, of the labeled active ingredient, unless more

restrictive laws apply. Compounding guidelines in USP-

NF speciﬁ cally address the following drug forms:

Capsules, powders, lozenges, and tablets

Emulsions, solutions, and suspensions

Suppositories

Creams, topical gels, ointments, and pastes

Compounding Processes

The goal of the compounding process is to “minimize

error and maximize the prescriber’s intent.” The following

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

Equipment Used in Nonsterile

Compounding

Compounding requires specialized equipment to obtain

the best quality medications. An electronic balance is

commonly used for speed and accuracy of measurement

(see Figure 1-1). Graduates (ie, glass or plastic cylinders

and conicals) are used to measure the volume of liquid

ingredients (Figure 1-2). It is recommended to use the

smallest graduate that will hold the volume to be mea-

sured. In addition, it is important to measure the volume

of liquid accurately by placing the graduate on a stable

surface (ie, counter top of work area) and read the mea-

surement at the bottom of the meniscus.

An ointment slab (also called a “pill tile”) is a square

glass tile that is used for preparing and mixing creams

and ointments. Similarly, many facilities use ointment

paper (eg, pads of 12” × 12” disposable parchment pa-

per) instead of an ointment slab because of convenience

in reducing clean-up time (Figure 1-3).

Mortars and pestles are used to crush, grind, and blend

various ingredients. The mortar is a deep bowl, and the

pestle is a club-shaped tool that when stamped or pound-

ed vertically into the well of the mortar causes the con-

tents of the mortar to become pulverized (see Figure1-4).

Mixing is usually achieved by moving the pestle in a

circular motion in the mortar. Mortars are available in a

variety of materials and sizes. Glass, porcelain, ceramic,

and Wedgwood™ are commonly used. Wedgwood™ of-

fers a rough surface to allow grinding and reduction of

particle size but is very difﬁ cult to clean and thus prevent

cross contamination of preparations. Glass and porcelain

offer smooth, easily cleaned surfaces.

Ointment mills are commonly found in compound-

ing pharmacies. Most have three rollers with small,

adjustable spaces between the rollers (see Figure 1-5).

When preparations pass through the rollers, particle size

is reduced.

Parenteral Drug Administration

Medications can be administered to patients in numer-

ous ways. Medications not given to patients by mouth

(enterally) are referred to as parenterally administered.

Parenteral administrations can include intravenous (IV),

intramuscular (IM), and subcutaneous (SQ), or below the

skin. IV solutions are commonly administered to patients

as a means of replacing body ﬂ uids and as a vehicle for

Figure 1–1. Electronic balance.

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Assisting the Pharmacist

take medications orally. Direct administration of IV med-

ications into the blood also provides a predictable rate of

administration. Certainly, IV medications have disadvan-

tages, such as the risk of infection, the pain of the injec-

tion, and the immediate effect of the administration in the

introducing drugs into the body. Medications are not ben-

eﬁ cial to the patient until they reach the blood and are

distributed to the body. IV medications are introduced

directly into the blood and therefore have the most rapid

onset of action. IV medications, therefore, have many

beneﬁ ts over oral medications, which have to be absorbed

from the gastrointestinal tract, or IM medications, which

have to be absorbed through the muscle mass. IV medi-

cations can be given to patients who are unconscious, un-

cooperative, nauseated, vomiting, or otherwise unable to

Figure 1–2. Graduated conicals and cylinders.

Figure 1–4. Mortar and pestle.

Figure 1–3. Ointment slab.

Figure 1–5. Ointment mill.

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

around the catheter site. If the patient has a condi-

tion that results in prolonged bleeding time, extra

care and caution should be used, especially when

removing the catheter.

Allergic reaction

—When a patient has an allergic

reaction to a substance given parenterally, the reac-

tion is usually more severe than if the same sub-

stance were given by another route (eg, by mouth,

topically, or rectally). One reason for this is that

substances given parenterally cannot be retrieved

like substances given by other routes. For example,

substances administered topically can easily be

washed off, those given orally can be retrieved by

inducing vomiting or by pumping the stomach, and

those given rectally can be ﬂ ushed out using an en-

ema. When a drug that has caused allergic reactions

in a large number of patients is given intravenously,

the patient should be monitored closely. If the likeli-

hood of an allergic reaction is especially high, a test

dose (a small amount of the drug) may be given to

see how the patient reacts.

Incompatibilities

—Some drugs are incompatible

with other drugs, containers, or solutions. If an

incompatibility exists, the drug may precipitate, be

inactivated, or adhere to the container. These unde-

sirable outcomes may be difﬁ cult to detect with the

naked eye. A visual inspection of the ﬁ nal product

should always be performed to observe any cloudi-

ness, coring, or signs of irregularity. Solutions with

known or detectable incompatibilities should not be

administered to patients.

Extravasation

—Extravasation occurs when the IV

catheter punctures and exits the vein under the skin,

causing drugs to infuse or inﬁ ltrate into the tissue.

Extravasation may happen when the catheter is

being inserted or after it is in place if the extrem-

ity with the IV catheter is moved or ﬂ exed too

much. Using a stiff-arm board to prevent excessive

movement near the catheter site may help maintain

regular ﬂ ow and prevent extravasation and inﬁ ltra-

tion. Extravasation and inﬁ ltration can be painful

and usually requires that the IV be restarted. Some

drugs, such as certain chemotherapy agents, may

cause severe tissue damage if they inﬁ ltrate the tis-

sue. While there are medications to alleviate some

of the effects of extravasation and hot and cold

compresses to arrest progression, in some cases

this tissue damage can be so severe that it requires

surgery or even loss of the limb.

event of an error. Some medications are not suitable for

IV administration because of their stability or absorptive

properties.

Special training is required for personnel who pre-

pare and administer sterile IV solutions. The process

of preparing IV products using preset steps to ensure

a sterile ﬁ nal product is known as aseptic technique.

Basic aseptic technique should be used when handling

parenteral dosage forms, as well as irrigations and oph-

thalmics (see Chapter 12 of the Manual for Pharmacy

Technicians, Medication Dosage Forms and Routes of

Administration).

Risks of IV Therapy

IV therapy offers a rapid, direct means of administering

many life-saving drugs and ﬂ uids. A high percentage of

IV therapy is administered without any problems, but

there are some risks:

Infection

—Infections can result if a product con-

taminated with bacteria is infused into a patient.

Because the IV bypasses the body’s normal barrier

system, bacteria reach the bloodstream directly.

Bacteria can be introduced into products during

preparation, administration, production, and through

improper storage. The rate of infection or sepsis due

to contaminated infusions has steadily decreased

since health care practitioners and product manufac-

turers have implemented training and quality assur-

ance programs. Despite these efforts, human touch

contamination continues to be the most common

source of IV-related contamination.

Air embolus

—The incidence of an air embolus is

low because many solutions are administered using

infusion pumps equipped with an alarm, called an

air-in-line alarm, that sounds when air is in the

IV line. Solutions infused by gravity do not need

alarms because the infusion automatically stops

when there is no more ﬂ uid for gravity to push

through the IV line. Even when a bag runs dry, large

amounts of air are not infused. In adults, 150 or

200 ml of air given quickly through an IV can result

in harm. Infants and pediatric patients are adversely

affected by a much lower amount of air. Filters are

available on some IV sets, and they also stop air

bubbles and add another measure of safety.

Bleeding

—IV therapy may cause bleeding. When

the IV catheter is removed, bleeding may occur

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Assisting the Pharmacist

Development and maintenance of a sterile com-

pounding area complete with sterilized equipment

and supplies

Development and maintenance of the skills needed

to properly use an LAFW

Aseptic Technique

Aseptic technique is a means of manipulating sterile

products without contaminating them. Proper use of an

LAFW and strict aseptic technique are the most important

factors in preventing the contamination of sterile prod-

ucts. Thorough training in the proper use of the LAFW

and strict aseptic technique, followed by the development

of conscientious work habits, is of utmost importance to

any sterile products program.

Sterile Compounding Area,

the Clean Room

Sterile parenteral solutions must be free of living micro-

organisms and relatively free of particles and pyrogens.

Room air typically contains thousands of suspended

particles per cubic foot, most of which are too small to

be seen with the naked eye. These suspended particles

include contaminants such as dust, pollen, smoke, and

bacteria. Reducing the number of particles in the air im-

proves the environment in which sterile products are pre-

pared and can be done by following several practices.

A sterile compounding area’s counters, work surfac-

es, and ﬂ oors should be cleaned daily while walls, ceil-

ings, and storage shelving should be cleaned monthly

at a minimum. Segregated compounding areas must be

separate from normal pharmacy operations, nonessen-

tial equipment, and other materials that produce parti-

cles. For example, the introduction of cardboard into the

clean environment should be avoided. Trafﬁ c ﬂ ow into

a clean area should be minimized. Floors should be dis-

infected periodically, and trash should be removed fre-

quently. Trashcans should be taken outside the IV room

before pulling the trash from the container. This will

minimize the creation of particulate matter and the risk

of spills in the clean room. More sophisticated aspects of

clean room design include special ﬁ ltration or treatment

systems for incoming air, ultraviolet irradiation, air-lock

entry portals, sticky mats to remove particulates from

shoes, and positive room air pressure to reduce con-

taminant entry from adjacent rooms or hallways. Clean

rooms are often adjoined by a room, called an anteroom,

that is used for nonaseptic activities related to the clean

Particulate matter

—Particulate matter refers to

unwanted particles present in parenteral products.

Some examples of particulate matter are micro-

scopic glass fragments, hair, lint or cotton ﬁ bers,

cardboard fragments, undissolved drug particles,

and fragments of rubber stoppers, known as cores.

Particulate matter that is injected into the blood-

stream can cause adverse effects. Improvements in

the manufacturing processes have greatly reduced

the presence of particulates in commercially avail-

able products. Care must be taken in the pharmacy

so that particulate matter is not introduced into

products. All products should be visually inspected

for particulate matter before dispensing. Some

institutions may use inline ﬁ lters to help minimize

the amount of particulate that reaches the patient.

Pyrogens

—Pyrogens, the by-products or remnants

of bacteria, can cause reactions (eg, fever and chills)

if injected in large enough amounts. Because a py-

rogen can be present even after a solution has been

sterilized, great care must be taken to ensure that

these substances are not present.

Phlebitis

—Phlebitis, or irritation of the vein, may

be caused by the IV catheter, the drug being ad-

ministered (because of its chemical properties or

its concentration), the location of the IV site, a fast

rate of administration, or the presence of particulate

matter. The patient usually feels pain or discomfort,

often severe, along the path of the vein. Red streak-

ing may also occur. If phlebitis is caused by a par-

ticular drug, further diluting the drug, then giving it

more slowly, or giving it via an IV catheter placed

in a vein with a higher, faster-moving volume of

blood may be helpful.

Aseptic Preparation of

Parenteral Products

As the use of parenteral therapy continues to expand, the

need for well-controlled admixture preparation has also

grown. Recognizing this need, many pharmacy depart-

ments have devoted increased resources to programs that

ensure the aseptic preparation of sterile products. The fol-

lowing are the main elements on which these programs

focus:

Development and maintenance of good aseptic tech-

nique in the personnel who prepare and administer

sterile products

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

preﬁ lter, which is similar to a furnace ﬁ lter, removes only

gross contaminants and should be cleaned or replaced

regularly. The preﬁ ltered air is then pressurized to en-

sure that a consistent distribution of airﬂ ow is presented

to the ﬁ nal ﬁ ltering apparatus. The ﬁ nal ﬁ lter constitutes

the entire back portion of the hood’s work area. This

high efﬁ ciency particulate air, or HEPA, ﬁ lter removes

99.97% of particles that are 0.3 micron or larger, thereby

eliminating airborne microorganisms, which are usually

0.5 microns or larger.

Vertical LAFW

Laminar ﬂ ow workbenches with a vertical ﬂ ow of ﬁ ltered

air are also available. In vertical LAFW, HEPA-ﬁ ltered

air emerges from the top and passes downward through

the work area (see Figure 1-6). Because exposure to some

antineoplastic (anticancer) drugs may be harmful, these

drugs are usually prepared in vertical LAFW to minimize

the risk of exposure to airborne drug particulates. The

types of vertical laminar airﬂ ow hoods (LAH) used for

the preparation of antineoplastics contain airﬂ ow within

the hood and are referred to as biological safety cabinets

(BSC).

The critical principle of using LAFW is that noth-

ing must interrupt the ﬂ ow of air between the HEPA ﬁ l-

ter and the sterile object. The space between the HEPA

ﬁ lter and the sterile object is known as the critical area.

The introduction of a foreign object between a sterile

object and the HEPA ﬁ lter increases wind turbulence

in the critical area and the possibility that contaminants

from the foreign object may be carried onto the ster-

ile work surface and thereby contaminate an injection

port, needle, or syringe. To maintain sterility, nothing

should pass behind a sterile object in a horizontal LAH

or above a sterile object in a vertical LAFW.

Materials placed within the LAFW disturb the pat-

terned ﬂ ow of air blowing from the HEPA ﬁ lter. The zone

of turbulence created behind an object could potentially

extend outside the hood, pulling or allowing contaminat-

ed room air into the aseptic working area. When laminar

airﬂ ow is moving on all sides of an object, the zone of

turbulence extends approximately three times the diame-

ter of that object. When laminar airﬂ ow is not accessible

to an object on all sides (for example, when placed ad-

jacent to a vertical wall), the zone of turbulence may ex-

tend six times the diameter of the object. Working with

objects at least 6 inches from the sides and front edge of

the hood, without blocking air vents is therefore advis-

able to maintain unobstructed airﬂ ow between the HEPA

room operation, such as order processing, gowning, and

stock storage.

Sterile products should be prepared in Class 100 en-

vironments, which means environments containing no

more than 100 particles per cubic foot that are 0.5 micron

or larger in size. LAFWs are frequently used to achieve a

Class 100 environment.

Laminar Airﬂ ow Workbenches

The underlying principle of laminar airﬂ ow workbenches

(LAFW) is that twice-ﬁ ltered laminar layers of aseptic air

continuously sweep the work area inside the hood to prevent

the entry of contaminated room air. There are two common

types of LAFW: horizontal ﬂ ow and vertical ﬂ ow.

Horizontal LAFW

LAFW that sweep ﬁ ltered air from the back of the hood

to the front are called horizontal LAFW (see Figure1-6).

Horizontal ﬂ ow workbenches use an electrical blower

to draw contaminated room air through a preﬁ lter. The

Figure 1–6. Horizontal and vertical laminar airﬂ ow

workbench with the basic components labeled.

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Assisting the Pharmacist

Jewelry should not be worn on the hands or wrists

when working in the LAFW because it may intro-

duce bacteria or particles into the clean work area.

Actions such as talking and coughing should be

directed away from the LAFW working area, and

unnecessary motion within the hood should be

avoided to minimize the turbulence of airﬂ ow.

Smoking, eating, and drinking are prohibited in the

aseptic environment.

All aseptic manipulations should be performed at

least 6 inches within the hood to prevent poten-

tial contamination caused by the closeness of the

worker’s body and backwash contamination result-

ing from turbulent air patterns developing where

LAFW air meets room air.

LAFWs should be tested by qualiﬁ ed personnel

every 6 months, whenever the hood is moved, or if

ﬁ lter damage is suspected. Speciﬁ c tests are used to

certify airﬂ ow velocity and HEPA ﬁ lter integrity.

Although the LAFW provides an aseptic environ-

ment, safe for the manipulation of sterile products, strict

aseptic technique must be used in conjunction with prop-

er hood operation. The use of the LAFW alone, without

the observance of aseptic technique, cannot ensure prod-

uct sterility.

Personal Attire

The ﬁ rst component of good aseptic technique is proper

personal attire. Compounding personnel should remove

personal outer garments, all cosmetics, and all hand,

wrist, and other visible jewelry or piercings before en-

tering the ante room or segregated compounding area.

Clean room attire should include dedicated shoes or

shoe covers, head and facial hair covers, and face masks/

eye shields applied in this order to help reduce particu-

late or bacterial contamination. After hand washing as

described below, clean garments, which are relatively

particulate free, should be worn when preparing sterile

products. Clean room attire will depend on institutional

policies and often are related to the type of product be-

ing prepared. Many facilities provide clean scrub suits or

gowns for this purpose. Scrub suits should not be worn

home to ensure that no contaminants are transported

home and that the process of cleaning the clothing does

not introduce lint onto the low-lint clothing. In addition,

suits should be covered up when leaving the pharmacy

to minimize the contamination from areas such as the

cafeteria.

ﬁ lter and sterile objects. The hands should be positioned

so that airﬂ ow in the critical area between the HEPA ﬁ lter

and sterile objects is not blocked.

The following are general principles for operating

LAFWs properly:

An LAFW should be positioned away from excess

trafﬁ c, doors, air vents, or anything that could pro-

duce air currents capable of introducing contami-

nants into the hood.

If an LAFW is turned off, nonﬁ ltered, nonsterile air

will occupy the LAFW work area. Therefore, when

it is turned back on, it should be allowed to run for

15 to 30 minutes before it is used (manufacturer rec-

ommendations should be consulted for each hood).

This time allows the LAFW to blow the nonsterile

air out of the LAFW work area. Then the LAFW

can be cleaned for use.

Before using the LAFW, all its interior working

surfaces should be cleaned with 70% isopropyl

alcohol or another appropriate disinfecting agent

and a clean, lint-free cloth. Cleaning should be

performed from the HEPA ﬁ lter in a side-to-side

motion beginning in the rear of the hood and mov-

ing toward the front (in a horizontal LAFW) so

contaminants are moved out of the hood. The hood

should be cleaned often throughout the compound-

ing period and when the work surface becomes

dirty. Some materials are not soluble in alcohol

and may initially require the use of water to be

removed. After the water is applied, the surface

should be cleaned with alcohol. Plexiglas sides,

found on some types of LAFWs, should be cleaned

with warm, soapy water rather than alcohol. Spray

bottles of alcohol should not be used in the LAFW,

and because they do not allow for the physical

action of cleaning the hood, they can damage the

HEPA ﬁ lter, and they do not ensure that alcohol

is applied to all areas of the surface to be cleaned.

Alcohol should be allowed to dry to increase its ef-

fectiveness as a disinfectant.

Nothing should be permitted to come in contact

with the HEPA ﬁ lter. This includes cleaning solu-

tion, aspirate from syringes, or glass from ampules.

Ampules should not be opened directly toward the

ﬁ lter.

Only objects essential to product preparation should

be placed in the LAFW. Paper, pens, labels, or trays

should not be placed in the hood.

01_PharmTechExam_C01_p01–28.indd 15

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

Pop Quiz!

Work inside an LAFW must be

done at least how many inches

from the sides?

Handwashing

Touching sterile products while compounding is the most

common source of contamination of pharmacy-prepared

sterile products. Because the ﬁ ngers harbor countless

bacterial contaminants, proper hand washing is extreme-

ly important. Every entry into a sterile product should

include scrubbing your hands, nails, wrists, and forearms

to elbows thoroughly for at least 30 seconds with a brush,

warm water, and appropriate bactericidal soap before per-

forming aseptic manipulations. Dry hands completely,

using either lint-free disposable towels or an electronic

hand dryer.

Gloving

After appropriate hand washing is complete and attire is

put on, antiseptic hand cleansing should be performed

using a waterless, alcohol-based surgical hand scrub just

prior to the last item worn before compounding begins,

sterile gloves. Sterile gloves are only sterile until they

touch something unsterile or until they are torn and al-

low bacteria from the hands to enter the work area. For

example, if it becomes necessary to scratch or touch the

face while wearing gloves, they will need to be changed.

For these reasons, always wash your bare hands thor-

oughly as noted above, before unwrapping and putting

on the gloves. Occasionally, workers develop allergies

to latex as a result of repeated use of latex gloves. As a

result, many institutions have now turned to using only

non-latex gloves.

Equipment and Supplies

Another important factor in aseptic preparation of sterile

products is the correct use of appropriate sterile equip-

ment and supplies, including syringes and needles.

Syringes

Syringes are made of either glass or plastic. Most drugs

are more stable in glass, so glass syringes are most often

used when medication is to be stored in the syringe for an

extended period. Some medications may react with the

plastics in the syringe, which would alter the potency or

stability of the ﬁ nal product. Disposable plastic syringes

are most frequently used in preparing sterile products be-

cause they are cheaper, durable, and are in contact with

substances only for a short time. This minimizes the po-

tential for incompatibility with the plastic itself.

Syringes are composed of a barrel and plunger (see

Figure 1-7). The plunger, which ﬁ ts inside the barrel, has a

ﬂ at disk or lip at one end and a rubber piston at the other.

The top collar of the barrel prevents the syringe from slip-

ping during manipulation; the tip is where the needle at-

taches. To maintain sterility of the product, the syringe tip

or the plunger should not be touched. Many syringes have a

locking mechanism at the tip, such as the Luer-lock, which

secures the needle within a threaded ring. Some syringes,

such as slip-tip syringes, do not have a locking mechanism.

In this case, friction holds the needle on the syringe.

Syringes are available in numerous sizes, ranging from

0.5 to 60 milliliters (ml). Calibration marks on syringes

represent different increments of capacity, depending on

the size of the syringe. Usually, the larger the syringe ca-

pacity, the larger the interval between calibration lines. For

example, each line on a 10 ml syringes represents 0.2 ml,

but on a 30 ml syringe, each line represents 1 ml.

To maximize accuracy, the smallest syringe that

can hold a desired amount of solution should be used.

Syringes are accurate to one-half of the smallest incre-

ment marking on the barrel. For example, a 10 ml syringe

with 0.2 ml markings is accurate to 0.1 ml and can be

used to measure 3.1 ml accurately. A 30 ml syringe with

1 ml markings, however, is only accurate to 0.5 ml and

should not be used to measure a volume of 3.1 ml. Ide-

ally, the volume of solution should only take up one-half

to two-thirds of the syringe capacity. This avoids inad-

vertent touch contamination when the syringe plunger is

pulled all the way back.

Figure 1–7. A syringe with the basic components

labeled.

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Assisting the Pharmacist

the syringe and is often color-coded to correspond to a

speciﬁ c gauge. The tip of the needle shaft is slanted to

form a point. The slant is called the bevel, and the point is

called the bevel tip. The opposite end of the slant is called

the bevel heel.

Needles are sent from the manufacturer individually

packaged in paper or plastic overwraps with a protective

cover over the needle shaft. This guarantees the sterility

as long as the package remains intact. Damaged pack-

ages should be discarded.

No part of the needle itself should be touched.

Needles should be manipulated by their overwrap and

protective covers only. The protective cover should be

left in place until the needle or syringe is ready to be

used. A needle shaft is usually metal and is lubricated

with a sterile silicone coating so latex vial tops can be

penetrated smoothly and easily. For this reason, needles

should never be swabbed with alcohol.

Some needles are designed for special purposes and

therefore have unique characteristics. For example, nee-

dles designed for batch ﬁ lling have built-in vents (vent-

ed needles) to avoid the need to release pressure that

might form in the vial. Another example is needles with

built-in ﬁ lters, meant to be used with products requiring

ﬁ ltering, such as drugs removed from a glass ampule.

Drug Additive Containers

Injectable medication additives may be supplied in an

ampule, vial, or preﬁ lled syringe. Each requires a differ-

ent technique to withdraw medication and place it in the

ﬁ nal dosage form.

When measuring with a syringe, the ﬁ nal edge (clos-

est to the tip of the syringe) of the plunger piston, which

comes in contact with the syringe barrel, should be lined

up with the calibration mark on the barrel that corre-

sponds to the volume desired (see Figure 1-8).

Syringes are sent from the manufacturer assembled

and individually packaged in paper overwraps or plastic

covers. The sterility of the contents is guaranteed as long

as the outer package remains intact. Therefore, packages

should be inspected, and any that are damaged should be

discarded. The syringe package should be opened within

the LAH to maintain sterility. The wrapper should be

peeled apart, not ripped or torn. To minimize particulate

contamination, discarded packaging or unopened syring-

es should not be placed on the LAFW work surface.

Syringes may come from the manufacturer with a

needle attached or with a protective cover over the sy-

ringe tip. The syringe tip protector should be left in place

until it is time to attach the needle. For attaching nee-

dles to Luer-lock-type syringes, a quarter turn is usually

sufﬁ cient to secure the needle to the syringe.

Needles

Like syringes, needles are commercially available in

many sizes. Sizes are described by two numbers: gauge

and length. The gauge of the needle corresponds to the

diameter of its bore, which is the diameter of the inside

of the shaft. The larger the gauge, the smaller the needle

bore. For example, the smallest needles have a gauge of

27, whereas the largest needles have a gauge of 13. The

length of a needle shaft is measured in inches and usually

ranges from 3/8 to 3 1/2 inches.

The components of a simple needle are the shaft and

the hub (see Figure 1-9). The hub attaches the needle to

Figure 1–8. A close-up of a syringe showing how to

measure 1.5 ml. Note that the ﬁ nal edge of the plunger

piston is used to make the measurement.

Figure 1–9. A needle with the basic components

labeled.

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

To open an ampule, the head must be broken from

the body of the ampule. To make the break properly, the

ampule neck is cleansed with an alcohol swab and the

swab should be left in place. This swab can prevent ac-

cidental cuts to the ﬁ ngers as well as shattering of glass

particles and aerosolized drug.

Automated Compounding Sterile Product

Filling Equipment

Although hospitals and regulatory agencies have strict

guidelines that must be followed, including rigorous

training and competencies, the technical complexity of

sterile product preparation lends itself to inconsistency

among employees. Additionally, compounded sterile

products create potentially challenging situations for

pharmacists to verify product preparation accuracy. Au-

tomation can eliminate sources of preparation errors in-

herent to human factors; this technology ensures proper

handling, and accurate and sterile preparation of the IV

product.

Pop Quiz!

What kind of needle is used to

withdraw liquid from an ampule?

Labeling

Once an IV admixture or other sterile product is com-

pounded, it should be properly labeled with the following

information:

1. Patient name, identiﬁ cation number, and room

number (if applicable)

2. Bottle or bag sequence number, when appropriate

3. Name and amount of drug(s) added

4. Name and volume of admixture solution

5. Approximate ﬁ nal total volume of the admixture,

when applicable

6. Prescribed ﬂ ow rate (in milliliters per hour)

7. Date and time of scheduled administration

8. Date and time of preparation

9. Expiration date

10. Initials of person who prepared and person who

checked the IV admixture

11. Auxiliary labeling—supplemental instructions and

precautions

Vials

Medication vials are glass or plastic containers with a rub-

ber stopper secured to the top, usually by an aluminum

cover. Vials differ from ampules in that they are used to

hold both powders and liquids. The rubber stopper is usu-

ally protected by a ﬂ ip-top plastic cap or aluminum cover.

Protective covers do not guarantee sterility of the rub-

ber stopper. Therefore, before the stopper is penetrated,

it must be swabbed with 70% isopropyl alcohol and al-

lowed to dry. The correct swabbing technique is to make

several ﬁ rm strokes in the same direction over the rubber

closure, always using a clean swab.

Vials are closed-system containers, because air or

ﬂ uid cannot pass freely in or out of them. In most cases,

air pressure inside the vial is similar to that of room air.

In order to prevent the formation of a vacuum inside the

vial (less pressure inside the vial than room air), the pres-

sure should be normalized by ﬁ rst injecting a volume of

air equal to the volume of ﬂ uid that is going to be with-

drawn, into the vial. This step should not be done with

drugs that produce gas when they are reconstituted, such

as ceftazidime, or with cytotoxic medications.

Ampules

Ampules are composed entirely of glass and, once bro-

ken (ie, opened), become open-system containers (Figure

1-10). Because air or ﬂ uid may now pass freely in and out

of the container (no vacuum effect), it is not necessary to

replace the volume of ﬂ uid to be withdrawn with air.

Figure 1–10. An ampule with the basic components.

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Assisting the Pharmacist

or heavily contaminated. If only one pair is worn, tuck

the glove under or over the gown cuff so that the skin is

not exposed.

Biological Safety Cabinets

One of the most important pieces of equipment for han-

dling hazardous drugs safely is the Biological Safety

Cabinet (BSC). A BSC is a type of vertical LAFW that

is designed to protect workers from exposure as well as to

help maintain product sterility during preparation. BSCs

must meet standards set by the National Sanitation Foun-

dation (NSF Standard 49). Do not use horizontal LAFWs

to prepare hazardous drugs. BSCs must be operated con-

tinuously, 24 hours per day, and they should be inspected

and certiﬁ ed by qualiﬁ ed personnel every 6 months.

Preparing Hazardous Drugs

Before technicians handle a cytotoxic or other hazardous

drug, they must demonstrate proper manipulative tech-

nique and use of protective equipment and materials.

Drug Information

Pharmacy technicians are challenged with drug informa-

tion questions frequently throughout the workday and are

called upon to become knowledgeable about the handling,

availability, and uses of medications. A basic knowledge

of the resources available will make the technician more

resourceful and better able to assist the pharmacist with

certain drug information requests. Pharmacy reference

books and electronic media (including the Internet) that

are available in all practice settings often hold answers

to typical day-to-day practice-related questions. Before

responding to a drug information question, technicians

must clearly differentiate questions that fall within their

scope of practice from those that must be answered only

by a pharmacist.

Technicians should identify themselves as pharmacy

technicians so the person asking the question will know the

type of information that may appropriately be conveyed.

If there is any doubt about the nature of the question, the

technician should defer the question to the pharmacist. It

is important for the technician to learn who the person ini-

tiating the request is and to obtain the necessary contact

information (phone, fax, pager, etc.) in case the person

needs to be called back. The search for and response to

drug information requests will be different depending on

who is requesting the information. Knowing information

Many labels also now contain a bar code that con-

tains information regarding the medication, the patient,

and the anticipated administration. These are generated

by the pharmacy computer to reduce the frequency of

medication administration errors. Each product should

also include an expiration date, beyond which it should

not be used.

Preparation and Handling of

Cytotoxic and Hazardous Drugs

Some medications can be hazardous to those who touch or

inhale them. Because hazardous drugs initially involved

drugs used to treat cancer, the terms antineoplastic and

chemotherapeutic were used to describe them.

Preparation of these agents requires special proce-

dures for labeling, storage, and transport. Use of protec-

tive clothing, BSCs, and special handling of spills and

waste are also important. Special techniques related to

the actual administration of these products to patients

are not covered here. Additional information is available

from ASHP in the form of a Technical Assistance Bulletin

on Handling of Cytotoxic and Hazardous Drugs.

Protective Apparel

There is no substitute for good technique, but protective

apparel is another fundamental element in protecting per-

sonnel who handle or prepare hazardous drugs.

Most procedures require the use of disposable cover-

alls or a solid front gown. These garments should be made

of low-permeability, lint-free fabric. They must have long

sleeves and tight-ﬁ tting elastic or knit cuffs. They should

not be worn outside the work area and should be changed

immediately if contaminated. Shoe and hair covers may

also be required, depending on the institution’s policies.

Wearing gloves is essential when working with haz-

ardous drugs. Wash hands thoroughly before putting on

the gloves and after removing them. Use good quality,

disposable, powder-free latex gloves, such as surgical

latex. These gloves are preferred because of their ﬁ t,

elasticity, and tactile sensation. If only powdered gloves

are available, wash powder off before beginning to work.

Non-latex gloves are also available for those with an al-

lergy to latex. If two pairs are needed, tuck one pair under

the cuffs of the gown and place the second pair over the

cuff. If an outer glove becomes contaminated, change it

immediately. Change both the inner and the outer gloves

immediately if the outer glove becomes torn, punctured,

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

result in miscommunication and delivery of inaccurate in-

formation. Both scenarios could be potentially harmful to

the patient. Examples of questions that require a pharma-

cist’s interpretation and that should not be answered by a

technician are provided in Table 1-2.

Conducting the Search: Choosing the

Right References

The key to answering questions quickly and accurately is

knowing where the necessary information is likely to be

found. The ﬁ rst step is to consult tertiary references, then

secondary references, and ﬁ nally primary references.

Tertiary references are general references that present

documented information in a condensed and compact for-

mat. They include textbooks; compendia (eg, American

Hospital Formulary Service, Drug Information (AHFS

DI), Drug Facts and Comparisons); computerized sys-

tems such as Micromedex

Clinical Information System;

review articles; and much of the information found on

the Internet. Tertiary references are easy to use, conve-

nient, readily accessible, concise, and compact. Disad-

vantages of tertiary references are that information may

not be timely, the information could contain errors, and

tertiary references may not offer enough information on

a speciﬁ c topic because of space restrictions.

about the requestor, their training, and their knowledge of

the subject will have an impact on what the ﬁ nal response

will be and how it will be given. Obtaining background

information will help to determine what the needs of the

requestor are and will make the search for information

more efﬁ cient. Background information is especially im-

portant to determine if the question pertains to a speciﬁ c

patient or if it is a question that requires interpretation,

and therefore the expertise of a pharmacist. The urgency

of the request and the extent of the information needed

should also be determined so an appropriate amount of

time is allotted to answer the request. Classifying the type

of request helps to narrow the search and makes the search

process more efﬁ cient. Table 1-1 lists common types of

questions that technicians may get, with examples of

each. Technicians should not interpret a patient-speciﬁ c

question or provide information that may require profes-

sional judgment. A simply stated question can actually be

a complex patient-speciﬁ c situation. The pharmacist has

to ﬁ nd out more about the patient’s speciﬁ c problems and

apply clinical judgment to answer the question appropri-

ately. Many times, the person requesting the information

may indirectly be asking for a pharmacist’s point of view

or interpretation of a situation, and may thus require an in-

depth analysis and recommendation from the pharmacist.

Attempting to interpret or answer such a question could

Table 1–1. Classiﬁ cations of Drug Information Questions

Question Classiﬁ cation Examples

General Drug Information What is the brand name of warfarin?

Do Naprosyn and Aleve contain the same active ingredient?

Who manufactures Enbrel?

Is Prilosec available as a generic? Is it a prescription or over-the-counter (OTC) product?

Availability and Cost What dosage forms of Imitrex are available in your pharmacy?

Is Zoloft available as a liquid? If so, what size and concentration is available?

What are the prices of Adalat CC and Procardia XL?

How long is the shortage of albumin expected to last?

Storage and Stability Should Lovenox be stored in the refrigerator?

How long is a ﬂ u shot stable after it is drawn up in a syringe?

Calculations How many milliliters are in an ounce?

Preparation How should ampicillin be reconstituted?

Pharmacy Law In what controlled substance schedule is zolpidem (Ambien)?

Can Tiazac be substituted for Cardizem CD (is it AB rated)?

How many times can a prescription be transferred from one store to another?

Miscellaneous Where can I ﬁ nd the phone number for Sanoﬁ Aventis?

When will the patent for Lipitor expire?

Where can I get more Lovenox teaching kits?

Where can I ﬁ nd the Vaccine Information Sheet for the inﬂ uenza vaccine?

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Assisting the Pharmacist

should consult as many resources as possible and com-

pare information among resources.

Common References

Technicians should familiarize themselves with the refer-

ences in their practice settings to determine which sourc-

es best ﬁ t their needs. Using a systematic approach when

faced with a drug information question will aid in un-

derstanding the nature of the request, obtaining pertinent

background information, and answering the question.

Numerous resources are available to assist with answer-

ing drug information requests. Becoming familiar with

common resources will make the search process more

efﬁ cient. It is critical for pharmacy technicians to be able

to differentiate between basic drug information questions

that they can answer and questions that require clinical

Secondary references include indexing systems such

as Medline that provide a list of journal articles on the

topic that is being researched. Secondary systems are

used when new or very up-to-date information is re-

quired or when no information can be found in tertiary

references.

Primary references are original research articles pub-

lished in scientiﬁ c journals, such as the American Jour-

nal of Health-System Pharmacy (AJHP) or the Journal of

the American Pharmacists Association (JAPhA).

Other resources include pharmaceutical manufactur-

ers and specialized drug and poison information centers.

If the information cannot be found in a tertiary ref-

erence, then the technician should consult a pharmacist,

who may advise an alternative search strategy or consult

a secondary reference. If time permits, the technician

Table 1–2. Drug Information Questions Appropriate for Pharmacists

Question

Classiﬁ cation Examples Rationale

Identiﬁ cation and

Availability

What is paracetamol and what is its U.S.

equivalent?

Although it is appropriate for a technician to obtain technical

information about availability (eg, anticipated length/reasons

for a shortage), questions that require clinical knowledge,

such as therapeutic alternatives, must be answered by a

pharmacist

Allergies Which narcotic is safe to use in a patient

with a codeine allergy?

For allergy questions, the pharmacist must obtain more patient-

speciﬁ c information, such as a description of the allergy and the

condition being treated. Clinical judgment is required.

Dosing and

Administration

What is the usual dose of propranolol?

How long should ciproﬂ oxacin be given for

a urinary tract infection?

What is the best way to give gentamicin IV?

Answers to dosing and administration questions depend on

many factors, especially the indication for use and patient-

speciﬁ c information (eg, age, weight, and kidney and liver

function).

Compatibility Is Primaxin compatible with dopamine? More information is needed (eg, doses, concentrations, ﬂ uids,

and type of IV lines), and a pharmacist must interpret informa-

tion found in a reference and apply it to the situation.

Drug Interactions Is it OK to take aspirin with warfarin? Drug interaction questions are complex and require patient-

speciﬁ c information and interpretation by a pharmacist in

order to apply the signiﬁ cance of a potential interaction to a

speciﬁ c patient.

Side Effects What are the side effects of Lexapro?

Can Celebrex cause renal failure?

Package inserts and textbooks provide lists of side effects that

are often difﬁ cult to interpret and convey. Also, a pharmacist

must interpret whether the request is being made because an

adverse event is suspected with one or more medications.

Pregnancy and

Lactation

Is albuterol safe to use in pregnancy?

Can I get a ﬂ u shot if I am breastfeeding?

Pregnancy and lactation questions are complicated because

more information is needed about the patient, the stage of

pregnancy, and/or age of the infant. A pharmacist must inter-

pret the ﬁ ndings and apply them to the speciﬁ c situation.

Therapeutic Use Has clonidine been used to treat opiate

withdrawal?

The use of drugs for non-FDA approved uses often requires

evaluation and interpretation of the literature and clinical

judgment.

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

volume (Approved Drug Products and Legal Require-

ments) provides information on laws affecting pharmacy

practice.

The Physicians’ Desk Reference (PDR, published by

Thomson Medical Economics) contains manufacturers’

package inserts. A package insert is a manufacturer’s

product information sheet that provides general drug

information, such as how the drug works, indications,

adverse effects, drug interactions, dosage forms, stabil-

ity, and dosing information. The PDR is not comprehen-

sive and contains information only on select brand name

drugs. The information is written by the manufacturer

and approved by the FDA. It contains only information

about FDA-approved uses of the drug and does not pro-

vide information comparing that drug with similar medi-

cations. Therefore, using the PDR to compare products is

not as straightforward as using other reference books.

judgment, and therefore should be answered by a phar-

macist. The references described in the next few sections

are summarized in Table 1-3 with examples of the types

of information one might ﬁ nd in each.

General Drug Information

Drug Facts and Comparisons (a part of Wolters Kluwers

Health) is easy to use and available in regularly updated

print and electronic versions. It is a comprehensive gen-

eral drug information reference that provides complete

drug monographs. It is organized by therapeutic class

(eg, antihistamines, topicals) and includes tables that al-

low quick comparisons of drugs within the same class.

United States Pharmacopeia Drug Information (US-

PDI, published by Thomson) is a three-volume set that

provides medication information for health care profes-

sionals (Volume I) and patients (Volume II). The third

Table 1–3. Common Drug Information Requests and Reference Sources

Type of Information Needed References Likely to Have the Information

Product Availability

dosage form product strength brand and generic name

manufacturer indication

Facts & Comparisons Drug Information Handbook Internet PDR

Micromedex Clinical Pharmacology RedBook (not indication)

USPDI Pharmaceutical Manufacturer

Product Identiﬁ cation

dosage form product strength brand and generic name

manufacturer colored photographs of tablets/capsules

Facts & Comparisons PDR Clinical Pharmacology USPDI Micromedex

Drug Uses

FDA-approved indications other uses of the agent

AHFS Clinical Pharmacology Facts & Comparisons Drug Information

Handbook PDR (FDA-approved indications only) Micromedex USPDI

Drug Monographs

general drug information pharmacology indications and

uses drug interactions admixture information doses adverse

effects drug interactions

AHFS Clinical Pharmacology Facts & Comparisons Drug Information

Handbook Micromedex PDR USPDI

Injectable Drug Compatibility/Stability Information

drug diluent and solution compatibilities drug compatibility

conditions for handling and storing products (ie, glass vs.

plastic container, protection from light, ﬁ lters, refrigeration,

expiration, etc.)

AHFS King’s Guide Trissel’s Handbook on Injectable Drugs Package

inserts PDR Micromedex

Preparation AHFS King’s Guide Trissel’s Handbook on Injectable Drugs

Micromedex Package inserts PDR

Calculations Drug Information Handbook Micromedex

Hazardous Chemicals and Drugs

speciﬁ es hazards of the chemicals or drugs used at the

worksite guidelines for their safe use recommendations to

treat or clean up an exposure

Material Safety Data Sheets Micromedex

Pharmacy Law

Generic substitution (bioequivalence) Federal regulations

regarding handling and dispensing

USPDI Volume III Orange Book

Patient Information Clinical Pharmacology Facts & Comparisons Internet Lexi-Comp

MedlinePlus Micromedex Patient package inserts, Medication

Guides USPDI Volume I

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Assisting the Pharmacist

drug information, poison information, foreign drug infor-

mation, tablet and capsule identiﬁ cation, disease and trau-

ma information, herbal information, stability information,

compatibility information, pregnancy information, patient

information, and more.

Specialty References

Availability/Cost

Red Book (published by Medical Economics) contains

up-to-date product information and prices for prescription

drugs, over-the-counter products, and medical supplies. It

contains NDC numbers for all products, available pack-

aging, and therapeutic equivalence ratings (according to

the FDA’s Orange Book). It has a comprehensive listing

of manufacturers, wholesalers, and third-party admin-

istrator directories. There are sections with other useful

practical information, such as lists of sugar-, lactose-,

galactose-, and alcohol-free products; sulﬁ te-containing

products; medications that should not be crushed; and

color photographs of many prescription and over-the-

counter products.

Compatibility and Stability

Trissel’s Handbook on Injectable Drugs (published

by American Society of Health-System Pharmacists,

ASHP) is a textbook often used in hospital and home

health care pharmacies. It focuses solely on injectable

medications. Information includes data on the solubility,

compatibility, and stability of many different medica-

tions. Speciﬁ cally, this handbook is useful to determine

when two medications may be safely mixed together in

an IV bag, a syringe, or at a Y-site on an administration

set. This reference also addresses special handling re-

quirements of certain agents (glass vs. plastic contain-

ers, light restrictions, ﬁ lters, refrigeration requirements,

expiration, etc.).

King Guide to Parenteral Admixtures (published

by King Guide Publications, Inc.) is another reference

that is useful for compatibility and stability of injectable

medications.

Extended Stability of Parenteral Drugs

Extended Stability of Parenteral Drugs (published by

American Society of Health-System Pharmacists, ASHP)

contains stability data of injectable drugs that extends be-

yond 24 hours. The reference is intended for use by alter-

nate site infusion practices, such as home infusion.

American Hospital Formulary Service Drug Infor-

mation (AHFS DI, published by the American Society of

Health-System Pharmacists, ASHP) is a detailed, com-

prehensive, general drug information reference. This

textbook provides complete drug monographs that are or-

ganized by therapeutic class (eg, anti-infectives, cardio-

vascular). It provides detailed information about the use

of a drug, its side effects, dosing considerations, and so

on, and its coverage is not limited to FDA-approved uses

of medications. It is especially useful for preparation and

administration instructions for injectable products.

Lexi-Comp’s Drug Information Handbook and Drug

Information Handbook for the Allied Health Profession-

al (published by Lexi-Comp) are handbooks containing

general drug information monographs. They are widely

used because they are quick, convenient, and easy to use.

The Drug Information Handbook is alphabetically orga-

nized in dictionary format according to generic name.

The Drug Information Handbook for the Allied Health

Professional is not as comprehensive as the Drug Infor-

mation Handbook, but it may be appealing to technicians

because it allows quick access to basic data on the most

frequently used medications. Both publications contain

extensive appendixes with helpful charts, abbreviations,

measurements, and conversions.

Mosby’s Drug Consult (published by Elsevier

Science) is a comprehensive general drug information

reference. It provides complete drug monographs that

are organized alphabetically by generic drug names. This

textbook is more comprehensive than the PDR. A key

feature is its indexing system, which allows identiﬁ ca-

tion of all drugs within a therapeutic class, schedules of

controlled substances, pregnancy categories, and so on.

American Drug Index (published by Facts and

Comparisons) is an alphabetical listing of drugs with

brief information on each agent, including drug name

(generic, brand, chemical name), manufacturer, dosage

form, strength and packaging information, and gen-

eral uses (eg, general anesthetic, narcotic, antitussive).

It also contains pharmaceutical manufacturers’ phone

numbers and addresses, weight and measuring conver-

sions, and a list of drugs that should not be crushed.

Its extensive cross-indexing is useful to quickly identify

a brand or generic product or determine product avail-

ability information.

Micromedex

Healthcare Series is a comprehen-

sive reference system that is accessed electronically via

CD-ROM, Internet, or personal digital assistant (PDA).

Depending on the subscription, it contains comprehensive

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

Miscellaneous References

Material Safety Data Sheets (MSDS) are information

sheets provided by manufacturers for chemicals or drugs

that may be hazardous in the workplace. The primary

purpose of the MSDS is to provide information about the

speciﬁ c hazards of the chemicals or drugs (ie, to describe

acute and chronic health effects), guidelines for their safe

use, and recommendations to treat an exposure or clean

up a spill.

Drug Information and Poison

Control Centers

Formal Drug Information Centers are another source of

drug information. The centers throughout the country

vary in the types of services they provide, but most cen-

ters provide drug information for health-care profession-

als, assist with formulary management, and train phar-

macy students, residents, and pharmacists. Some centers

provide drug information for consumers as well.

The Internet

The technician must take care to ensure that the infor-

mation is current and up-to-date, and that it is accurate

and from a reputable source. Generally, Web sites that are

sponsored by the government, pharmacy and medical or-

ganizations, and medical centers are the most reputable.

Table 1-4 lists useful Web sites for drug information and

a brief description of what each site contains.

Pop Quiz!

Give an example of a

comprehensive tertiary reference.

Compounding

USP Pharmacist’s Pharmacopeia (published by U.S.

Pharmacopeia) is a reference that includes the ofﬁ cial

standards and procedures to ensure the strength, quality

and purity of sterile and non-sterile compounded prepara-

tions. The individual drug monographs contain informa-

tion on compounding, packaging, labeling, and storage

of pharmaceuticals. The reference also includes informa-

tion on veterinary compounding and food ingredients,

colorings, preservatives, and ﬂ avorings. It is a useful re-

source for pharmacy compounding because it provides

information on legal requirements and laws that apply to

compounding practices, as well as articles on the basics

of compounding.

Trissel’s Stability of Compounded Formulations

(published by the American Pharmacists Association,

APhA) summarizes formulation and stability studies that

are published for compounded formulations. Its drug

monographs provide guidance for preparing the products

as well as expiration dating, proper storage, and repack-

aging.

Herbal Medications and Dietary

Supplements

Natural Medicines Comprehensive Database (published

by Therapeutic Research Faculty) is a commonly used

reference for natural medicines, including herbals and di-

etary supplements. Individual monographs list the name

of the product, its common and scientiﬁ c names, uses,

safety, effectiveness, dosage and interactions with drugs,

foods, labs, or diseases/conditions. It is available in both

print and electronic forms.

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Assisting the Pharmacist

Table 1–4. Useful Web Sites for Obtaining Drug Information

Web site Address Description

Food and Drug

Administration

www.fda.gov Home page for the FDA; contains numerous

useful links for both consumers and health-care

professionals.

FDA Center for Drug Evaluation and

Research (CDER)

www.fda.gov/cder Contains links for consumers and health-care

professionals regarding drug information, such

as new drug approvals, drug shortages, safety

information, and generic drug bioequivalence

(Orange Book).

Drugs@FDA www.accessdata.fda.gov/scripts/

cder/drugsatfda/index.cfm

Contains information about FDA-approved

drugs. Users can ﬁ nd package labeling informa-

tion, generic drug products for brand name

products, patient information (including

Medication Guides), and review the approval

history of drugs.

Centers for Disease Control and

Prevention (CDC)

www.cdc.gov Home page for the CDC; contains information

about diseases, health topics, vaccines, traveler’s

health, bioterrorism, etc.

CDC Vaccine Information Statements www.cdc.gov/vaccines/pubs/vis/

default.htm

Link to Vaccine Information Statements that

explain the beneﬁ ts and risks of vaccines.

National Institutes for Health (NIH) www.nih.gov Home page for the NIH; contains information

about health topics, clinical trials, and the various

divisions of the NIH.

National Library of Medicine / Medline/

PubMed and MedlinePlus

www.nlm.nih.gov Home page for the U.S. National Library of

Medicine. Links to Medline Plus (health infor-

mation for consumers) and Medline/PubMed

(references and abstracts from biomedical

journals).

American Society of Health-System

Pharmacists (ASHP)

www.ashp.org Home page for ASHP; contains news related to

health-system pharmacy and many helpful links

for pharmacy professionals.

ASHP Drug Shortages Resource Center www.ashp.org/shortage Up-to-date information on current drug short-

ages, including which products are affected and

why, the anticipated time to resolution, and

alternatives.

ASHP Consumer Drug Information www.safemedication.com Reputable Web site for patient medication

information.

American Pharmacists Association

(APhA)

www.pharmacist.com Home page for APhA; contains news related to

pharmacy and many helpful links for pharmacy

professionals.

Institute for Safe Medication Practices

(ISMP)

www.ismp.org Homepage for the ISMP; contains medication

error alerts, a section for reporting, products

available for purchase, and medication error

prevention strategies.

Virtual Library Pharmacy www.pharmacy.org Contains links to pharmacy associations, phar-

maceutical manufacturers, governmental sites,

hospitals, journals and books, and more.

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

Self-Assessment Questions

1. Abbreviations are generally considered to be

unsafe and should therefore never be used in

prescriptions.

a. True

b. False

2. The ﬁ rst step in receiving either a prescription or

a medication order is to verify that all necessary

information is present, although this information

may vary depending on the pharmacy site

(outpatient versus inpatient).

a. True

b. False

3. The abbreviation for “before meals” is

a. a.a.

b. hs

c. pc

d. ac

4. Which piece of information is critical in an

ambulatory pharmacy environment when ﬁ lling

a prescription, but is often not known by the

pharmacy in a hospital?

a. patient’s allergies

b. name of the ordered drug

c. dose of the ordered drug

d. patient’s insurance information

e. name of the doctor

5. Every state’s laws regarding prescription transfer

are the same.

a. True

b. False

6. The ﬁ rst set of numbers in an NDC number

signify

a. the package size

b. the speciﬁ c product

c. the manufacturer

d. the schedule of the controlled substance

7. At the Point of Sale the patient’s signature is

required

a. when they receive the HIPAA information

b. when they receive a Patient Information Sheet

c. by some third Party Companies when the

patient receives the prescription

d. in some states when they refuse counseling

e. all the above

f. a, c, and d only

8. Examples of drugs with REMS include clozapine,

thalidomide, and

a. isotretinoin and dofetilide

b. isotretinoin and sildenaﬁ l

c. alosetron and methadone

d. sildenaﬁ l and tadalaﬁ l

9. Parenteral administration refers to drugs

a. given by mouth

b. administered only intravenously

c. administered intravenously and intramuscularly

d. given only subcutaneously

10. Which of the following is a possible risk

associated with IV therapy?

a. infection

b. bleeding

c. air embolus

d. incompatibilities

e. all of the above

11. Which of the following is false regarding the use

of a Laminar Airﬂ ow Workbench (LAFW)?

a. Hoods should be allowed to run for 15–30

minutes before use if they are not left on

continuously.

b. All compounding should be done at least

3 inches from the front edge of the hood.

c. Only essential objects should be taken into the

hood.

d. Jewelry should not be worn on the hands or

wrists when working in the hood.

e. Actions such as talking or coughing should be

directed from the LAFW work area.

12. Clean room attire should include

a. shoe covers

b. head covers

c. facial hair covers

d. face mask

e. sterile gloves

f. all the above

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Assisting the Pharmacist

Self-Assessment Questions

17. Which reference has the best information about

IV compatibility?

a. American Drug Index

b. PDR

c. Drug Facts and Comparisons

d. Package inserts

e. Handbook on Injectable Drugs

18. Drug Facts and Comparisons is considered a(n)

a. tertiary general drug reference

b. primary general drug reference

c. specialty drug reference that includes only

FDA approved drugs

19. The valid DEA number for Dr. Terry L Jones

would be

a. AT 4326915

b. AJ 2178944

c. AT 2178946

d. AJ 432910

20. The NDC number for a product on the package

label is 0536-3922-01. Which NDC number listed

below would be in the proper form for this drug

for remittance to a third party payer?

a. 0536-3922-01

b. 05363992201

c. 00536-3922-01

d. 05360-3922-01

13. Vials differ from ampoules in that they are used to

hold both liquids and powders.

a. True

b. False

14. A ____ is the most important piece of equipment

for handling and preparing hazardous drugs

safely.

a. LAFW

b. BSC

c. latex gloves

d. automated compounder

15. Which reference is important in describing good

compounding practices for technicians?

a. Lexi-Comp’s Drug Information Handbook for

the Allied Health Professional

b. Micromedex

c. Package inserts

d. PDR

e. USP 27

16. Which question can a pharmacy technician

answer?

a. When will the shortage of methylprednisolone

be over?

b. How much acetaminophen should I give my

2 month old infant?

c. Can propranolol make me dizzy?

d. Does simvastatin interact with grapefruit juice?

e. What should I substitute for morphine if my

patient is allergic?

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Pharmacy Technician Certiﬁ cation Review and Practice Exam

Self-Assessment Answers

1. b

2. a

3. c

4. d

5. b

6. c

7. f

8. a

9. c

10. e

11. b

12. f

13. a

14. b

15. e

16. a

17. e

18. a

19. b

20. c

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