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Check out a lesson from our online Pharmacy Technician certificate program.
When you have completed the instruction in this lesson from our online pharmacy technician Certificate program, you will be trained to:
As a pharmacy technician, you might work at a large, national chain drugstore. Or, you could find employment at a local hospital or a home care pharmacy company. Although these settings are different, the jobs will involve similar responsibilities.
There are three main pharmacy care settings:
Each of these settings can be further divided. For example, the typical independent “corner drugstore” is also a community-based pharmacy. By the end of this lesson, you’ll know the differences between the tasks of pharmacy technicians in each setting.
First, take a look at a day in the life of a pharmacy technician. Danielle’s typical day will give you a good sense of one possible scenario for your future career!
The pharmacy where Danielle works is in a retail store. Her uniform—black pants, white polo shirt, black shoes and blue smock—is spotless. Her name tag says “DANIELLE,” and underneath it says “Certified Pharmacy Technician.”
Danielle’s first task each day is to take out the backup tape that the computer runs every night and put in a fresh tape. Then, she brings up the cash register so it’s ready for the first customer.
Danielle goes to the computer’s interactive voice response (IVR) system next. Patients call in refill requests. The computer software lines up the calls in the pharmacy’s order queue. Danielle gets the process started. Today, 45 patients have called in refills.
After the calls are downloaded, Danielle fills the prescriptions. The IVR system produces paperwork for each prescription. She puts this paper into a bag, and then finds the medication. She counts out the pills, puts them into a vial and labels the vial. The labels may specify “take with meals,” “for use in eyes only” or other special instructions. Next, Danielle checks the fax machine. Doctors often fax prescriptions while the pharmacy isn’t open. When she fills each prescription, she leaves it on the counter. Raylene, the pharmacist, knows to double-check the orders that sit there.
Partway through Danielle’s morning prescriptions, a customer comes to the window. Terri wants a refill for her painkiller prescription. Danielle checks the prescription, which specifies “no refills.” Danielle politely tells Terri that she needs the physician’s approval before she can refill the prescription.
Raylene confirms that they can’t refill the prescription. She offers to call Terri’s physician about a refill.
Later, Danielle accepts the pharmacy’s drug order for that day. She takes the drugs out of the shipping boxes, puts identification stickers on them and puts each drug on the shelves in the proper location.
For the last hour, she does whatever needs to be done. Some days, she faxes refill requests to physicians. Sometimes she pulls expired drugs from their shelves. She always stops to help customers who come in for prescriptions.
Let’s take a look at some questions you might have, and read how Danielle answers them.
Danielle Answers Frequently Asked Questions
Why did you choose this career?
I wanted a job with flexible hours where I could be around people, do something to help others and still have time for my family.
How did you become a pharmacy technician?
I took an internet-based course. At the end of the course, I received a huge study book for the certification test. I also shadowed a pharmacy technician before the test.
What is your work schedule like?
I usually work with only one other person, a pharmacist, on a shift.
What is your work area like?
I don’t have a desk or a space that’s “just mine.” We all share the workspace.
What is your favorite part of the job?
Serving the customers. To me, the customers come first.
What is the biggest challenge?
Well, keeping the medications straight can be a challenge! Also, you have to keep up with drug announcements for re-certification.
What else would you tell someone who wants to be a pharmacy technician?
In jobs like mine, you do have to like people. You always have to remember that your customers are probably not feeling well. You can’t take it personally if they get impatient.
Let’s start our “Pharmacy Tour” with the community pharmacy, which may be at a drugstore that is part of a nationwide chain, for example. That’s just one kind of community pharmacy. The community, or retail, pharmacy fills prescriptions and provides drug related services to ambulatory care patients. Ambulatory care patients aren’t admitted to a facility, like a hospital. Anyone who sees a physician in the office is an ambulatory care patient. Patients who have outpatient surgery are also ambulatory care patients. These patients visit the community pharmacy for prescriptions.
Community pharmacies often carry many retail products other than prescription drugs, such as drug equipment, cosmetics, over-the-counter drugs and even candy and other consumer products. Community pharmacies attract many different kinds of customers. That’s why customer service skills are so important.Let’s start with a look at the kinds of community pharmacies.
The Five Types of Community Pharmacies
Pharmacy technicians who work in community pharmacies have diverse and challenging work! Their customers may range from a woman who wants shoe inserts to an asthma patient who is switching inhalers. Billions of U.S. customers take their prescriptions to community pharmacies.
But where, physically, will they take their prescriptions? Community pharmacies are located in one of five settings. Let’s look at each type of community pharmacy separately.
Independent pharmacy stores are NOT owned by a big corporation. Sometimes they’re large, but often, they’re small. They may specialize in one area of pharmacy. For example, they may focus on medical equipment. Usually, one pharmacist or a small group of pharmacists owns and manages the store. A pharmacy technician would be able to work with “the boss” directly.
Chain pharmacies are very common. In a chain pharmacy, several storefronts are owned by the same company. One company may own fifty stores or fifty thousand. The stores may be in one geographic area, or they may cover a region, like the Pacific Northwest. Or they may be a nationwide chain. Rite-Aid and CVS Pharmacy are two national chains.
Chain pharmacies can also be located as small parts of other stores. For example, grocery stores, like Safeway and Albertson’s, often have chain pharmacies. Discount stores, like Costco and Target, also have chain pharmacies. Chain stores tend to be alike coast to coast. They focus on prescriptions and over-the-counter medications.
A clinic pharmacy is typically located in physician office buildings. Patients of those physicians aren’t forced to fill their prescriptions there. However, the location makes it convenient for patients to stop by on their way out. Also, the physicians may share computing systems with the pharmacy. That gives the pharmacy more patient information, which lets the pharmacy better serve the patient.
Clinic pharmacies may also be part of a hospital building or a specialty center. For example, a stand-alone chemotherapy center might have a pharmacy. The clinic pharmacy would prepare the chemotherapy drugs that are used at the site. The pharmacy might also carry standard drugs, like painkillers, that chemotherapy patients typically require. Most clinic pharmacies carry little or no non-medical and non-prescription items.
Some managed care organizations, like some HMOs, have office buildings. The organization may also operate a managed-care pharmacy. Managed care pharmacies carry only the medications that the managed care organizations cover. Also, only the members of the managed care organization can use the pharmacy.
Some insurance plans let you mail types of prescriptions to a supplier. In a week, you would have a six-month or one-year supply of your medication. A mail-order pharmacy fills these types of prescriptions. They’re popular because they may have lower prices, and they’re also convenient for those on regular medications. Instead of making a trip to a store to get your refill, you simply drop the refill request into the mailbox. Pharmacy technicians have less face-to-face contact with patients in mail-order pharmacies. Their duties focus more on processing prescriptions.
As you can see, pharmacy technicians have lots of options! Any community pharmacy can provide a challenging, stimulating environment.
Components of a Community Pharmacy
So, what are the common components of community pharmacies?
Nine Common Components of Community Pharmacies
Let’s go “behind the scenes” to see where a pharmacy technician spends most of her day.
The prescription counter is a long, flat surface where pharmacy technicians or the pharmacist fills prescriptions. A consulting area may be attached to this counter. It may also just be part of the counter with a barrier that the pharmacist can raise. The pharmacist uses this area to counsel patients.
At this window, patients drop off prescriptions. They might ask for a refill verbally or turn in a written request for a refill. The pharmacy technician, on the other side of the window, picks up your order. She then asks you for personal information, which she inputs into the computer system. A pharmacy technician takes the order to the prescription counter and fills it. A pharmacist checks it. Privacy laws require that the window be set up carefully. The privacy of the patient must be protected at all times.
In a busy chain store, many customers drop off their prescription requests and then shop for other items. The prescriptions may be ready before the customer is. For this reason, the pharmacy space requires storage.
The pharmacist checks the processed prescription, and then the pharmacy technician takes it to the transaction window. There, she calls the name or number of the patient. If the person is not in the area, she files it by the patient’s last name. When patients finish shopping, they come to the transaction window and ask for their prescription. The pharmacy technician goes to the storage area and retrieves it.
Of course, the pharmacy’s stock of medications has to go somewhere, too! You may see rows and rows of shelving in pharmacies. The pharmacist supervises storage of controlled substances. These drugs are dangerous and must be treated carefully. The substances are always kept locked. The pharmacy technician works closely with the pharmacist if she needs to handle controlled substances. They double- and triple-check all parts of the order, from the prescription to the packaging.
The pharmacy refrigerator must be used only for medications. Food and drinks are strictly prohibited. The refrigerator is specifically intended for some special medications that must be stored at low temperatures—between 2 and 8 °C.
Today, every pharmacy depends on a computer system of some kind. Chain pharmacies are often on a network, which allows the pharmacy technician to refill a prescription for a patient who is on vacation or who has recently moved.
Computers are an important part of filling prescriptions today. Insurance companies often require the pharmacy to verify the prescription before filling it. Also, patient information is easy to retrieve from computerized records. Pharmacists and pharmacy technicians even use the Internet. Sometimes they download information about drugs or a condition to give to a patient.
Pharmacy professionals use a lot of equipment. They use balances and weights to measure the amounts of some drugs. They need glass rods and tubes to measure liquids in. They mix ointments on parchment paper or a board. They need machines or trays to count pills. They need caution labels of different types, and they need a mortar and pestle. In addition to storage for drugs, pharmacies require space to store all this equipment.
A mortar and a pestle are two tools that are usually used together. The mortar is the bowl. The pestle is a stick with a rounded end. Pharmacists grind tablets in the mortar with the pestle. They can then reformulate the powder into a smaller dose of the drug or mix it with another drug.1
Customer Pick Up
When a prescription is ready, you pick it up at the customer window. Sometimes it’s the same window as the transaction window. Other pharmacies have drive-through windows where customers pick up filled prescriptions!
The pharmacy technician verifies the identity of the person picking up the prescription. She will also ask if the patient has any questions about the prescription. If the patient wants more information, the pharmacist will help the patient.
Cash registers are an important part of the pharmacy business. Most cash registers have scanners that read bar codes on merchandise. The register connects to the pricing system, and the price appears automatically.
The pharmacy technician uses insurance information to figure out how much a customer owes. You’ll learn more about the forms of payment later in this lesson.
A sink must be available at the pharmacy, and it must be clean. Pharmacy technicians and pharmacists must use it often! Cleanliness is necessary to maintain a safe environment for handling drugs.
Customer Service in the Community Pharmacy
Pharmacy technicians may see many patients throughout the day, and handling these patients can require extra patience! Keeping customers happy is an important part of the job. When pharmacy technicians see people, they are likely to be sick, worried and tired. How do they cope?
First, the pharmacy technician tries to communicate professionally with all of the customers. She remains courteous and calm, and listens carefully. She knows that customers feel “heard” when she makes and maintains eye contact.
She reassures customers when she can carry out their requests. She fills prescriptions as quickly as possible, and gives patients an accurate sense of how long it will take.
Sometimes, she can’t do what the customer wants, but she offers positive action—not negative action. Instead of saying, “We won’t fill your prescription,” she says, “We need the physician’s approval.”
Sometimes the customer still isn’t satisfied. The pharmacy technician responds positively. She can offer to involve the pharmacist to resolve a dispute.
Many people are part of the pharmacy team, and they all focus on caring for the patient’s health. There may be one or two pharmacists and one or two other pharmacy technicians. Because work shifts rotate, everyone needs to work as a team for the pharmacy to operate smoothly.
Pharmacy technicians often discuss typical problem situations with the pharmacists. In this way, everyone knows the best ways to resolve problems. Also, everyone involves the pharmacists in customer service at the same point in the process. This ensures that all customers receive fair, good service.
The work at community pharmacies can be fast-paced, and teamwork helps to keep up with this pace. Sometimes, customers all seem to come in at once when no one expects them! Pharmacy technicians must be able to adjust quickly.
Next, you will learn more about the institutional pharmacy setting. First, take a moment to review your learning about community pharmacies.
For the following questions, choose the best answer from the choices provided, and write your answers on scratch paper.
1. Community pharmacies are open to _____.
a. anyone who arrives in an ambulance
b. ambulatory patients
c. only patients of a specific physician
d. only people who buy products at the attached grocery store
2. Which of the following type of community pharmacy is not owned by a large corporation?
a. Mail order
b. Managed care
3. Which of the following statements about chain pharmacies is true?
a. Chain pharmacies are limited to one city.
b. To be considered a chain, a company must sell produce.
c. To be considered a chain, a company must have two stores in two states.
d. Chain pharmacies can be local, cover one geographical area or spread from coast to coast.
4. Managed care pharmacies _____.
a. are open only to members of the managed-care organization
b. are open to anyone who arrives in an ambulance
c. carry all medications
d. routinely deliver medications to nursing homes
5. One of the most important skills for a mail-order pharmacy technician is _____.
a. the ability to upsell customers
b. the ability to quickly and accurately fill prescriptions
c. excellent customer service
d. a spotless driving record
6. Which of the following is an accurate definition of a prescription counter?
a. A person who counts prescriptions
b. The counter where prescriptions are filled
c. A machine that counts prescriptions
d. A pharmacist who counts prescriptions filled by pharmacy technicians
7. At the transaction window in a community pharmacy, _____.
a. the patient’s prescription becomes an official order for the pharmacy
b. the pharmacy technician serves drive-through customers
c. the pharmacy technician and pharmacist communicate with each other
d. customers can find information about the discount store’s sale prices
8. Which of the following statements about controlled substances is true?
a. Pharmacy technicians are in charge of storing them.
b. Pharmacy technicians cannot use them.
c. Pharmacists cannot use them.
d. By law, controlled substances must be stored according to procedures.
Check your answers with the Answer Key at the back of this instruction pack. Correct any mistakes you may have made.
Patients stay in hospitals for a relatively short time. There, they receive supervised, structured medical care. Pharmacists are directly involved with patients in hospitals. They work with physicians and other caregivers to develop a plan for each patient’s pharmaceutical care. They also work with caregivers to monitor how well the patient responds to the medications. In very large hospitals, pharmacists specialize. They may work exclusively in pediatrics, nutrition support, oncology or some other area.
Nursing homes are a type of long-term care facility. Patients usually stay in there for a longer period of time than they do in hospitals. Other long-term care facilities include behavioral health centers and intermediate-care facilities. Patients in these settings require time to recuperate from serious illness or injuries. Sometimes, patients require ongoing skilled nursing care. Pharmacists still interact with patients in long-term care facilities. However, they are usually less involved on a daily basis with these patients.
In both hospitals and long-term care facilities, pharmacy technicians help free the pharmacist’s time for patient care. They perform a wide range of duties, which you’ll see in this section. We’ll focus on hospital pharmacies, but remember that pharmacy technicians’ work at long-term care facilities is similar.
Changes in Hospital Pharmacy
As recently as 30 or 40 years ago, hospital pharmacies were very different than they are today. They employed fewer people. They didn’t have as much responsibility.
Typically, they were located in the hospital basement. From this isolated location, pharmacists sent supplies of medications to patient care areas. The medications were stored in bulk in areas on each wing. Nurses calculated, measured and prepared medications for patients. Nurses even prepared all the IV solutions, without equipment pharmacy technicians use today.
That doesn’t sound very appealing, does it? But times change. The major changes have been related to technology and finance. We’ll cover these changes separately.
You know that x-rays and many other technological advances have changed the way physicians today “see” the body. New types of machines have also affected the world of the hospital pharmacy. The most obvious is the computer. However, it’s not the only one!
New technology changes in manufacturing processes have changed how drug companies do business. They can produce high-quality drugs that cost less. They can produce a wider range of drugs. They can easily change how they package drugs. Drug companies now offer small packages of medications. For example, one package has all the arrhythmia medication a heart patient needs in a 12-hour period. Pharmacy technicians spend less time repackaging medications.
Automated dispensing machines keep track of medications, either in a pharmacy or in a patient care area. They monitor which medication was removed from the machine. They identify who removes the medication. They also track what patient the medication is for. Automatic mixers also help pharmacy technicians create liquid medications quickly.
Computers can do more than track inventory and patient information. Doctors can enter drug orders into a hospital’s computer system. Nobody needs to transcribe or interpret the orders, so there’s less chance for mistakes. Patients receive drugs faster. Pharmacists and pharmacy technicians can do other tasks. The computer system even prints the label.
You might think that machines will replace pharmacists and pharmacy technicians. However, the opposite is true! Technology lets pharmacists and pharmacy technicians focus on other tasks. Hospital pharmacists are now involved directly in caring for patients. Pharmacy technicians are free to take on a wider range of drug mixing and dispensing duties. The healthcare world will always need professionals with a strong knowledge of medications.
In the past, Medicare and Medicaid systems were different. These programs cover many millions of U.S. patients who are retired or disabled. Initially, these systems covered many more of the costs of patient care. Doctors didn’t have incentive to try the least expensive treatments to see if they worked. Medicare covered whatever they said the patient needed.
The situation is very different today! Medicare and Medicaid, as well as other insurance companies, focus on cutting costs. Hospitals compete to offer the best services for the lowest prices. Obviously, sometimes patients need expensive care. Newer systems encourage hospitals and physicians to keep costs low. It’s impossible to provide health care at no cost. Hospitals will always need to keep giving good health care efficiently.
One other financial concern is that drug costs continue to rise. It costs a pharmaceutical company millions of dollars to develop new treatments. When a new drug goes on the market, the drug company must make that money back. Their profit helps them research a different new treatment.
Not every new drug is more effective than older drugs. But sometimes, new drugs are the best or only tool. Infections that were once cured by one antibiotic adapt and become “supergerms.” The antibiotic is no longer effective, so a new one is necessary.
Now, you know the ways in which hospitals are different today. How is today’s hospital organized?
How Is a Hospital Organized?
Hospitals are organized like businesses. Different people specialize in different tasks. The pharmacy technician role is unique compared to the many other roles.
The sample hospital organization chart you see here is just a sample, as all hospitals are organized a little differently. Let’s walk through the organization chart. The top level of management is the hospital’s Board of Directors. The Chief Executive Officer (CEO) and the medical staff report to the Board. The Board helps the CEO and medical staff set the direction of the hospital. The next level includes directors of divisions.
A sample hopsital organization chart
If you’ve located the Pharmacy on the chart, you know where we’re headed. We’re interested in the COO. She is responsible for three departments: professional services, ancillary services and support services. The pharmacy is part of the professional services department.
How Is a Hospital Pharmacy Organized?
You already know that technology and financial pressure have changed hospitals. So, what’s different about today’s pharmacy?
Pharmacy hospitals today are one of two types: centralized and decentralized. Let’s look at centralized pharmacies first.
Centralized Hospital Pharmacies
Centralized pharmacy services have a central location. All pharmacy personnel work in this location; all the dispensing, IV mixing, compounding and information-checking happens here. All the necessary equipment is here, as well as drugs and supplies. At the window, outpatients of the hospital’s surgery center get prescriptions filled. Pharmacy technicians fill medication carts and then take the carts to patient care areas.
Centralized pharmacies have many benefits. When all the materials and equipment are in one location, fewer people are required to do the work. Also, less equipment is necessary for the staff and services aren’t duplicated. It’s an efficient system in some ways.
However, centralized pharmacies also have drawbacks. Even though they have more patient information, they still may not have everything they need. A full patient record may not be available. Without that information, pharmacists can’t fully assess the patient’s drug needs. Also, pharmacists don’t routinely see patients in this setting.
If someone on the eighth floor needs an antibiotic IV, the patient will wait a while! First the pharmacy receives the order. The pharmacy technician prepares the IV, and the pharmacist checks it. Then someone delivers it to the eighth floor, but there might also be fifteen other deliveries on the way.
Some of the technology you learned about earlier can address some of these needs. Pharmacies are also trying a new form of organization, which you’ll learn about in the next section.
Decentralized Hospital Pharmacies
A decentralized pharmacy still has a central location, but it has satellite locations in patient care areas.
Each satellite is a separate area of the hospital. It might serve two or three patient care units. At the satellite, pharmacy technicians and pharmacists store, prepare and dispense drugs. Each satellite might have one pharmacy tech and one pharmacist. The central location holds the main storage areas for bulk supplies and medications. Part of the pharmacy technician’s responsibility is stocking the supplies needed in the satellite.
The main advantage to a decentralized pharmacy is the location. Pharmacy staff can respond quickly to patient drug needs. Pharmacists can talk directly with patients about their full range of medications. Pharmacists can monitor patients’ responses to drugs. Pharmacy staff is more available to other staff, like doctors and nurse assistants, to consult about patient care.
The main drawback to a decentralized pharmacy is cost. Each satellite must contain equipment, sets of reference materials and computers, which can become quite expensive. Satellites also require more people to work at them.
You can think of the services in this type of pharmacy in two ways. Some services focus on products, while other services focus on people. All services focus on quality.
The Thing’s the Thing
When you think of a pharmacy, what’s the first word that comes to mind? It’s probably drugs. When it comes right down to it, the hospital pharmacy’s basic function is to provide medication for patients. To provide medication, pharmacies must maintain inventories of drugs. They must also dispense drugs. All of these services are called product-focused services because the product is the focus. Let’s look at each service separately.
Today, hospitals use the unit-dose distribution system. In the unit-dose distribution system, the pharmacy dispenses only one day’s worth of medication for each patient. This system is efficient and safe. It follows these basic steps:
1. The physician writes the order. A copy goes to the pharmacy.
2. Pharmacy technicians (or pharmacists) fill the order. They have access to patient information, such as drug allergies and patient weight. They prepare individual doses of the medications.
3. Medications—pills, liquids and injections—for the next 24 hours are put into labeled trays, which are then taken to the patient care area on a cart.
This form of dispensing has many advantages. It reduces medication errors. Pharmacies maintain better control over medications. Patients can be billed for medications more precisely. Pharmacy and nursing staff are used more effectively. Computer technology makes it easy to change medications during the day while keeping track of everything.
Investigational Drugs. Sometimes, hospitals participate in experimental drug trials with special groups of patients who are closely monitored. Pharmacy technicians may keep records of clinical tests required to monitor patients, control the inventory and prepare and dispense the drugs.
As you can see, each of these services focuses on a particular product. As you have learned, the pharmacy can play other roles. Let’s look at them now.
The Patient’s the Thing
Now you know that many of the hospital pharmacy’s services focus on medications. However, the pharmacy also provides patient services.
Medicare requires pharmacists to provide patient counseling about their medications. This requirement started a whole movement toward doing more than providing drugs. Pharmacists today offer nutritional support services and drug information, and they help monitor how drugs act and interact in their patients. These patient-focused services became part of the pharmaceutical care model.
Pharmaceutical care means providing drug therapy to help a patient become measurably better, with a better quality of life. When the pharmacist takes on pharmaceutical care, she becomes the patient’s advocate. Everything she does must be for the patient’s benefit. She monitors how well the drugs work and how the patient feels about the drug therapy.
Pharmacy technicians also play a role in pharmaceutical care services. They may input important information about patients’ reactions in drug studies, which are then used to check the patients’ progress. Pharmacy technicians also review the patient database for missing information, collect it from patients and flag medication orders that differ from the database.
The point of patient-focused pharmacy services is to make patients healthier. At the same time, patients can be happier. The care is better and the costs are still under control.
So, some hospital pharmacy services focus on products, and some focus on services. But quality is always important.
The Quality’s the Thing
Part of any hospital pharmacy is a focus on quality service. Often, quality is one of those hard-to-define words. You know it when you see it, though. Say you order a cup of coffee in a restaurant. Is the cup clean? Is the server cheerful? Does the coffee taste good? Is it at the right temperature?
It’s easier when quality has a definite meaning in a particular setting. Organizations that accredit or certify hospitals have definitions of quality services. Two concepts are important in the hospital pharmacy setting: quality control and quality improvement. They’re slightly different.
Quality control is a method for providing a service or product at a certain standard. Notice that it’s a method: a specific procedure or system is in place to follow. The result of a quality control method is also specific. The results might be zero errors. The results might be a clean cup of coffee at a specific strength at a specific temperature.
Quality control requires specific, complete written procedures. All staff must be trained to follow those procedures. Safety nets—a pharmacist’s check, for example—are included at important parts of the procedure.
Quality control is only as good as the procedure that is specified. Have you ever followed a recipe to the letter and created a disaster? Maybe the problem is in the recipe!
Quality improvement takes a slightly different approach from quality control. However, both approaches are important. In fact, you will see how they work hand in hand.
Quality improvement (QI) is sometimes called continuous quality improvement (CQI). Another term you may have seen is total quality management (TQM). Whatever acronym you use, the meaning is the same. Quality improvement is a systematic approach to improving the quality of a product or service.
Let’s say that you want to improve the procedure for preparing an antibiotic IV. The first QI step is to focus on the problem. The problem is that too often, the final IV bag is contaminated with a powdery substance. The next step is to assemble a team to work on the solution. The team might include a pharmacist, other pharmacy technicians and nurses who administer the IV. The team agrees on how the task is currently performed. This is easy—they have a specified procedure. They check to be sure everyone follows the procedure. Do all the bags produced in the pharmacy have the powder? If some don’t, why not? After these investigations, the team selects a different procedure to see if it makes a difference. They will then test it and measure the results.
As you see in the example, these projects require lots of data. The data must be written down and saved. Each change to the procedure is documented. Data supports their decision to change the procedure. Sometimes the data suggests they try a different approach. Regardless, quality improvement initiatives require data. Hospital QI teams use these tiny pieces of information, combined with other hospital information, to improve services.
Where do the policies and procedures come from? Who regulates what happens in hospitals and hospital pharmacies? That’s the topic of the next section.
Regulating Hospital Pharmacies
Hospitals and hospital pharmacies are regulated by many agencies. Two of the most important organizations are at the federal level.
Federal-level Regulatory Agencies
The purpose of The Joint Commission is to “help healthcare organizations help patients.”2 The Joint Commission has created guidelines and standards for all parts of a hospital, including the hospital pharmacy. The Commission grants accreditation to healthcare organizations that meet these guidelines and standards. Hospitals must re-accredit every three years.
The Centers for Medicare and Medicaid (CMS), a part of the U.S. Department of Health and Human Services, inspects hospitals and grants approval to treat Medicare patients. If a hospital isn’t CMS approved, it won’t receive reimbursement for treating Medicare patients. Most hospitals treat Medicare patients, so maintaining approval is very important.
State-level Regulatory Agencies
Two other organizations also affect hospital pharmacies. Their specific requirements vary by state. Each state has some form of the following two agencies:
Quality control methods include safety nets in the form of checks and balances. For example, the work pharmacy technicians do is inspected by pharmacists. Well, for the overall operation of hospitals, these regulatory agencies are the safety net. They ensure that hospitals provide high-quality health care at a reasonable cost.
The hospital pharmacy is part of a large web of healthcare services. Many of the services are the same in hospital pharmacies and community pharmacies. All the people who work in the hospital, from security guards to groundskeepers to physicians, contribute to patient health.
Before moving on to the third pharmacy setting, check your understanding of the hospital pharmacy with the following Practice Exercise.
1. How are hospital pharmacies and nursing home pharmacies similar?
a. They are both types of institutional pharmacies.
b. They are both types of long-term care pharmacies.
c. In both pharmacies, pharmacy technicians counsel patients.
d. They are not similar.
2. Which of the following has not been part of the change in hospital pharmacies?
a. Drug companies and their manufacturing technology.
b. Equipment companies and the types of imaging they can do.
c. Equipment companies that produce pharmacy dispensing machines.
d. Computing technology, such as personal digital assistants.
3. A drug company makes drugs available in different-sized packages. How does that affect a pharmacy technician’s work?
a. It means she spends less time re-packaging medication.
b. It puts her out of work entirely.
c. It forces her to use computer technology.
d. It means she really needs a personal digital assistant.
4. A physician inputs an order directly into the hospital pharmacy’s drug order system. How does this affect a pharmacy technician’s work?
a. She no longer has to decipher physician handwriting and there are fewer opportunities for mistakes.
b. Physicians can’t blame pharmacy technicians for wrong diagnoses.
c. Pharmacy technicians have more free time to change patient dressings.
d. She requires a personal digital assistant to read it.
5. Which of the following is a reason why newer drugs are more expensive than older drugs?
a. Physicians must be convinced to try new drugs, and that requires a lot of advertising dollars and incentives.
b. It costs the pharmaceutical company money to research and develop the new treatment, and in the early years of the drug’s use, the company has to make up that money.
c. They aren’t more expensive—that’s a myth.
d. Older drugs are always more effective than newer drugs, which means patients have to take more of the new drug, which costs more.
6. In a centralized hospital pharmacy, _____.
a. the work occurs in satellite pharmacies
b. pharmacy offices are located on the top floor of the hospital
c. all pharmacy personnel work in one location and perform all their tasks there
d. pharmacists and pharmacy technicians have access to all of the patient’s healthcare information
7. A decentralized pharmacy _____.
a. replaces a central pharmacy location
b. still has a central pharmacy location
c. requires more responsibility from physicians for communication with patients
d. requires more responsibility from pharmacy technicians for patient counseling
It’s time to turn to the companies that provide home care services for patients. The goal of home care service companies is to give patients institutional-level care in their homes.
Some home care companies offer all kinds of health-related services in the home, such as long-term oxygen treatment or assistance with personal care. You’ll learn more about the variety of home care services in a moment.
One type of home health service is called long-term infusion therapy. Infusion therapy is administering medication or nutrition through an IV. Thirty years ago, otherwise healthy patients stayed in the hospital for their long-term infusions. Hospital and family costs were high for a patient with such a limited need. Thus, home infusion therapy was born. Today, general home care is booming, for many reasons.
Why Is Home Care Expanding?
The Wide Range of Home Care Services
Infusion therapy is one form of home pharmacy service. You’ll learn more about home pharmacy service below, but there are also other options.
Types of Home Care Services
Home health care—Most people who receive home care need health care. Some people need skilled or semi-skilled nursing care. Perhaps they need complicated dressings changed. Others may have a dietician or a medical social worker. The patient may need help managing her diabetes. Even physical therapists, occupational therapists and speech therapists offer home care. Most states license home healthcare agencies. More than half are also certified to treat Medicare patients.
Personal care and support—Sometimes patients just need help with activities of daily living, such as help with bathing, hair care, shaving, even brushing teeth. Others need help preparing food or caring for their home. People providing these services may live in the home or visit at specific times.
Home equipment services—Some patients living at home require special equipment, which can include oxygen tanks, canes, walkers, wheelchairs or even large items, like hospital beds and elevated commodes. The Joint Commission, which accredits equipment providers, requires services, not just equipment. That’s why respiratory therapists often work for home equipment service companies. They help patients on long-term oxygen manage their breathing equipment and deliver oxygen to tanks. Uterine monitors, ostomy supplies and phototherapy lights, and services, are also provided.
For your interests, the most important home care service is home pharmacy service. The home services in this area often overlap with some services that community pharmacies provide. However, a true home pharmacy service has the following unique features:
1. Patients may be homebound and receiving nursing care. Patients may interact with pharmacy personnel only in their home or by phone.
2. The pharmacist, perhaps with the nurse or the patient’s hospital pharmacist, monitors the patient’s pharmacy care. The pharmacist may order tests to check the patient’s response to medications. Part of the pharmacy technician’s job at visits may be to input all temperature data into a personal digital assistant. Later it is downloaded and a pharmacist reviews it.
As you can see, dropping a prescription for a patient is different from offering full pharmaceutical care in the home. Many home pharmacy care services offer specialty services, such as infusion therapy and hospice care, which focuses on providing comfort to terminally ill patients. Some mail-order pharmacies also specialize in products for specific types of patients, and these are considered home care pharmacies, too.
So, now you’ve seen what home care services are all about. Now, how does a patient become a candidate for home care?
The Home Care Process
Let’s see how someone becomes a home care patient.
Intake: Becoming a Patient
>Step 1: Determine the need for home care.
Mrs. Freed has developed a serious vision problem. Her physician ordered IV steroids for her condition. While she is on the steroids, her kidneys needed to be monitored. However, both Mrs. Freed and her daughter were anxious for Mrs. Freed to stay in her own home. She has no other illnesses, so her physician agreed.
Step 2: Connect the patient with a home care provider.
Many times, patients move into home care from the hospital. In those cases, a discharge coordinator at the hospital performs this step. The discharge coordinator ensures that patients leaving the hospital have support services they need. In Mrs. Freed’s case, her physician has a social worker at his practice. The physician made the referral, and the social worker made the contact.
The intake coordinator or nurse’s assistant at the service takes the call. She gets Mrs. Freed’s information—address and phone number, diagnosis, type of treatment and care she needs, insurance information and other medical information.
Step 3: Evaluate the case.
The intake coordinator then takes Mrs. Freed’s information to the health team, who wants to be sure someone is able to perform the tasks associated with infusion therapy. Mrs. Freed isn’t otherwise ill, so she can perform some tasks. Her daughter is also available to help. Mrs. Freed’s insurance covers the care, and the team accepts Mrs. Freed.
Step 4: Provide the service.
At this point, the health team determines the type of infusion device that Mrs. Freed should use. The pharmacy technician’s tasks include gathering the supplies needed: dressings, tubing, needles and syringes. In a sterile environment, she then prepares the steroid medication. She pulls together the educational materials.
The home care team is then ready to visit Mrs. Freed. The company’s nurse shows Mrs. Freed and her daughter the drug and supplies. She also teaches them how to take care of the catheter. The team reviews the paperwork, explains the tests required for kidney function and gives Mrs. Freed and her daughter their pager numbers.
Step 5: Develop a care plan.
Upon the nurse’s second visit that day, she sees that Mrs. Freed is doing well. She and the rest of the team have developed a care plan for Mrs. Freed. The care plan specifies all parts of Mrs. Freed’s home care, including how the team will check to be sure the medication is working, signs of complications that Mrs. Freed and her daughter should watch for and Mrs. Freed’s supplies delivery schedule.
As their part of the plan, the staff at the company keeps records of Mrs. Freed’s home care, such as the physician orders, prescriptions, drugs and supplies and lab results. They also keep records of every time one of the staff communicates with Mrs. Freed or her daughter, and they set up a twice-weekly delivery schedule for drugs and supplies.
Empathy: A Special Requirement
Luckily, Mrs. Freed wasn’t an emergency intake patient. Sometimes, patients are discharged and need to be set up with home care in just a few hours. It can be a big adjustment to make in a short time, so that’s why home care providers require empathy.
The Goals of Home Care
The following main goals apply to all types of home care:
By now, you’ve seen how home pharmacy care fits into the bigger picture of home care services. It’s time to compare the role of the pharmacy technician in all three settings: community pharmacy, institutional pharmacy and home pharmacy care.
In this step, we’ll expand on many of the important types of tasks that are typical for each type of pharmacy technician. Let’s start in the community pharmacy.
The Role of the Community Pharmacy Technician
You already know the different types of community pharmacy settings, and you know that pharmacy technicians in community pharmacies serve customers. One of their primary tasks is filling prescriptions.
However, pharmacy technicians in community pharmacies must also be familiar with third-party payment systems. In fact, untangling a customer’s insurance requirements can be one of the most helpful customer service tasks! Let’s look at four payment-related tasks that pharmacy technicians typically perform.
Understanding Third-party Payments
A third-party program reimburses the pharmacy for the drugs and services it provides. Third-party payers can be insurance companies or programs, like Medicare. These programs can be large or small, but regardless of the size, the third-party payment program pays in one of two ways.
Two Mechanisms for Third-party Payments
1. Fee-for service—Sometimes, patients pay the pharmacy for their medication. They save their receipts and submit the receipts to their third-party payer. The payer then reimburses the patient. Obviously, this mechanism is easy for the pharmacy. Each transaction is complete when it’s rung up.
However, this mechanism sometimes operates differently. Sometimes the pharmacy provides the service and drugs to the patient. Then the pharmacy bills the third-party payer. The third-party payer then reimburses the pharmacy.
2. Capitation—Sometimes a pharmacy enters into an agreement with an insurance company. The pharmacy receives a specified amount of money for a group of patients. It doesn’t matter how many prescriptions or other services the patients use. The agreement is usually set up to pay a dollar amount per patient per month. For example, say the plan pays the pharmacy $5 per patient per month for 150 patients. The pharmacy receives $750 per month. If only 10 patients use the pharmacy, the pharmacy receives $750. If four patients receive eight different prescriptions each, the pharmacy still receives $750.
The most popular mechanism is fee-for-service in some form. Capitation was popular 10 or 15 years ago, when many HMOs were new. With capitation, the pharmacy can plan better—it knows how much income that company will provide each month. But fee-for-service is more flexible for patients and insurers.
The community pharmacy technician must obtain information from the patient about the patient’s insurance plan. Even returning patients have sometimes changed jobs or found another payer, so it is important to confirm the insurance information.
Coordination of benefits is a practice used to ensure that insurance claims are not paid multiple times when a patient is insured under multiple insurance plans. The idea behind it is that someone on multiple plans might be tempted to submit claims to all of them, pocketing the excess cash. If healthcare benefits are coordinated, the insurance companies share the burden without overpaying, and the insured is fully covered—but not covered to excess.
Once the patient’s insurance information is received, the pharmacy technician still has to ensure that the patient is eligible for that coverage. Many insurance companies issue cards to their patients. The card lists the name of the primary person who’s covered. Verifying the patient’s eligibility information is important to the business of the pharmacy. It lets the pharmacy collect payment for products and services as efficiently as possible.
Using the Right Formulary
Now the pharmacy technician needs to see what medications the insurance company uses. The list of drugs approved by the insurance company is the formulary. The company only pays for drugs that are on the formulary.
Different insurance companies use different formularies. Each company negotiates prices and rebate programs with different manufacturers. That’s why formularies differ from company to company.
Charging the Right Amount
Next, it’s time to ring up the sale. How much the patient will pay for a prescription depends on the type of co-payment or deductible she has.
Most third-party payers require the patient to pay at least some money for each prescription. The payer usually has one of the following four co-payment systems:
The Role of the Institutional Pharmacy Technician
When you learned about the hospital pharmacy technician job, you saw how complicated the hospital is. Hospitals today are still undergoing changes. The role of the pharmacy technician can vary greatly. Let’s look at the most important roles of the hospital pharmacy technician.
Maintaining Medical Records
The pharmacy may have its own computer system that connects to the larger hospital computer system. The pharmacy technician must maintain accurate records on each patient, including the following information:
The information that the pharmacy technician may use most often is the patient’s height and weight. It’s vital for calculating appropriate dosages.
Preparing Unit Doses
The pharmacy technician prepares the unit doses for individual patients in the wards. She packages each patient’s medications for the next 24 hours in separate packages, loads them into a cart and, after the pharmacist checks her work, distributes the medications to the appropriate wards.
Some medications already exist in pill or liquid form. Others need to be prepared “from scratch.” Often, a written procedure—like a recipe—is in place for a drug. In those cases, the pharmacy technician follows those written procedures to prepare the drug. Following “the recipe” to make a drug is called compounding.
Here’s where math skills come into play. The pharmacy technician must understand the original procedure thoroughly. Then, she must be able to alter the dosage depending on the patient’s size. A man who’s 5’6” and weighs 150 pounds requires a different dose than a man who’s 6’ and 250 pounds.
You know how many foods have “best before” dates on them? Most drugs do, too—even over-the-counter drugs. The same is true for drugs used in a pharmacy. How you store a drug can help it retain its potency for its full lifespan. The pharmacy technician must be aware of the drugs that require special storage and be sure that they’re stored properly.
Most drugs are administered to patients by a nurse or physician. However, drugs must make their way from pharmacies and satellites to the appropriate areas of the hospital. You’ve seen how to prepare unit doses for hospital wards. That’s one form of drug administration.
Pharmacy technicians also follow specified procedures when they prepare and deliver medications to other hospital areas, such as outpatient centers, nursing homes and emergency departments. The pharmacy technician is responsible for packaging these medications appropriately and delivering them in a timely way.
Entering Computer Data
Besides patient information, other types of information are important to the hospital pharmacy. If the pharmacy fell behind in data entry, the billing system for the hospital would not be efficient. It would be difficult to keep up with inventory because the pharmacy wouldn’t know how many units of each drug had been used. The pharmacists would not have the most up-to-date information on the patients.
The hospital pharmacy technician is responsible for tracking drug inventory. Part of the job requires checking the stock of each nursing unit in the hospital. She checks the amount of each medication that’s there; she makes sure it has not expired and that it is stored properly. If some medication is damaged or expired, she replaces it. She also tracks how much new medication each nursing unit needs.
Other pharmacy technicians perform this role for other nursing units. All the information feeds into the inventory records for the whole hospital. You’ve seen the role bar codes and other technology can play in managing drug inventory. But you also know that computers can’t perform all functions.
So, pharmacy technicians ensure that the drugs are ordered in time. When drugs are received, they check the receipt against the invoice and against the drugs in the boxes. Then they stock the shelves and send the appropriate amount of the new drugs to each nursing unit and to each satellite. They make sure drugs are stored appropriately in each location.
Using a combination of technology and pharmacy technicians’ skills, the hospital pharmacy can run efficiently and cost-effectively.
Each time the pharmacy technician fills a medication order, she must prepare a label. Often, computer systems prepare labels automatically based on the data that the pharmacy technician enters. That requires careful data entry! The label must mean the same thing to everyone who sees it—no shorthand allowed. It includes the following standard information:
A good label helps ensure the patient’s safety. Pharmacy technicians and pharmacists check the label against the package’s actual contents. They also check the label against the original medication order. The pharmacist initials the medications before they leave the pharmacy. In this way, everyone can be sure that the patient gets exactly what the physician prescribed.
Federal legislation protects the patient’s privacy. Pharmacies, like all healthcare providers, are bound by this legislation. Other people should not be able to see the information the pharmacy maintains. Patients must sign waiver forms that allow physicians and pharmacies to release specific information for specific purposes.
Usually, simple, common-sense measures prevent breaches of confidentiality. Pharmacy technicians may compare notes about their jobs, but they never discuss specific patients or personalities. Gossip is a breach of trust.
You know how important communication skills are for a pharmacy technician. In the course of her day, she sees patients and their families. She certainly sees other healthcare workers, and needs to be able to communicate effectively with everyone.
Drugs are chemicals. To work with chemicals effectively, you need to maintain a clean, safe environment. Keeping the work area organized and clean prevents pharmacy technicians from exposure to unsafe chemicals.
Each pharmacy area has emergency procedures and plans. The hospital or facility has facility-wide plans, too. Pharmacy technicians must be familiar with these procedures. When an unsafe condition or emergency occurs, the pharmacy technician must know what to do.
Now, let’s look at the role of the home care pharmacy technician.
The Role of the Home Care Pharmacy Technician
Remember the list of home care services that patients can receive? Some home care patients are sicker than others. Other home care patients have many kinds of health problems.
In all cases, home care requires a team effort from all involved in providing care and coordinating services. Let’s look at all the team members and their roles in home care.
The Physician’s Role
In health care, the team leader is the physician. She bears the ultimate responsibility for the health care the patient receives. The physician may not see the home care patient regularly—sometimes not even weekly. However, all orders for patient care must come from the physician and must be in written form. All changes to the order require the physician’s approval.
The Nurse’s Role
The nurse and the pharmacist provide the physician with most of the patient information. The nurse usually takes the lead role in teaching home care patients about their care. The education could be about medical devices, dietary changes or even how to give a sponge bath.
The nurse assesses how well patients follow prescribed plans, and she ensures that patients have the support they need.
The Pharmacist’s Role
You can think of the pharmacist as the information source for all drug-related information for the entire team. The pharmacist may consult with the physician about the best medication for the patient. The pharmacist also consults with the physician and the nurse about nutritional support for patients.
With the nurse, the pharmacist helps set up a care plan. The pharmacist educates both the patient and the nurse about the drugs, symptoms and appropriate laboratory data.
The pharmacist also monitors the patient’s progress. The pharmacist tends to focus on monitoring adverse drug reactions, documenting infections and tracking hospitalizations from home care. The pharmacist also monitors the patient’s laboratory data and overall progress to ensure that the pharmaceutical care is working on behalf of the patient.
The Pharmacy Technician’s Role
This role is to support the pharmacist by performing a wide range of tasks. Many times, especially in large home infusion services, the pharmacy technician spends much of her time preparing sterile IV products. In a small infusion company, the pharmacy technician might prepare IV products part of the time and spend other time on other tasks.
The list below is a sampling of the types of tasks a home care pharmacy technician might perform:
The Patient Service Representative’s Role
Some home care companies assign a person simply to be the patient’s point of contact. This is the person the patient calls if she runs low on a particular supply. She may be the person the patient calls if she has a problem with equipment. She maintains regular contact with the patient, sometimes weekly and sometimes more often. She may help coordinate deliveries. Often, the pharmacy technician fills this role.
The Reimbursement Specialist’s Role
Somebody has to be sure the bills get paid. In home care agencies, that person is the reimbursement specialist. She talks to insurance companies and knows Medicare and Medicaid policies inside and out. She coordinates all the billing for the services the company provides. She processes collections from patients and from their insurance companies. She even resolves disputes and keeps the insurance company up-to-date on the patient’s progress and therapeutic plan. She rarely sees patients, but what she does directly affects their care.
The reimbursement specialist also provides some input into the care plan by making sure that the drugs the home care team wants to use are covered by the insurance company. If they aren’t, she may try negotiating with the insurance company. Performing all these functions in a timely way keeps the company financially viable.
The Patient’s Role
With all these people caring for the patient in her own home, the patient has nothing to do, right? Wrong! The patient’s job is to get well. When the patient recuperates at home, getting well can require a lot of work! The burden of care may fall on her shoulders. She may also have a caregiver, a family member or friend, who takes care of some daily tasks.
Because so much depends on the patient’s ability to participate in her own care, she also has input into the care plan. She and other caregivers have a right to be involved in decision-making. After all, everyone on the home care team actually works for one person’s benefit—the patient’s.
Now you know about all the exciting possibilities for pharmacy technicians in home care. Before we wrap up this lesson, test your understanding of home care pharmacies and the role of pharmacy technicians in all areas of care in this Practice Exercise.
Step 12: Practice Exercise 2-3
1. Which of the following is a unique feature of home pharmacy care?
a. The patient is usually homebound and may communicate with the pharmacy only by phone.
b. The patient orders medication delivered to the home for convenience.
c. The patient comes in to see the pharmacist once a week.
d. The pharmacist is unaware of many of the patient’s medications.
2. Why must pharmacy and nursing personnel be available to home care patients 24/7?
a. Home care patients hardly ever call, so giving the numbers isn’t a problem.
b. Home care patients can be overwhelmed by new responsibilities and may need support.
c. Home care patients are entitled to personal care any time of the day or night.
d. Home care patients would prefer to go to the hospital’s emergency room.
3. Which of the following best defines a third-party payment program?
a. A company that pays pharmacies to use their own special drugs
b. A company that pays patients to go to specific pharmacies
c. A company that reimburses pharmacies for drugs and services it provides
d. A company that reimburses patients for staying well
4. In a fee-for-service system, _____.
a. the pharmacy is charged a set fee per patient, regardless of the care given
b. the patient may save pharmacy receipts and send them to the insurance company for reimbursement
c. the pharmacy charges the patient based only on the patient’s income
d. patients must be pre-approved by physicians for specific educational services
5. A pharmacy technician verifies eligibility with an insurance company because _____.
a. the patient may be covered even though her name isn’t on the company card
b. insurance companies never issue cards to their clients
c. patients always try to cheat pharmacies out of antibiotics
d. it’s hard to fill a prescription when you don’t know how much the patient will pay
6. What is the best definition of a formulary?
a. A formal procedure for mixing drugs
b. A formula for calculating patient dose
c. A list of drugs a specific insurance company covers
d. A formal agreement between pharmacists and patients
7. Why is it important for an institutional pharmacy to have the patient’s height and weight?
a. They provide information to the federal government about obesity.
b. They use this information to calculate appropriate dosages.
c. They don’t need this information.
d. Medicare won’t cover the patient without this information.
8. Compounding is best defined as _____.
a. a leg broken in more than one place
b. following a procedure to make a drug “from scratch”
c. improving a procedure to dispense a drug
d. calculating a patient’s charge based on the previous day’s charge
9. The role of the pharmacy technician on the home care team is to _____.
a. direct the work of others
b. counsel the patient about possible conflicting medications
c. prepare medications, arrange for delivery and coordinate the IV room
d. serve as a drug resource for the rest of the team
Pharmacy technicians have a lot of options. They also have a lot of important responsibilities! They perform many tasks that directly and indirectly affect the health of patients.
Community pharmacies rely on the customer service skills of pharmacy technicians. These businesses do more than provide drugs for patients who are sick. Pharmacy technicians also often help them unravel the mysteries of their insurance drug plans. Professional knowledge, behavior and attitude are vitally important in this setting.
Institutional pharmacies also require good communication skills. Pharmacy technicians may specialize in one type of work, or they may also perform a variety of functions, from filling prescriptions to maintaining inventory and making deliveries. Pharmacy technicians are an important part of a hospital’s healthcare team.
Home care agencies are a growing area of health care in general. The opportunities for pharmacy technicians are growing. These companies and the pharmacy technicians may specialize. In large companies, pharmacy technicians may prepare IV solutions for much of the day. Pharmacy technicians can also work for smaller companies and perform more varied tasks.
In all of these pharmacy settings, pharmacy technicians must demonstrate their knowledge of medications. They must follow procedures safely and effectively. They must be able to get along well with all different types of people, from customers or patients to physicians and pharmacists.
This lesson should have given you a good sense of the importance of communication skills. In the next lesson, you’ll start learning the special language of pharmacy—abbreviations. But first, test your learning of pharmacy technicians’ roles with the following Quiz.
Once you’ve mastered the course content, locate this Quiz in your Online Course or your Assignment Pack. Read and follow the Quiz instructions carefully.
1 “Molcajete (Mortar and Pestle).” GourmetSleuth.com. Web. 27 May 2014.
2 “About Us.” The Joint Commission. Web. 27 May 2014.
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