What Your Pharmacist Didn’t Tell You.

Safety Guidelines for Medications


Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 1- Approximate time required: 60 min. 

Educational Goal: 

To instruction on medication guidelines not normally given to care givers.

Educational Objectives:

1. List the drugs with special handling instructions.

2. List the drugs that have to be refrigerated.

3. Example how to use spay inhalers

4. Tell how to legally dispose of drugs

5. Give instruction about which drug that shouldn’t be crushed



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Disclaimer  -    The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.


What Your Pharmacist Didn’t Tell You

Safety Guidelines for Medications



      How often do you talk in-depth with the doctor about the medication your residents use? How much time have you spent with the pharmacist when your patient gets a new drug? How many times have you read through the literature that comes with the meds every month? If you’re like the vast majority of caregivers, the honest answer is probably- never, just enough time to pay for the drug and get home and “What literature? Oh, you mean those papers I throw away.”  Of course you’re not the only one who isn’t up to speed. How often has the doctor called you? How much time does the pharmacist spend with you? As for the literature- what is significant and what’s not? There’s a ton of boring reading that doesn’t seem important.

     The truth is, I should know better. I’m a pharmacist but I fall into the same traps myself time after time. Not enough and too much info at the same time. Unfortunately, it’s just something you’ll have to deal with. That’s the world of medicine we live in. The following article offers a few items I think are important that you may not know. I hope it helps in your caregiving.


Drugs with Handling Concerns


     The skin is a pretty good barrier to the vast majority of drugs that might come in contact with your skin, but there are a few you should watch out for. Pregnant females or those of child-bearing age are at most risk. Surgical gloves, medicine dispensing cups, and common sense are probably all the protection that is needed.

Those drugs are:                                      

All chemotherapy drugs. These are power drugs specially designed to kill cells. If you’re required to dispense them, don’t, not until you get detailed instructions.

Finasteride (brand names: Proscar and Propecia) can cause birth defects and feminization of the male fetus.

Testosterone and Estrogen can come in creams and patches and are designed to be absorbed through the skin – anyone’s skin, not just the patient’s.  Testosterone brand names include: Androderm, AndroGel, Axiron, Fortesta, and Testim.  Females and children should avoid even touching the application sites on the male. Estrogen brand names  include creams such as Estrace vaginal and Premarin cream . Patches include Alora, Climara, Estraderm, Estradiol Patch, Vivelle, and Vivelle-Dot.

Nitroglycerin brand name patches– include Minitran.  The cream  is NitroBid. These can cause headaches as a side effect even in caregivers who give careless applications.

A caregiver note about nitroglycerin sublingual (under the tongue) meds.

     Nitroglycerin is considered by some medical professionals to be addicting. it is  supposed to be a rescue medication for angina or heart attack – not a routine medication. If your resident insists on using them on a regular basis, they may be addicted. If they do need them all the time, time-released capsules or patches might be more appropriate choices.


Refrigerated Items


     There are a few drugs that break down quicker at room temperature. You see them stored at the pharmacy in there refrigerator. Ever wondered if you have to keep them in your fridge?

Commonly used meds that need to be refrigerated and what you need to know once you get them home:

Calcitonin nasal, brand name –Miacalcin. - Opened bottles may be stored at 59oF to 86oF in upright position for 35 days. –Fortical - After opening, store bottle in use in an upright position for up to 30 days at 68o to 77°F.

Benzoyl peroxide/clindamycin, brand name –Duac - Good for 60 days, unrefrigerated.

Latanoprost brand name –Xalatan - Can store at room temperature not to exceed 77°F  for up to six weeks. Off-label information indicates unopened bottle stable when maintained at continuous room temperature 77oF for 12 months.

Lorazepam intensol oral concentrate (liquid) - Off-label information indicates stable when maintained at continuous room temperature 77oF for 30 days.

Becaplermin cream brand name –Regranex - Off-label information indicates that unopened tubes left out of refrigerator are stable up to 86oF for up to six days or less, one time only.

Promethazine suppositories, brand name –Phenergan - Should always be stored in the refrigerator.

Insulin-type meds

Insulin is injected straight into the body, so special care has to be taken in its storage and use:

  1. Never freeze.
  2. Never expose insulin to direct heat or light.
  3. Inspect insulin before every use. Any insulin that has clumps or solid white particles should be thrown away. Insulin that is supposed to be clear should not have any cloudy appearance. If so, throw it away.
  4. Unopened, not-in-use insulin should be stored in a refrigerator.
  5. Opened, “in-use” insulin should be stored at room temperature below 86º F. Why? Injecting cold insulin can hurt.  
  6. Generally, vials of insulin can be stored at room temperature for 28 days. Easy-to-use pens can be considerably different - only seven days in some cases, up to 42 days in others.
  7. Do not ever assume you are using the correct insulin based solely on what it looks like or where it is stored. Always read the label before and after use. Avoid mistakes made by storage mix ups. Cut the prescription label off and throw away the box after you open them up.
  8. Insulin suspensions should never be shaken. Instead, roll the vial or pen cartridge in your hand to mix them up. 

For a more complete insulin storage guide, go to: http://www.dhs.wisconsin.gov/rl_dsl/publications/GudStrgInsulin.pdf


Inhaler Use


     Inhalers must be used correctly for maximum benefit, and it’s your job to see that they are used correctly. You can’t assume that the patient knows how to use them. There are a lot of people who think they know how but don’t.  Inhalers are packaged with instructions. Become familiar with them.

A few instructions that are easily missed:

  1. Prime spray inhalers (test sprays sprayed into the air) before first use or if inhaler has not been used for a while.
  2. Shake well before each use.
  3. Patients should rinse the mouth out after inhaler use, especially if they taste the medicine. This will help prevent fungal infections.
  4. If the patient has difficulties in using spray inhalers, have the doctor order a spacer or a spacer with a mask. They will make inhalers much easier and more effect to use. The spacer requires a prescription,. A warning though, a lot of insurances won’t pay for them.
  5. Clean the mouthpiece (plastic part of inhaler) with water and air dry thoroughly.
  6. If there are multiple inhalers prescribed at the same time, use the bronchodilator or “rescue inhaler” first. It will quickly open the lungs and the other inhaled medicines will go deeper into the lungs.
  7. Don’t forget to have the patient take their rescue inhaler with them on outings away from your home. If you don’t know which one that is ask. It’s usually the one with albuterol in it.
  8. Albuterol can make the patient feel jittery. The feeling goes away pretty quickly on its own. Young children don’t understand this feeling, and they can act like they’re hyperactive.


Don’t Crush or Chew Meds


     Pretty straightforward, but what if your residents chew up meds despite what you tell them, or what if you have to put the meds down a g-tube? If you have these or other cases that involve pill crushing or chewing, go over each med with the doctor. In general, medications you should be concerned about are pills that say extended, sustained, controlled, timed or slow release, enteric coated, sublingual (under the tongue), and all potassium pills. For most of these medications, if you have to crush them there are alternatives with the same therapeutic results.

   Special note about g-tubes and meds. Some medications adhere to the plastics of a g- tubes. Not all pharmacists and even doctors know which ones. Hospital and long-term Care pharmacies should know more about which meds wouldn’t clog a g-tube.

For a more complete do-not-crush  list, go to:  http://www.ismp.org/tools/donotcrush.pdf


What to do with Unused Drugs


     There is an ever-growing group of very stupid people who swipe prescription  drugs and use them to try to get a buzz. It doesn’t seem to matter if it’s a heart medication or laxative. Unused meds must be disposed of correctly. It used to be acceptable to  dump them down the toilet, but all those drugs in the sewer system started to affect the environment and gum up the public sewer system. The federal government issued the following guidelines:

Do not flush prescription drugs down the toilet or drain unless the label or accompanying patient information specifically instructs you to do so. For information on drugs that should be flushed, visit the FDA’s website.

   To dispose of prescription drugs not labeled to be flushed, you may be able to take advantage of community drug take-back programs or other programs, such as household hazard waste collect events that collect drugs at a central location for proper disposal. Call your city or county government’s household trash and recycling service and ask if a drug take-back program is available in your community.

If a drug take-back or collection program is not available:

  1. Take your prescription drugs out of their original containers.
  2. Mix drugs with an undesirable substance, such as cat litter or used coffee grounds.
  3. Put this mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag.
  4. Conceal or remove any personal information, including prescription number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off.
  5. Place the sealed container with the mixture, and the empty drug containers, in the trash.


Here is a website that lists drug collection locations for Oregon cities.






     I hope you can use the information in this article for the betterment of your clients. If my words have made a difference in the lives of those who need help, I sleep better at night. Remember to get educated about the medications. They are powerful tools to help keep your patients healthy and functioning properly.




 1. Pharmacist’s Letter Detail-Document#: 220339 Detail-Document#: 240406 Proper Use of Dry Powder Inhalers (DPIs)

2. Medication and Drugs. EMedicine Health


3 Stability of Refrigerated and frozen Drugs Pharmacist’s Letter detail-Document#:241001. October 2008. Volume 24. Number 241001


4. Guideline for Insulin Storage. Department of Health Services .State of Wisconsin


5. Proper Disposal of Prescription Drugs. Office of National Drug Control Policy 2009


6. John F Mitchell, Oral dosage forms that should not be crushed. Institute for Safe Medication Practices Mar 2012


7. Insulin Safety in Your Home. Consumer MedSafety .org




What Your Pharmacist Didn’t Tell You.

Safety Guidelines for Medications 

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