I’ve been wanting to fill you in on my new job, and I’m finally getting to it. I’m enjoying being back at work: the social side of it, chatting to patients (sorry: customers!) and staff; using my brain in a critical way not just considering what to eat for the next meal; and earning a pay check is not a bad thing either! Especially since we’ve started to think about buying a house for ourselves, and I just found out from a broker that banks don’t accept income from insurance companies in their calculations!! Which means before this job my effective income to a bank for house buying purposes was zero!! Ouch! Now its more than zero from this job; not by much, but hey, the little things have to be appreciated. It just might take a bit longer for that goal to eventuate. It’s a bit sucky to be penalised for being sick though, and unfair to Chester. But putting that aside, I thought I’d do a bit of show and tell about my regular Thursday shift.
On Thursdays I check Webster packs. Most people look at me blankly when I say that. I keep forgetting that its really only a sentence that makes sense to healthcare professionals or people who have a Webster pack. Even in the last case, the concept of checking a Webster pack still might not be evident. So let me explain.
When I walk in on Thursday morning, I make my way through the pharmacy shop, through the dispensary to the “checking tables” in a corner in the room behind the dispensary. Someone else more involved in making the packs will have printed out lists for several nursing homes with their patient’s names printed alphabetically. This is basically my to-do list for the day. I don’t know which list get printed on which days, or what order they go in, or how it’s all decided; I leave that alone. I just pick up the top list and head out into yet another room. On a shelf “out the back” (an enormous shed-sized room behind the room behind the dispensary) will be a box or two of dose administration aids (DAAs) sorted alphabetically for each nursing home. I mostly call DAAs Webster Paks because that was the original patented name, or the most well known name anyway, but there are other brand names so you might hear them called by: Medico Paks, Sure Paks, others. It’s a cardboard manilla-type folder (but sturdier) with holes cut out for a plastic insert to fit that collects the patient’s medications in the appropriate amount at the correct time slot and then is sealed with an aluminium backing and heat, usually an iron. Yep just your regular everyday iron will do the trick! Don’t forget to turn it off before you go home!
This is not the type of plastic box with clip shut lids that you purchase in a pharmacy; that’s called a dosette box. We’re dealing with a more disposable option.
So, at the start of the day I grab the top nursing home list, find the matching box, and the start checking. How fast I’m meant to go, how many packs I’m meant to check per unit of time, whether I’m on schedule or not are among many other things that I don’t know and haven’t yet had explained to me about this pack checking business; maybe some day I’ll understand how and why!
So here is the box as it comes off the shelf. Obviously I’ve ensure patient privacy so there are no names or faces. You can see that there are a lot of packs per box, and usually between 1 and 3 boxes per nursing home, or section of the nursing home; some are very large!! So you can see the cardboard “folder” with a front flat cardboard flap, a square spine and then a cut out back piece ready for the plastic insert to fit into the holes. There are four times of day that medications can be given in a standard pack, but we can be quite flexible for example with Parkinson’s patients who need more frequent doses at more times across the day. Medications are filled into the plastic insert while its laying flat then immediately sealed with heat to ensure the medication’s integrity.
On the left is a pack as it looks when you open up the folder and lay it flat. The foil does make it challenging to check sometimes with the light reflecting into your eyes at certain angles. On the right side of this photo is the checking list, names not included but room number, how many packs the patient has, and over by their name is a section that I sign to say that I have checked the pack and it is accurate to what is prescribed. No more, no less.
What I’d LIKE my signature to mean is that I’ve reviewed the dose, the duration, the reason for taking it, the frequency that its taken, whether it interacts with anything else, whether it fits current guidelines, whether its still needed…but I dream! Not my job, not my place. Too thorough, says my boss. So stick to the script, and you’ll be thanked by your workplace, even if your inner pharmacist is dying inside!! Melodrama much! I’d so love to be the review pharmacist, or back in my familiar hospital setting but I’m not, so to save myself a lot of trauma and the mental anguish that is reality not agreeing with ideals, I must resign myself to checking what is actually there against what the doctor, rightly or wrongly, wants to be there and that will be that! To sooth my inner pharmacist I’m writing down issues as I go. I can’t do anything about them, but somehow noting that I’ve picked up on it makes me more peaceful. Of course I’ll never be able to do anything with it but its a token gesture.
Say I look at the patient in room 069 at the top of that list. They have one pack. I get their pack out of the box, and then I check it…hence the “checking” table. It’s terribly inventive! To check it, I need to look at the other side of the pack. The pack comes like a manilla folder: inside the front flap is this list of all the medications in the pack, and inside the back flap are all the medications in their slots. See below. I have to say I love the descriptions, when they are complete. Knowing the colour, the shape, any markings, whether its scored and more makes checking quicker for sure. But I’ve found quite a few descriptions aren’t complete and leave you a bit up the creek, and some of the colours are quite off the actual colour, but you get used it. There are only so many medications that the majority of nursing home patients are on so you get very familiar with a lot of appearances.
A TERRIBLE photo at some angles, but its accurate in that we have to tilt the backing of the folder this way, that way, another way to see all of the tablets, and to see them without distortion from the plastic refraction or the foil glare and reflection.
As you can see, the inside front flap has a lot of detailed information about the medication name and brand name, strength, type of formulation e.g tablet or capsule, shape, colour, markings and more. This information is used to cross check each and EVERY medication with perfect accuracy down to the individual tablet before I sign off to say that every that is meant to be in the pack is in there.
Give it a go. I know the visuals are poor, but can you identify the tablets based on their description? That’s pretty much the majority of my task.
Do you need to be a pharmacist to do this job? At this point yes, because legally a pharmacist must perform the final check of every prescription-only dispensed medication before it is released outside of the pharmacy. Strictly speaking this is just an accuracy check, as in checking that one white tablet with BL marking is in slot B. In another industry a less qualified person would be doing this job. But its wasteful to have a technician check the medication if a pharmacist has to come along behind and do the exact same thing. I will say that knowledge of drug formulations, of doses, of the classification of scripts as prescription-only or drug-of-dependence, knowing which medications are cytotoxic or only given weekly only is pretty essential to the task. And they don’t do a short course for that; it takes a four year degree to transfer that knowledge into a brain. Which means that for now pharmacists are stuck with what can be a tedious task! Especially for 8 hours straight! Luckily I do it one day a week only. I mean we understand how important it is, but its still tedious!! I distract myself thinking of other aspects like whether the dosing is correct, whether they really need the medications that they are prescribed and…oops! Not meant to be thinking about that!
So box after box, list after list, pack after pack we plow on! And that, my dear friends, is my Thursday!
It can be very satisfying when I pick up errors, I have to say. A tablet that accidentally got chopped in half so we only have a half dose here; a duplicate capsule in one slot there making a double dose; an empty pack, some glitch of the packing machine; a random capsule of goodness knows what that’s dropped in one slot, something the patient isn’t prescribed; a chipped tablet so we can’t determine the strength; a couple of missing doses; a tablet missing from one slot found in another slot; a label that doesn’t match the medications – whose are they? When I’m finding errors I feel like its a worthwhile job. When I’m not finding anything I feel like I’m missing something, and that I’m wasting time: is the other checker finding more than me, less than me? Should it be the same, different, nobody knows? After all the errors should be random, but sometimes there’s a trend.
I forgot to mention the reason that we check these packs, other than that a pharmacist legally must perform the final check before a medication is handed out. The packs are filled using robot machines so there is potential for error if a tablet drops from a canister when its not supposed to; if the tablet is damaged when it drops from the canister onto the receiving tray; if a canister runs out of medication in the middle of a pack; and many more permutations.