This article outlines the teaching of good pharmaceutical practice
to pharmacy undergraduates at the University of Port Elizabeth,
South Africa
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| Accuracy and technique are but two of the essential components of good pharmaceutical practice |
Good pharmaceutical practice is a broad term encompassing the safe use and
therapeutic efficacy of dispensed medicines. The recent case of the dispensing
of a defective medicine due to a pharmaceutical error1 highlights the need for
a discussion within the profession. Certain areas come to mind: the relevance
of undergraduate training; dispensing errors made; and the continuous professional
development of pharmacists.
Dispensing errors can occur due to dosages or ingredients that are calculated
incorrectly, prescriptions and labels that are read incorrectly, patient or
product details that are entered onto the label incorrectly, and the attachment
of the label onto the incorrect item. In a recent American study, it was found
that in an ambulatory care pharmacy, interruptions and distractions over a half-hour
period were associated with dispensing errors, a majority of which involved
incorrect label information.2
Much has changed since the early 1900s when pharmacists were trained during
a period of apprenticeship under the auspices of a qualified pharmacist. The
pharmacist’s professional responsibility was, and still is, to ensure the
proper storage, handling, dispensing, purity and legal status of drugs. Today,
however, the profession is embracing the contemporary term “pharmaceutical
care”, which can be defined as “the pharmacist’s responsibility
for provision of drug therapy for the purposes of achieving definite outcomes
that improve a patient’s quality of life”.
However, in private community and hospital pharmacies throughout the world,
the conflict between commercialism and professionalism is still apparent in
the practice of pharmacy. The commercial environment of pharmacy necessitates
that economic factors influence much of its practice, especially when the pharmacist’s
reimbursement is based on the number of prescriptions dispensed. A division
between pharmacists who are mostly concerned with the accurate and efficient
distribution of prescriptions, and those who are more concerned with providing
information and services to ensure optimum drug therapy usually occurs.3
Pharmacy students no doubt have to be trained and educated to cope with both
these aspects.
The curriculum of the pharmacy department at the University of Port Elizabeth
in South Africa is evolving to cater for the chemical/pharmaceutical aspects
as well as the clinical/pharmacy practice elements. Hopefully its pharmacy graduates
will be able to exercise pharmaceutical practice in the broadest sense through
ensuring the physicochemical stability of the product, the correct dispensing
thereof, and for providing the correct product information to the patient, besides
being involved in optimising drug regimens when necessary.
This all round approach to the training and educating of a competent pharmacist
differs from the view put forward in California, which is that two classes of
pharmacists be created to cut down on the number of prescription errors and
to short-circuit a predicted over-supply of registered pharmacists. Under the
Californian proposal, registered dispensing pharmacists would be responsible
for ensuring the distributive functions and the dispensing and labelling of
prescriptions, and would also carry most of the liability burden attached to
the performance of technicians, whereas pharmaceutical care practitioners would
focus on patient counselling and the running of special clinics.4
In South Africa, the training and education programme produces a graduate in
pharmacy in the broad sense of the word. The unit standards for competencies
of entry level pharmacists, recently proposed by the South African Pharmacy
Council (SAPC), are5
| Chloroform-containing preparations: the potential for errors | |
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However, due to the shortage of manpower, the main function of many pharmacists
in the practice setting remains that of dispensing, and this trend is reflected
elsewhere in the world.6
The fact that many South African pharmacists function both as dispensers of
medication and as pharmaceutical care practitioners in busy hospital or community
pharmacy environments may be a factor contributing to the increasing number
of dispensing errors reported to the SAPC.7
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| Students learn how to measure the pH of an alcohol-free, sugar-free paracetamol formulation |
Teaching dispensing practice
In an attempt to combine the factors mentioned above into a relevant programme
for modern pharmacy students, a module on dispensing practice is undertaken
during the second year of study. In order to cope with the dispensary pressures
in modern pharmacy, this BPharm undergraduate module has many facets, ranging
from performing calculations, compounding specific formulations and working
with dispensing computer programs to dispensing proprietary items from the mock
dispensary. A local computer software program (Pharmassist) is used to complete
patient records and to produce the dispensing labels. The year-long module runs
concurrently with one on pharmaceutical formulation. Dispensing practice provides
the practical exposure to compounding and labelling which are also studied in
theory. In a survey performed in 1998, it was found that many students considered
the practical reinforcement of the theory, and the theoretical understanding
of extemporaneous compounding, to be mutually beneficial.
Most students produce satisfactory extemporaneously prepared products. During
the very first practical session, senior assistants demonstrate how not to make
a pharmaceutical preparation. The students have to recognise errors such as
the incorrect reading of a meniscus and the accidental use of the incorrect
ingredient. Strict attention is also paid to keeping the working environment
orderly, clean and tidy so as to avoid accidental dispensing or compounding
errors and contamination. Techniques of standard acceptable dispensing practice
are reinforced on an ongoing basis. Labelling is carried out according to the
standard methods used for labelling proprietary products. Unfortunately, such
stringent labelling is not usually applied in pharmacy practice, where most
labels are computer-generated and there is often insufficient space for additional
details.
Research projects
To maintain the educational element one expects from a university graduate,
students are encouraged to embark upon their first pharmaceutical research
project during the dispensing practice module. They select a topic and proceed
to formulate and test their own product, also considering appropriate packaging
and marketing aspects. Peer collaboration is encouraged during this section
of the work, and an oral presentation of findings is given to the rest of
the class. The annual visit to a local pharmaceutical manufacturing company
allows students to see various processes on a large scale, reinforcing much
that the students have been taught.
It is not possible to teach every aspect of dispensing, verification of prescriptions
and dosages and all the other elements that fall within the scope of the practice
of pharmacy, during this single module. Students are also expected to complete
a minimum of 240 hours over a period of three years, working in a pharmacy
of their choice (these hours do not constitute part of the preregistration
internship that is completed at the end of the undergraduate degree).
One must also equip students with the skills to develop protocols for good pharmaceutical
practice once they enter the profession. This is in agreement with the editorial
comment which stated that “protocols should be established and calculations
should be checked and checked again and recorded systematically”.8
Applied pharmaceutical practice in a clinical environment was introduced at
the University of Port Elizabeth in 2000. Students are encouraged to work in
groups and to explore ways of making a hospital or pharmacy environment safer
and more hygienic and to develop systems that avoid accidental contamination,
including cross-contamination, incorrect dispensing and calculation errors.
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| Students learn the use of dispensary software in small groups, after which they enter prescription and patient details individually |
Pharmacy students and calculations
The area that causes most consternation among students is that of pharmaceutical
calculations. A pass in mathematics at school-leaving level is one of the prerequisites
for conditional acceptance into the pharmacy programme. However, it is more
often the arithmetic that needs attention, and it is arithmetical errors that
often creep into pharmacy dispensing errors. To draw students’ attention
to arithmetical errors, a test of 14 simple pharmaceutical calculations is done
at the beginning of the year. The incorrect answers are graded according to
the type of error made. A type I error (which occurs frequently) indicates that
the student has the correct digits in the answer, but the decimal place is incorrect.
In type II errors, the answer has no correct digits, and the arithmetical methodology
used is incorrect. Type III errors are where a percentage has been calculated
incorrectly, which occurs surprisingly often.
The module on dispensing practice provides opportunities for students to practise
doing calculations in various ways, including the following:
Students are encouraged to verify their answers by using an alternative method
of calculation. This is in accordance with International Pharmaceutical Federation
recommendations, which state that all calculations should be double-checked.10
In order to allow registered pharmacists the opportunity of practising their
pharmaceutical calculation skills, a regular mini-feature could be included
in pharmaceutical journals, with worked examples to provide a service to the
profession.
Conclusion
No system can be better than the best person operating it. No syllabus is
foolproof, no training absolute. Perhaps educators and pharmacists world-wide
could collaborate in educating undergraduates and encouraging colleagues in
these aspects of good pharmaceutical practice.
Therèse Kairuz currently lectures on pharmaceutics to second-year pharmacy students and on biopharmaceutics to fourth-year students. Professor Raj Naidoo is head of Port Elizabeth university’s pharmacy department