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INTRODUCTION

Managing drug inventory in a pharmacy is a common task for pharmacy technicians. Data suggest that pharmacy technicians spend nearly one-quarter of their workday maintaining medication and inventory control systems.¹ Drugs are typically purchased from a wholesaler, each of which may have a unique system for ordering and in some situations may have the ability to establish a perpetual inventory that automatically maintains set quantities of commonly used medication. It is important in the delivery of high quality patient care to ensure that medication is available when it is needed by patients. Pharmacy technicians must balance keeping adequate inventory that can fulfill patient needs with minimizing unnecessary stock. Most drug wholesalers have a return process that can be used when excess amounts of drugs or unneeded drugs are on the pharmacy shelf.

Today’s pharmacy technicians are called upon to perform a wider variety of tasks including prescription input, medication counting and filling, as well as maintaining inventory control systems.² Medications that remain on hand for long periods of time can be costly to the pharmacy and have a negative financial impact. To further complicate management, drug inventory can be affected by a number of factors such as new or first-in-class medications, patent expirations, and inventory spoilage (ie, time or storage conditions that cause medicines to weaken), and drug recalls.³ In order to maintain an adequate, cost-effective supply of medications, both technicians and pharmacists must ensure that effective inventory procedures are established and maintained. The following continuing education course will review common factors that impact drug inventory and offer recommendations on how to manage these situations effectively and efficiently.

IN WITH THE NEW: THE IMPACT OF NEWLY APPROVED MEDICATIONS ON INVENTORY CONTROL

Each year the U.S. Food and Drug Administration (FDA) Center for Drug Evaluation and Research (CDER) approves many new medications, which can include new dosage forms of existing medications, new indications, generic formulations, or novel agents.⁴ In 2017 and 2018, the combined number of novel medications approved was 105; approximately one-third (34) of these medicines were identified as first-in-class, meaning they have a new and unique mechanism of action for treating a medical condition.^4,5 As new products become available, pharmacy technicians should become familiar with their product labeling, dispensing requirements, and the anticipated need for the drug. Another factor to consider is the schedule of the medication. Ordering, receiving, and record-keeping requirements vary based on the schedule of a drug and on-hand tracking requirements must also be considered. For example, the FDA approved Epidiolex for the treatment of seizures associated with two rare and severe forms of epilepsy, Lennox-Gastaut syndrome and Dravet syndrome, in patients two years of age and older in 2018. Epidiolex contains cannabidiol (CBD), a chemical constituent of the cannabis plant (commonly referred to as marijuana). The CBD in Epidiolex is extracted from the cannabis plant and is the first FDA-approved drug to contain a purified extract from the plant. The Drug Enforcement Administration (DEA) placed Epidiolex in schedule V.⁶ Because it is a controlled substance, an initial count of all Epidiolex stock on hand must be performed and recorded to be in compliance with 21 C.F.R. § 1304.11(d).⁶ Invoices must be retained for two years and be kept separate from other records.⁷ In addition, after the initial amount of stock is recorded, each pharmacy is required to include Epidiolex in the controlled substance inventory that occurs at least every two years.⁶

Epidiolex must be dispensed with its accompanying FDA-approved patient Medication Guide (MedGuide) because of its potential for causing liver impairment and suicidal thoughts.⁸ A MedGuide is a paper handout written in patient-friendly language that provides information centered on the safe and appropriate use of a particular medicine.⁹ The FDA requires that MedGuides supplement certain prescribed drugs and biological products when the Agency determines any of the following: (1) certain information is necessary to prevent serious adverse effects; (2) patient decision-making should be informed by information about a known serious side effect with a product; or (3) patient adherence to directions for the use of a product are essential to its effectiveness.⁹ Importantly, each MedGuide must be given directly to each patient or each patient's agent when the product is dispensed, unless an exemption applies (ie, patient is admitted to an inpatient ward). Many pharmacy software systems automatically print MedGuides when medications are dispensed but pharmacy staff should also be familiar with the drugs that must be accompanied by these guides. Technicians should alert pharmacists to explain the information presented in each MedGuide to patients if they need assistance. A current list of medications requiring MedGuides can be found on the FDA's website at: http://www.fda.gov/Drugs/DrugSafety/ucm085729.htm.

Once a new product is stocked, pharmacy personnel should closely monitor new product entries during the first several months to ensure the product is moving off the shelf and not showing out-of-stock.

PHARMACY INVENTORY BASICS

A sufficiently stocked pharmacy inventory typically includes basic stock plus safety stock. Basic stock is the amount of inventory carried on hand to meet an average demand level, while safety stock is the amount of inventory kept on shelves to account for fluctuations in demand.¹⁰ Benchmarks for assessing quantities of basic and safety stock include inventory turnover (the number of times inventory is used during the year) and inventory turn days (the average number of days' worth of stock on hand); the mathematical formulas for each of these terms is listed below in Table 1.

A basic understanding of the above-mentioned benchmarks is essential because sustaining excessive quantities of slow-moving inventory is not cost efficient. For these reasons, many pharmacies often adopt a just-in-time (JIT) inventory strategy, or wait-and-see approach, regarding newly approved or expensive medications, only stocking selected items as demand requires. To further illustrate this approach, the following pharmacy practice example is presented:

Pharmacy practice

Duane is a pharmacy technician at an independent community pharmacy. While stocking over-the-counter pain relief medications, Duane is stopped by a woman, KW, and asked if Orilissa (elagolix) is available in the pharmacy. KW explains her doctor has told her about Orilissa, a new medicine to treat endometriosis, a condition she has suffered from for many years. After searching through the order-entry system and pharmacy shelves, Duane and the pharmacist determine that elagolix will have to be specially ordered. Duane communicates this information to KW and also mentions that it is only available as a brand-name product. She further comments that the copay for the medicine would be $50 (based on her insurance plan) and would be ready for pick up tomorrow afternoon. KW leaves the prescription and indicates that she will stop back tomorrow evening to get the medication. Why do scenarios like this occur in pharmacy practice?

Discussion

Because elagolix was recently approved, there is a good chance that is not yet stocked in the pharmacy due to its price point. Most pharmacies wait to stock a new product until a prescription is received for it. If a supplier's payment terms were 2% net 15 days and the turnover of elagolix averaged 60 days, the stock would not be sold before the supplier must be paid, which would increase the overall cost of the pharmacy's stock. For this reason, elagolix, and other medications with similar turnover rates, may need to be specially ordered in designated situations, further emphasizing the importance of building rapport with existing and potential patients.

OUT-OF-STOCK MEDICATION

In addition to understanding product labeling and dispensing requirements that accompany newly approved medicines, it is important for pharmacy technicians to recognize the demographics and be acquainted with the needs of the patient population they serve. According to a recent customer satisfaction survey involving chain drug store pharmacies, pharmacy staff and customer interactions are an increasingly important driver of satisfaction¹¹; notably, ensuring a continuous supply of medication was among the topics of conversation that impacts customer satisfaction the most.¹¹ When a pharmacy is out of an item that a customer needs or wants, the overall impact can be substantial. When an item is out-of-stock (OOS), it should be communicated to the patient so that a course of action may be planned. Many pharmacy systems send an automated message or automated call to the patient. Often, the needed product can be ordered to be dispensed at a later date but in certain situations the need is immediate. In some instances, OOS items can lead to patient harm (eg, life-threatening emergencies) therefore pharmacy staff should consider what a medication is for when discussing OOS items with a patient.¹⁰ Technicians should consult a pharmacist if they are unsure of the consequence of delaying the start of a new medication or interrupting an existing treatment. Patients should be presented with information when a medication is OOS regarding the cost of the medication, the expected arrival date and time, the option to transfer the medication to another pharmacy, etc so that they can make an informed decision and avoid any unnecessary frustration.

Another situation that may occur in the pharmacy is having some of a needed medication on-hand but not the full amount needed by the patient. In this case, the pharmacy can partially fill the prescription and complete the amount when the medication is in stock again. This can also cause confusion for patients and must be explained. Pharmacies usually provide three to five days' supply to the patient, allowing time to order and restock the drug. Pharmacies may charge patients a portion of the total cost for the partial fill or wait and charge the patient for the full amount when the balance is complete. It is important to verify that the medication can be obtained before a prescription is partially filled and that the patient will accept the cost of the completion if there is no initial charge. As with OOS prescriptions, having a conversation with the patient and making sure they understand the situation can improve patient satisfaction.

One reason that products may be OOS or only in limited supply on the pharmacy shelf is drug shortages. Periodically, companies are unable to supply drugs due to manufacturing problems, supply chain issues, FDA compliance problems, business failures, drug recalls, and raw material availability.¹² Shortages can leave patients without important medication. All pharmacy staff should be aware of current drug shortages so that patients are given correct information regarding when their prescription will be available and interventions can be made (eg, contacting prescribers for alternative medication approval) to prevent interruption of therapy and patient harm. Communication regarding shortages is also very important in the hospital setting. Pharmacy staff must implement proactive processes to avoid issues that may stem from drug unavailability. This includes identifying alternatives, establishing protocols to modify existing orders, and relaying information to all hospital staff through the electronic medical record or direct communication.¹³ Lists of current drug shortages is available at the links listed below:

http://www.accessdata.fda.gov/scripts/drugshortages/default.cfm
https://www.ashp.org/Drug-Shortages

MAKING THE SWITCH: BRAND TO GENERIC TRANSITIONS

Generally, it takes approximately 10 to 15 years to bring a new medicine to market and costs up to $2.6 billion.^14,15 These new drugs are under patent and exclusivity protection for a limited amount of time. When periods of exclusivity expire (5-7 years), manufacturers can submit an abbreviated new drug application (ANDA) to the FDA for approval to manufacture and sell generic versions of the medication. The ANDA process does not require the same level of studies and trials that were needed for the initial approval of the ingredient in question.¹⁶ Brand to generic transitions generally occur in the following ways: (1) authorized generics are initiated by innovator pharmaceutical companies or (2) branded products are directly converted to generic formulations.

The Drug Price Competition and Patent Term Restoration Act of 1984 (commonly known as the Hatch-Waxman Act) was designed to ease the introduction of generic drugs into the marketplace.¹⁷ In addition, the Act encouraged generic drug manufacturers to challenge a patent associated with a brand-name medicine prior to its expiration by allowing a 180-day market exclusivity period for the first generic manufacturer (first filer).¹⁷ This means the first filer would not have competition from other generic manufacturers during the first 180 days of distribution. However, this marketing exclusivity period does not prevent an innovator company from introducing its own generic version (eg, referred to as an authorized generic) during this time period, which allows the brand-name manufacturer to maintain its market share longer.¹⁸

An authorized generic is the brand-name company's own product repackaged and marketed as a generic drug either through a subsidiary or a third party.¹⁸ The drug usually has the identical color, size, shape, dosage form, strength, as well as active and inactive ingredients as the branded product. With authorized generics, pharmacies can usually expect the same supply chain reliability they experienced with the branded product, considering the authorized generic company benefits from multiple years of manufacturing experience and the steady availability of raw materials.¹⁸ Because authorized generics compete directly with generic medicines that are FDA approved under an abbreviated new drug application (ANDA), the overall cost of nonbranded medicines is reduced, which further assists pharmacies and consumers.¹⁸ In fact, a Federal Trade Commission (FTC) empirical study of the competitive effects of authorized generics found that when a brand company chooses not to launch an authorized generic during the 180-day marketing exclusivity period reserved for the first-filing generic under the Hatch-Waxman Act, consumers end up paying higher prices for generic products.¹⁸

Making a rapid transition from a brand to a generic formulation is a critical element of effective inventory management, but requires a certain amount of readiness.¹⁹ To maximize savings on soon-to-be-available generic medicines, pharmacy technicians and staff should begin to decrease the on-hand inventory of branded medicines so generic substitutes can be utilized as soon as they are available.¹⁹ One key indicator to assist in this decision-making process is inventory turn days (Table 1). Once you are aware of the average number of days' worth of branded stock on hand, informed decisions regarding the best method to reduce remaining stock can be made. Many prescription insurance plans will not pay for a brand name medication without a specific request from the prescriber when a generic alternative becomes available. Therefore, it is important to anticipate the switch and order the generic version so that patients will not have a lapse in treatment or pay unnecessary prices for needed therapy.

Another important aspect of the transition from a brand to generic formulation is patient education. Patients should be made aware that they are receiving a new generic version of a medication and that it may appear different (ie, color, shape, imprint). Patients may voice concerns about the switch. Technicians should help patients understand the regulations that are involved with the manufacturing of generic drugs and be prepared to answer questions, and seek pharmacist involvement when asked about the equivalence of the two products. It should also be noted that many different companies may manufacture generic versions of the same drug. It is ideal to maintain the same generic version in stock but this is not always possible due to pricing and availability. Patients should receive information about the unique appearance of medication when changes in dispensing occur.

INVENTORY SPOILAGE: WHEN GOOD DRUGS GO BAD

Medicines have expiration dates and storage requirements for which pharmacy technicians must be aware. Pharmacy technicians play a key role in receiving orders from drug suppliers and storing the drugs in the pharmacy. Medicines that have expired or have been stored inappropriately can lead to altered drug activity, significant reductions in potency, and possible harm to the patient.³ These effects are referred to as inventory spoilage. It is important that pharmacy technicians continually validate storage conditions in the pharmacy and check all stock for medicines regularly for expiration dates.

Expiration dates and beyond-use-dates

The expiration date of a medicine is defined by the United States Pharmacopeia (USP) as the time during which the article may be expected to meet the requirements of the pharmacopeial monograph provided it is kept under the prescribed conditions.²⁰ Expiration dates are based on stability studies of the drug in the original unopened container, although drugs are considered to be in date until the manufacturer's expiration date has lapsed, assuming proper storage and packaging as stated in the product package insert. However, exceptions may apply to drugs that has been identified as having a shortened expiration date once the container is opened. For example, dabigatran (Pradaxa), an anticoagulant indicated for the prevention of stroke in patients with atrial fibrillation, must only be dispensed in the manufacturer's container—not amber prescription vials—due to moisture-related concerns. Also, the medication must be discarded within 4 months after the container is opened.²¹ A manufacturer's expiration date is usually expressed in terms of month/year or day/month/year. If only the month and year are stated on the manufacturer's product, the medicine may be used until the last day of the stated month.²⁰ For example, if the expiration date on manufacturer's label states 5/19, the drug can be used until May 31, 2019, assuming proper storage and packaging.

Most pharmacies, whether in the community or institutional setting, have specific policies in place regarding the rotation of new and old stock items to minimize inventory spoilage. For example, when shelving medicines from a new drug shipment, new products are placed on shelves behind older products so those with shorter expiration dates are used first.²² Other inventory strategies that help reduce spoilage include affixing colored stickers to stock items that are approaching expiration; limiting the use of short-dated items in crash carts, rapid intubation kits, and heart team boxes; and assigning technicians to specific pharmacy bays to continuously monitor for medications that may be going out of date.²² Additionally, as select products near expiration, pharmacy technicians must be familiar with the credit/return practices of their wholesaler(s), considering each supplier usually has policies and procedures that must be followed in order to receive credit on returns.²³ It is important to process returns on a consistent basis from a financial standpoint and to maximize pharmacy shelf space.²³

Importantly, the terms expiration date and beyond-use-date (BUD) are not to be used interchangeably. A BUD is the date beyond which medications that have been manipulated and/or repackaged and stored or dispensed in a container other than the original manufacturer's container should not be used.²⁰ Pharmacists routinely affix BUDs to prescription vials that are nearer than the expiration date on the stock bottle because the following factors must be taken into consideration during the dispensing process: the conditions under which the medication is to be stored by the patient, the nature of the drug being dispensed, and the frequent opening of the container.²⁰ According to USP, the BUD for a multiple-unit container, such as a prescription vial, is the expiration date on the manufacturer's label or 1 year from the date the drug is dispensed—whichever is earlier.²⁰ Similarly, for nonsterile solid or liquid medicines that are repackaged into single-unit and unit-dose containers, USP states the BUD should be 1 year or the time remaining of the manufacturer's expiration date—whichever is less.²⁰ Reconstitutable medications (eg, antibiotic suspensions that require the addition of water) have specific BUDs that should be communicated to patients. In most cases, the course of treatment is shorter than the BUD for these drugs, but in certain circumstances, such as longer than usual treatment duration or small doses, the antibiotic may reach the BUD before the patient's therapy is complete. This should be considered during the dispensing process and before adding water to any reconstitutable medication. Insulin is another example of a drug that may be affected by the BUD. Once vials of insulin or insulin pens are initially used, they should be discarded after a time period recommended by the manufacturer which is typically 28 days. This is important when calculating the days' supply (ie, the length of time the quantity dispensed to a patient should last based on the instructions from the prescriber) and determining the amount of insulin to dispense. The following pharmacy practice example will help to explain this situation:

Pharmacy practice

Duane, the pharmacy technician, is presented with a prescription for insulin glargine (Lantus) vials from patient MM. This is the first insulin glargine prescription for this patient. The prescription states that the patient should inject 20 units of insulin glargine subcutaneously every night at bedtime. The prescribed quantity is one vial with a duration of therapy of 30 days and 2 refills. How does this prescription present a challenge and what is the most appropriate action to take?

Discussion

Many concerns may be present when a patient begins insulin therapy. In this situation, Duane must calculate the days' supply for one vial of insulin using the directions on the prescription. The concentration of the insulin glargine vial is 100 units/ml. Each vial contains 10 ml of insulin glargine meaning that each vial contains 1,000 units of insulin glargine. If MM is using 20 units at bedtime each day, one vial would last 50 days. However, the information from the manufacturer states that vials should not be used beyond 28 days after their first use. If the prescription is filled with the one vial, then MM would need to be instructed to discard the vial and any remaining insulin after 28 days and the prescription for one vial should be given a 28 day supply. This will results in waste and potentially wasted expense. Duane looks at the insulin glargine (Lantus) pen devices and they contain 3 ml of 100 units/ml. Duane calculates that one 300-unit pen would be a 15 day supply and that dispensing 2 pens would result in the desired 30 day duration of therapy and not require any insulin to be thrown away. Duane discusses the situation with the pharmacist and has determined that MM’s insurance will cover the pens with no additional copay increase. The pharmacist contacts the doctor to have the prescription changed to the pen devices.

Notably, discussion of BUDs for sterile and nonsterile compounded products is beyond the scope of this manuscript; however, each topic is addressed in USP Chapter <797> and USP Chapter <795>, respectively.

PUT IT BACK! RETURN TO STOCK AND RECALL CONSIDERATIONS

An estimated 3% of the 3.6 billion prescriptions written annually are abandoned at the pharmacy.²⁴ If a medication has not been picked up by a patient, it can be returned to stock (RTS) (ie, placed back on the shelf with the pharmacy inventory) once it has been credited back to the patient's profile.²³ When returning an item to inventory, the product should not be put back into the original stock container. This can reduce any potential problems that might arise from mixing lot numbers, different manufacturers of the same drug, or even different drugs. Also, recall that the USP definition for BUDs applies to drug that are no longer in their original container.²⁰Thus, when replacing an RTS item to the shelf, it should be kept in its amber prescription container and should retain the same BUD that was placed on the prescription label. This keeps the repackaged product in line with USP standards. It is common practice among pharmacies to return items to stock every 7 to 12 days. By developing a standardized approach for handling RTS products, pharmacies can maximize inventory dollars and lessen the practice of excessive billing. In a similar way, RTS rules have been established for community pharmacies that use delivery services. If a prescription is unable to be delivered and does not leave the possession of the driver, it can be returned to stock. However, according to the National Association of Boards of Pharmacy (NABP), the type of delivery service that is used influences which items can be returned. For example, consider the 2 scenarios listed below:²⁵

1. If a pharmacy attempts but is unable to deliver a prescription medication using its own staff or its own local delivery service, then the prescription medication may be returned and reused by the pharmacy if: (1) it is in the original manufacturer's packaging or the dispensing pharmacy's original packaging; and (2) returned immediately to the pharmacy.
2. If a pharmacy attempts but is unable to deliver a prescription medication using an approved common carrier, then the prescription medication may be returned and reused by the pharmacy if: (1) it is in the original manufacturer's packaging or the dispensing pharmacy's original, sealed, and tamper-evident packaging; and (2) returned to the pharmacy within 14 days of the unsuccessful delivery attempt.

In addition, all medications that were unable to be delivered must meet the following requirements in order to be returned to stock: (1) each returned medicine must have a BUD of at least 6 months from the date of return; (2) the returned packaging of each medicine must demonstrate that the product's integrity and stability have been maintained; and (3) each returned medicine must be evaluated by appropriate pharmacy staff to ensure that it is not adulterated or misbranded.²⁵ Importantly, pharmacy personnel should not return a drug to stock once it has been dispensed or delivered to a customer because the strength, quality, purity or identity of the product can no longer be guaranteed.

Another situation in which drugs are returned is a drug recall. In this case, they will not be returned to stock but will be removed from the pharmacy according to procedures outlined by the pharmacy and distributors. This may also impact OOS and partially filled prescriptions. Recalls occur when a product or device is removed from the market or a correction is made either because it is defective or potentially harmful. A company may discover a problem and initiate a recall on its own. Other times a company recalls a product after the FDA discovers a problem with a product. It is important to process all recalls in a timely manner to avoid any potential patient harm.²⁶

FDA recalls are categorized as class I, II, or III based on the likelihood of harm to the patient.²⁶ Recall submissions to the FDA are required to provide detailed information needed to identify the product in question and process the recall. NDC numbers, lot numbers, and UPC codes can be used to select the recalled product. Also included is the level in the distribution chain to which you are extending the recall (ie, wholesale/retail/pharmacy/medical user). In the case of a user level recall, the pharmacy should contact all patients who may have received the recalled drug and advise the patient on what to do with the medication. Product should be promptly removed from the shelf and from the will-call bin so that it cannot reach the patient.²⁷

The recall strategy should also "Explain if this recall will create a market shortage that will impact on the consumer." ²⁷ The removal of a drug and the length of time that it is unavailable can impact the health of patients if the medication is not available from another source, or if other sources are depleted due to the recall. Pharmacy staff should be prepared to offer options to patients so that they can continue therapy. This may include contacting providers to request an alternative medication for the patient that can be used until the drug is available again. Lists of recalled products may be found at: http://www.fda.gov/Drugs/DrugSafety/DrugRecalls/default.htm.

HOT AND COLD: REGULATING STORAGE CONDITIONS

It is important that pharmacy technicians have a firm understanding of the temperature ranges for which medicines must be stored because spoilage significantly impacts drug inventory and patient safety. All pharmacies are required to be kept at controlled room temperature (CRT). CRT is defined as a temperature maintained thermostatically that encompasses the usual and customary working environment of 20°C to 25°C (68°F to 77°F), resulting in a mean kinetic temperature (MKT) that is not more than 25°C or 77°F.²⁰ Table 2 defines USP recommended temperature ranges that should be followed when storing medications, and adherence to these storage practices can help evade costly storage and handling mistakes.

This is a significant concern because exposure to inappropriate temperatures can reduce the strength and effectiveness of vaccines. As a result, patients are not provided with maximum protection against preventable diseases.²⁸ Consequently, it is important that every pharmacy technician is aware of storage recommendations for all medications, especially vaccines, considering the growing number of vaccines that are administered in the pharmacy setting.²⁹ Notably, some medicines have storage requirements that are slightly different from those temperature ranges described in Table 2. For example, before lyophilized varicella virus vaccine (Varivax) is reconstituted, it must be stored at a temperature that is between -50°C and -15°C (-58°F and +5°F), which is different from the recommended USP freezer temperature range of -25°C to -10°C (-13°F to 14°F).³⁰ Appropriate storage information can be found in section 16 of the product package insert for each drug available, How Supplied/Storage and Handling.³¹ With regard to the appropriate storage and handling of vaccines, the following two references may be useful:

• Centers for Disease Control and Prevention (CDC) Vaccine Storage and Handling Toolkit. http://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf
• Immunization Action Coalition (IAC) website, which contains product package inserts in PDF format for each U.S. licensed vaccine. http://www.immunize.org/.

It is good practice to develop a working list of refrigerated and frozen medicines to post in the pharmacy so personnel are reminded about the storage requirements for specific medicines, particularly when shelving new orders. Due to the frenetic pace of many pharmacy work days, situations may arise when storage requirements of medicines are interrupted for a short period of time. In each circumstance, the pharmacist must be notified because the package insert, stability references, or the manufacturer may need to be consulted to determine how the interruption may impact product stability.³² The following rules for handling refrigerated and frozen medication may help prevent these situations from occuring:³²

Key messages regarding drug inventory

• Section 16 of the manufacturer’s product insert provides specific, detailed storage and handling protocols for individual medicines (How Supplied/Storage and Handling).
• Because some medicines must be protected from light, it is best to keep refrigerated products in their original containers. This also helps to minimize confusion with labels that look similar.
• When new orders arrive at the pharmacy, unpack and put away refrigerated/frozen items first to limit spoilage.
• Ideally, refrigerator temperatures should be recorded at least twice daily. Ensure that pharmacy staff members are recording each temperature on a retrievable document.
• Once a prescription for a refrigerated medication has been filled and checked, place it back in the refrigerator until the patient arrives to pick up the medication.
• Be familiar with the pharmacy’s back up plan in the event of a power outage. Medications that are stored in the refrigerator are often very expensive and can be costly in the event of inventory spoilage.

CONCLUSION

Pharmacy surveys demonstrate that one of the most important patient satisfaction markers is continuous access to their medications. Not only do pharmacy technicians play a key role in the safe, effective, and continuous use of medications, but they provide pharmacists with logistical support to keep operations running smoothly. By taking an active role in efficient inventory management, such as taking precautionary steps to limit inventory spoilage and monitoring prescription inventory turn days, technicians will enable pharmacists to shift their focus toward direct patient care while at the same time ensuring that pharmacy operations are cost-effective.

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21. U.S. Food and Drug Administration. Medication Guide: Pradaxa (dabigatran etexilate mesylate). http://www.fda.gov/downloads/Drugs/DrugSafety/UCM231720.pdf Accessed March 17, 2020.
22. Technician Tutorial, Drug Expiration and Beyond-Use Dates. Pharmacist’s Letter/Pharmacy Technician’s Letter. November 2017. Therapeutic Research Center website. https://pharmacist.therapeuticresearch.com/Content/Segments/PRL/2015/Oct/The-Ins-and-Outs-of-Pharmacy-Inventory-9046. [subscription required.] Accessed April 6, 2019.
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24. IMS Institute for Healthcare Informatics. Medicine Use and Shifting Costs of Healthcare: A Review of the Use of Medicines in the U.S. in 2013. April 2014. https://oversight.house.gov/sites/democrats.oversight.house.gov/files/documents/IMS-Medicine%20use%20and%20shifting%20cost%20of%20healthcare.pdf Accessed March 17, 2020.
25. National Association of Boards of Pharmacy. National Association of Boards of Pharmacy Position Statement on the Return and Reuse of Prescription Medications in the Community Pharmacy Setting. July 2009. https://nabp.pharmacy/wp-content/uploads/2016/07/Return-Reuse-Rx-10-2012.pdf. Accessed March 17, 2020.
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30. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (DHHS). Vaccine Storage and Handling Tool Kit: January 2019. https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf Accessed March 17, 2020.
31. U.S. Food and Drug Administration (FDA). Selected Requirements of Prescribing Information. https://www.fda.gov/media/71836/download Accessed March 17, 2020.
32. Technician training tutorial: stay cool: storing meds in the fridge or freezer. Pharmacy Technician's Letter. 2012;28(12):281230. Therapeutic Research Center website.

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