People everywhere expect the medicines they receive in hospitals, clinics, pharmacies and drug shops to be of good quality. But often medicines are dispensed by counting them out with bare hands. Through this practice, the medicines can become contaminated and may not work properly. This can have serious health implications.
Pharmacy attendants at Madisi Community Hospital in Madisi, Malawi
Judy Wang, Alison Wong, Sarah Morrison and Tina Brock from Management Sciences for Health report on the issues that affect all health workers who handle medicines.
Why is counting medicines with bare hands a problem?
Using bare hands to count and dispense medicines can lead to contamination of the product. When medicines come into prolonged contact with skin, moisture, oils, bacteria and viruses can be transferred directly to the tablets or capsules. This can cause the medicine not to work as well, as it should or it might even make the patient more ill. Contaminated medicine could be especially problematic for persons who are at high risk of infection, including children or adults living with HIV or AIDS.
Bare hand dispensing not only contaminates the medicine that is given to the patient today, but it can also taint the remaining stock in the product container, causing problems for future patients. In addition, when dispensers count different types of tablets with their bare hands, one straight after another, the powder residue can be transferred between products and this might lead to an allergic reaction being attributed to the wrong medication. This could reduce access to effective agents or increase the unnecessary use of more expensive medicines.
Medicines must be handled very carefully during the dispensing process. There are some guidelines that describe the characteristics of a good dispensing environment. They include having adequate equipment, performing regular equipment cleaning, and following good staff hygiene practices(1,2,3). But strict implementation of these guidelines has been a challenge in the developing world.
In fact, despite a long history of informal campaigns to promote appropriate dispensing practices, the bare hand counting of medicines remains fairly common in Africa, Central Asia, South East Asia and several Latin American and Caribbean countries(4,5). This is possibly because health workers and pharmacy support staff are not provided with enough knowledge about good dispensing practices, they don’t have access to the necessary equipment, and standards are only enforced in a limited way.
What can we do to improve the quality of care provided?
Addressing the challenges to good dispensing practices solely through isolated campaigns has not been an effective or sustainable solution. With this in mind, we recommend a more comprehensive approach. Dispensers need to be provided with more knowledge about handling medicines properly; they need access to proper dispensing equipment; standards for good dispensing should be enforced at each facility; and the public need to be informed and have higher expectations about the quality of medicines.
Train health workers to dispense medicines properly
We must make sure that all cadres who provide pharmacy support services are trained in the principles of good dispensing. This means that students in all medicines-related training programmes worldwide should be specifically advised against bare hand counting of medicines as part of the formal curriculum. Tutors who teach in these programmes and those who train dispensers through informal mechanisms must model good practice. Pharmacists and technicians who supervise dispensers must evaluate these activities and provide feedback.
Ensure access to suitable dispensing equipment
We must also ensure that all dispensing sites have access to suitable dispensing equipment. The guidelines recommend using a plastic counting tray and spatula; but despite being relatively inexpensive, these products are not abundant worldwide. To increase their availability locally, professional societies, councils, governments and Ministries of Health should work together on a campaign aimed at requiring manufacturers and agents to provide these important supplies as a condition for registering in, and selling medicines to, the specific country.
While this is being addressed, dispensers without access to trays should count medicines on a clean, flat surface (such as the container lid or plain paper). A clean spoon, tongue depressor or dull knife can be used in place of a counting spatula. If no clean surface is readily available, medicines can be counted by hand if disposable gloves are worn during the process.
Enforce standards for good dispensing
We encourage local regulatory agencies to include and enforce appropriate stock control and handling as part of the facility accreditation process for official registration as a provider of medicines, whether this is within a hospital, clinic, pharmacy or drug shop. Work with drug sellers in Tanzania(6) and Uganda suggests that such practices can influence the likelihood that good practices are followed.
Raise awareness in the public
Patients have a right to good quality medicines, as part of effective health service provision, and they need to be aware that bare hands can contaminate medicines. Public awareness campaigns about access to good quality medicines play an important role.
Please join us in spreading the word about important issues to improve medicine dispensing practices and stay tuned for more information about how you can join our global campaign.
References
1. MANAGEMENT SCIENCES FOR HEALTH. (1997). Managing drug supply. 2nd Ed. (West Hartford, CT: Kumarian Press)
2. INTERNATIONAL PHARMACEUTICAL FEDERATION (FIP). (1997). Standards for quality of pharmacy services – good pharmacy practice. [http://www.fip.org/files/fip/Statements/latest/Dossier%20004%20total.PDF]
3. UNITED STATES PHARMACOPEIA DRUG QUALITY AND INFORMATION PROGRAM and collaborators. (2007). Ensuring the quality of medicines in resource-limited countries: an operational guide. (Rockville, MD: The United States Pharmacopeial Convention). [www.usp.org/worldwide/dqi/resources/technicalReports]
4. HAFEEZ A, KIANI AG, UD DIN S, et al. (2004) Prescription and dispensing practices in public sector health facilities in Pakistan: survey report. (Journal of the Pakistan Medical Association 2004; 54(4): pp187-91). [http://www.jpma.org.pk/PdfDownload/381.pdf]
5. Survey of field offices for the Strengthening Pharmaceutical Systems program 2010; data on file.
6. CENTER FOR PHARMACEUTICAL MANAGEMENT. (2008). Accredited drug dispensing outlets in Tanzania – strategies for enhancing access to medicines program. Prepared for the strategies for enhancing access to medicines program. (Arlington, VA: Management Sciences for Health). [http://www.msh.org/seam/reports/TANZANIA_Final_ADDO.pdf]
Filed under: Access to medicine Tagged: | access to medicines
I read your articlewithout lots of interest and will really atest that this practice is so common especially in the rural areas.
I would also point another crucial issue which is that of poor hanndling and storage of drugs in most drug stores and even health centers.This is an issue which some governments have been fighting over as in some countries drugs vendors carry drugs in baskets under the sun the whole day and are also pepetrators of the act of counting drugs with bare hands.
Eric in cameroon