PRESCRIPTIONS4-5DEMONSTRATION OF PACKAGING - 1/9
DEMONSTRATION OF PACKAGING TO PATIENTS
AIM
The aim of these guidelines is to indicate an efficient procedure when dispensing to chronic or seriously-ill patients or to a third party, any packaging which could pose practical problems. The targeted fields are those of all medicines and cosmetics, but excluding medical devices (see Procedures specific to medical devices). These should result in better compliance.
IN CHARGE
Any person qualified to dispense in any of the above fields.
INTERVENTIONS
WHERE?
-at the counter if no ‘special’ confidentiality is required
-in a more spacious setting if room is needed for a demonstration
-in a more discreet setting* for illnesses requiring greater confidentiality (serious or troublesome pathologies); further explanations may also be necessary in a quiet place (for someone having problems understanding).
-at the patient’s home if he cannot get about.
*It is up to each pharmacy to decide on a convenient place (which will not be reserved exclusively for this task).
WHEN?
(1)The precise instants are indicated in dark print in the following reminder of the dispensing sequence:
-welcome
-validation of prescription
-preparation of prescription
-demonstration and correct usage (advice, indications for use)
-intake plan and payment (administrative part)
-reminder of key points of treatment (if required)
(2)Circumstances:
-when the packaging in itself is complicated, for example in the treatment of asthma, for contraceptives and medicines to be made up…..
-in some socio-cultural contexts; for example a foreigner who is not used to French medicine forms (drinkable ampules, suppositories)
-for handicaps like being deaf and dumb or having impaired sight and hearing
Be careful! It is sometimes necessary to demonstrate the most basic principles.
HOW? WITH WHAT MEANS?
The examples which follow are all in the ophthalmic field. The steps described are however valid for all awkward packaging (see Appendix 1). Whether there is a demonstration or not, any practical indications that may be required are always repeated (see Appendix 2). Three situations are to be differentiated:
-the treatment is familiar to the patient (patient known to the pharmacy and who has already received an explanation of how the packaging works, a patient who is new to the pharmacy but who is on long-term treatment, first delivery to a third party but a renewal for the patient);
-the treatment is unknown to the patient (new medicine to be taken occasionally, first delivery of long-term treatment);
- delivery to a third party or mandatory (the third party knows neither the patient nor the packaging well, for example the caretaker or a neighbour; the third party knows the patient well but not at all the packaging, for example, the partner or health professional.)
Treatment familiar to the patient
Treatment unfamiliar to the patient
DELIVERY TO A THIRD PARTY
- for treatment familiar to the patient
* it can be considered that the demonstration has already been given
* an information booster can however be given (see TOOLS above)
* through the third party, the member of the dispensing team remains at the patient’s disposal for any further information by giving his name and the telephone number of the pharmacy.
* for complicated medicines, it is preferable to have direct contact with the patient concerned. This may be:
-an appointment at the pharmacy during slack hours
-a home visit ( when delivering)
-for treatment unfamiliar to the patient
* the demonstration will be given to the third party (see above: «Treatment unfamiliar to the patient») if he seems capable of transmitting the information to the patient without deforming it.
-for all treatment
*it is essential to ensure the third party’s full understanding as he will have to transmit the information to the patient.
DATA TO BE KEPT
A brief, descriptive note should be drawn up (and added to the patient’s history, whether computerised or not):
-explanation and first delivery to a third party ( e.g.: «3rd P»)
-the patient experiences problems using the product or making it work (e.g.: «pb. packaging»)
-understanding problems: deafness, ………(e.g.:«handicap», «understanding»)
-arrange for a demonstration next time….(e.g.: «redo demo»)
Adopt the same abbreviations for all the dispensing team (see Appendix 3).In the case of non-listed examples: update the list and inform the rest of the team.
HANDLING PROBLEMS
PATIENT PROBLEM
i.e. demonstration not understood.
-explain again and ask the patient to imitate:
-choose a quieter and more private setting
-take more time for this additional explanation
-simplify the demonstration as much as possible
-as a last resort, suggest an appointment with a member of staff to take a dose of the medicine
-Check if the patient has any disorder requiring a daily visit and contact the appropriate service. In this case, the dosage intake could be fixed during a nurse’s daily visit.
PROBLEMS DUE TO THE PACKAGING ITSELF
In this case, notify
-PHARMACOVIGILANCE at the first and every subsequent incident (example: «vaginal suppositories» from FLAGYL for gynaecological use which have been mistakenly taken for normal suppositories.)
the laboratory concerned (when several cases among customers)
REFERENCES
APPENDIX 1: EXAMPLES OF PACKAGING AT THE ROOT OF PROBLEMS AND/OR REQUIRING SPECIAL ATTENTION WHEN DEMONSTRATING OR USING
BLISTER PACKS:
-pack containing both bi- or triphasic contraceptives and neutral tablets
MIXTURES:
-solmucol (the active substance is in the bottle-top)
-antibiotics and other mixtures to be made up (Mucomyst)
AEROSOLS / SPRAYS
-treatment for asthma (e.g. Ventoline)
-tritinine sprays
-Locabiotal (problem of three nozzles)
-Deturgylone (complicated to prepare)
OINTMENTS / GELS
-Progestogel (ruler-like measuring device for dosage)
TRANSDERMIC DEVICES
-tritinine patches
-hormonal patches
-nicotine-substitution patches
MEDICINES TO BE KEPT IN A COOL PLACE BUT USED AT ROOM TEMPERATURE
-DERINOX
-Some eye-drops
GYNAECOLOGICAL ROUTE
- ovules
OPHTHALMIC ROUTE
- Sterdex (packaging)
-Bacicoline eye-drops (reconstitution)
SELF-SURVEILLANCE
-glycemia-measuring device
-pregnancy tests
MEDICINES FOR EXTERNAL USE
-corn cures
-special dressings (hydrogel, blister-preventing,….)
-ointment for warts
APPENDIX 2: INSTRUCTIONS FOR THE USE OF EYE-DROPS OR OPHTHALMIC OINTMENT
GENERAL GUIDELINES
(1)Ask the patient if he wears contact lenses. If so, check that there is no incompatibility between the components of the eye-drops/ointment and the lenses.
NB: Risk of modifying the lenses
Risk of negative reaction to the lenses (adsorption, colouring, deterioration, sticking-plaster impression….)
(2)Before using, note on the container the length of time left for use. The simplest is to indicate the date when the patient should stop using it.
(3)Remind patients that:
-Single-dose units are to be used on one occasion only. They should not be used again and should therefore be thrown away after use.
-NB: This sort of packaging is recommended in the case of hypersensitivity to preserving agents (as there are none) or for occasional use.
-Multi-dose preparations must be used exclusively by one and the same person.
(4)Inform the patient that his vision may be impaired just after applying oily drops or ophthalmic ointments.
(5)When using several different preparations, space out applications of drops every ten minutes, keeping the least liquid for last, and in particular ointments after drops.
(6)Conform to storage recommendations, for example preparation to be kept in the refrigerator or away from the light.
(7)For both eye-drops and ophthalmic ointment: to avoid contamination of the nozzle, never let it come in contact with the eye.
HOW TO USE EYE-DROPS
(1)Wash hands carefully before touching (just as when making up eye-drops before their first use).
(2)Shake before use.
(3)Keep handkerchiefs on hand for stray drops.
(4)Let the preparation warm to room temperature: ophthalmic medicines should if possible be administered at 37°C (98.4°F.). If cold, blinking will increase and and accelerate their elimination.
(5)When applying the product:
-whether seated or standing, lean the head backwards and look up;
-pull down the lower lid to form a «pocket» (see drawing)
-apply one to two drops (no more!) in the lower conjunctival pocket;
-slowly close the eye (without tensing up);
-rotate the eye-ball for a few seconds to spread the solution over the whole surfaceof the eye;
-keep the eyes closed for at least two minutes;
-at the same time, exert a slight pressure with the index finger on the inside angle of the eye to close the tear-ducts, so that the solution will not flow into the nasal passages.
NB: When administering to onself, it is wise to stand in front of a mirror.
For elderly people, find a third person to administer ophthalmic medicines (in a sitting or lying position)
For restless children, apply a drop in the inside corner of the eye (in a lying position); even if the drops reach the outside lid when the eyes are closed, they run over the cornea and the conjunctiva when the eye spontaneously opens.
HOW TO USE OPHTHALMIC OINTMENT.
(1)The same indications should be applied as for eye-drops. The following however should be noted:
-A thin strip of ointment 5 to 10 mm long is applied directly from the tube into the lower conjunctival pocket (without the nozzle coming into contact with the eye); otherwise, a clean small stick can be used.
-After applying, close the eyes and make circular eye movements under closed eye-lids.
(2)In the case of a stye or cyst, the ointment should be applied at the site of the inflammation.
APPENDIX 3: EXAMPLE OF A LIST OF ABBREVIATIONS FOR A PATIENT’S HISTORY
NB: this list of abbreviations should be regularly updated, with care to complete and also eliminate
-Pb: problem
-Pkg: packaging
-3rd P: explanation and first delivery to a third party
-Pb pkg: problem when using or getting the preparation to work
-Understanding: problem of understanding
-Handicap: patient with a handicap(this can be specified): deafness, impaired sight,….
-Redo demo: arrange for a further demonstration when the patient next comes (to check if he has understood…)
Date of version: 09/02 Date of application: / Author: Melanie GOUDALIEZ. with the assistance of the dispensing team and clinical pharmacy of the Faculty of Pharmacy, Lille 2