P&T News: August 1994, Vol. 15, No. 2
Nancy Lasack, R.Ph.
Peer Review Status: Internally Peer Reviewed by Alan H.
Mutnick, Pharm. D., Assistant Director of Clinical Practice,
Department of Pharmacy
Duplicate Prescription System
The Duplicate Prescription System at the UIHC is structured to
produce an original and exact copy of the medication order. Under
this system, the Pharmacy Department is authorized to dispense the
take-home supply of medication from the copy of the prescription and
return the original prescription to the patient for obtaining
continuing supplies in the local community. The use of other,
nonstandard prescription blanks within the UIHC is not authorized.
The "essential elements" of a prescription are (please refer to figure of prescription on previous page):
A. Patient name, address, hospital number, birthday and date prescription is written. This information may be transmitted to the prescription by using the patient's addressograph plate. The hospital number is essential to assure that the intended patient receives, and is billed for, the correct medication.
B. The name, strength, and quantity of the drug. Medications should be ordered by the generic name, not by the proprietary or trade names.
Hospital policy and the Joint Commission on Accreditation of Healthcare Organizations standards permit the use of drug name abbreviations in medication orders only if the abbreviation has been specifically approved by the hospital and it appears on a published list. "Coined" abbreviations such as HCTZ, AZT and ddC are not acceptable medical abbreviations, may be misinterpreted, and may cause drug errors. Medication orders that contain nonapproved drug name abbreviations are not valid. Pharmacists are authorized to withhold dispensing of medications ordered via nonapproved abbreviations. The approved drug name abbreviations are provided on pages 49-50 (gray-colored section) in the 1991 Formulary and Handbook; approved medical abbreviations are found beginning on page 159 of the pink-colored section.
A separate prescription blank must be used for each drug prescribed.
For Drug Enforcement Administration (DEA) narcotics and controlled substances, including anabolic steroids, the quantity should be written in words as well as numbers to prevent alteration of the prescription.
The quantity of drug to be dispensed should be indicated; it may be further clarified by a check in the appropriate box to indicate to the pharmacist to dispense a prepackaged quantity or the exact quantity. Outpatient prescriptions should be written for no more than a 30-day supply with continuing supplies to be prescribed as refills. In order to minimize patient delays, the pharmacist is authorized to round the quantity dispensed to the nearest available prepackage quantity (usually a one-month supply) only for prescriptions with refills authorized. (See pages 60-62 in the gold-colored section in the front of the 1994 Formulary and Handbook for listing of the prepackaged drugs which are provided for patient convenience.)
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Outpatient Prescription Medication Supply Limits |
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The United States Supreme Court has ruled that medications purchased by hospitals (at special instituional prices) must be for inpatient use or for dispensing a limited take-home supply. The following rules must apply: |
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C. Directions to the patient. Clear and concise directions will assist your patient in the appropriate use of the medication. "Take as directed" should be avoided. Your patient may forget or confuse verbal directions or lose a separate note. The Pharmacy Department will complete a patient medication calendar for tapered or intermittent dosage schedules. The "PRN" designation should include the purpose of the medication (e.g., PRN sleep, PRN pain).
D. Signature, printed name, physician code. In addition to signing the prescription, print your name legibly below your signature along with your UIHC 4-digit physician code, and indicate your practitioner status by circling the appropriate initials to the right of the signature line. This will facilitate communications with health care practitioners throughout the state who have a need to accurately identify the prescriber, and it will also decrease the possibility of forgery. To prevent illegal drug diversion, supplies of prescription blanks may not be signed by the prescriber in advance of use. Prescriptions must only be signed by the prescriber at the time prescriptions are written for a specific patient. Physician assistants must also indicate the name of their supervising physician in the designated space.
E. DEA number. Your personal Drug Enforcement Administration (DEA) registration number must be included on all prescriptions for drugs classified as controlled substances. This step is a safety mechanism to prevent prescription forgery because each DEA number can be checked to verify its validity. When your DEA number is omitted, it is illegal for any pharmacy to fill the prescription. Pharmacy does not have a list of every prescriber's DEA number; therefore, this omission causes your patient to be inconvenienced until the deficiency is corrected.
When physician assistance prescribe DEA Schedule III, IV or V drugs, the prescription must also contain the DEA number of the supervising physician and the physician assistant's license number. Physician assistants are not authorized to prescribe DEA Schedule II drugs, and advanced registered nurse practitioners are not authorized to prescribe any controlled substances within the UIHC.
Applications forms for personal DEA registration at the UIHC and instructions for completion are available at the Pharmacy Office, Room CC-101 GH
F. Drug allergies. The patient's mediation allergies should be specified in this space on one of the prescriptions for each set of prescriptions. If there are no known allergies, please check the box next to "NKA." The pharmacist will obtain or confirm allergy information with the patient as necessary at the time the prescription is presented to the Ambulatory Care Pharmacy.
G. Containers without safety closures. "Childproof" containers with safety closures are used for dispensing all prescription medications (with limited exceptions) in accordance with the Poison Prevention Packaging Act of 1970. You may indicate the need for nonsafety closures for a patient for whom childproof containers may cause difficulty be checking the designated box.
H. Refill designation. Always circle "no refills" or specify the number of times and/or the last date the prescription may be refilled. "PRN" is not a valid refill designation.
Prescriptions may be refilled at the Pharmacy Department only for hospital staff and dependents at the same address or for patients who medications are not commercially available. Prescriptions for this eligible patient group (excluding controlled substances) may be refilled a maximum of 11 times or for 12 months - whichever is less.
Prescriptions for DEA controlled substances in Schedules III, IV and V may be refilled a maximum of five times or for six months - whichever is less. Prescriptions for Schedule II controlled substances may not be refilled.
Discharge Prescriptions for Inpatients
The Pharmacy Department provides discharge medication counseling
for all patients for the UIHC.
To allow for proper prescription review and processing and to provide medication counseling for patients on the inpatient care units, discharge prescriptions to be filled by the Pharmacy Department should be written and forwarded to Pharmacy the day prior to discharge.
Telephoned Prescriptions
Prescription orders for "take home medications" are not permitted
to be telephoned to the Pharmacy Department except in case of an
emergency. In this situation the prescription order must be
countersigned by the prescribing physician or dentist within 72
hours. This policy is intended to reduce prescription forgeries and
to provide the mechanism for a double check on written prescription
orders as a safety measure. Physician assistants and advanced
registered nurse practitioners may not dictate oral orders for
medications which are to be prepared or dispensed within the UIHC.
Unused Supplies of Medication
Iowa law mandates that for the protection of the public health
and safety, medications that have been dispensed to outpatients may
not be accepted for return, exchanged, or resold. Therefore, the
Pharmacy Department may not accept medication returns or issue credit
to patients who request return of unused supplies of medication. If
the patient's reaction to a newly prescribed medication cannot be
anticipated, it may be prudent to initially prescribe less than a
30-day supply. Continuing supplies may then be obtained as refills
once it is determined that the patient can tolerate the medication.
Prescriptions for House Staff
The UIHC medical care program permits house staff physicians and
dentists to write prescription for medications stocked at UIHC for
themselves and members of their immediate family (defined as a spouse
or child living with the house staff member) at no charge if
medically necessary. Hospital policy requires that prescriptions for
Schedule II narcotics written for immediate family and personal use
must be signed by another member of the staff who possesses a
personal DEA registration number.
To minimize waiting time for clinic and discharge patients, house staff are asked to plan ahead so that refills and new prescriptions for nonurgent medications are presented one day and picked up the following day. This will allow Pharmacy staff to fill house staff prescriptions at less busy times.
Storage of Prescription Blanks
To reduce the incidence of theft of UIHC prescription blanks and
to reduce illegal drug diversion, access to UIHC prescription blanks
is limited. Prescription pads and single prescription blanks are
stored only in secure centralized locations (e.g., medical conference
rooms or medication preparation rooms) of the ambulatory care clinics
and inpatient care units. Patients, visitors, and unauthorized
hospital staff members should not have access to these locations.
Authorized prescribers may carry prescription blanks in their
jacket/coat pockets.
In addition to controlled storage, prescription blanks are serialized, and dispersal of all prescription pads and storage destination is documented by Pharmacy staff. These procedures permit a trace of stolen prescription blanks.
Medication Orders Written By Physician Assistants and Advanced
Registered Nurse Practioners
Physician assistants and advanced registered practitioners may
write medication and treatment orders only when acting pursuant to
policies or protocols approved by the Clinical Service Head and
reviewed and approved by the Professional Practice Subcommittee.
Copies of established protocols shall be provided to the Pharmacy
Department by the Clinical Service Heads or the Professional Practice
Subcommittee.
Physician assistants and advanced registered nurse practitioners shall not have the authority to limit substitution or standardization pursuant to Pharmacy and Therapeutics Subcommittee protocols and shall not be authorized to override protocol or restricted drug indications.
For further information on prescribing medications, please consult pages 51-62 in the gold-colored section of the 1994 Formulary and Handbook.
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Prescription Writing Tips To Prevent Delays in discharge Prescription Processing | |||||
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The Pharmacy Department provides discharge medication counseling for all patients of the UIHC. To allow for proper prescription review, medication preparation, and medication counseling for patients on the inpatient care units, discharge prescriptions to be filled by the Pharmacy Department should be written and forwarded the day prior to discharge. The following flow diagram outlines the essential steps for processing discharge prescriptions: | |||||
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These procedures are outlined to familiarize all members of the health care team with the essential steps for processing discharge prescriptions for inpatients, and ultimately, avoid delays in the patient's departure from the hospital. _____ |
Background
Enoxaparin (Lovenox®) injection is a low-molecular-weight
heparin FDA-labeled for the prevention of deep vein thrombosis (DVT)
following hip replacement surgery. Depolymerization of standard
heparin, which has an average molecular weight of 12,000 to 15,000
daltons, produces fragments with a molecular weight of 4,000 to 6,000
daltons. Low-molecular-weight heparin fragments have relatively more
anti-Factor Xa activity than standard heparin, which may lead to an
increased antithrombotic effect. Low-molecular-weight heparins cause
less inactivation of thrombin, less inhibition of platelets, and less
vascular permeability, which may lead to less bleeding.1-3
Drug Use Evaluation Review
Concerns of potential adverse effects prompted a review of
enoxaparin utilization from December 1993 through February 1994 by
the Drug Use Evaluation Program. During the review period, 55
patients received enoxaparin. Of these, 52 (95%) patients received
enoxaparin as prophylaxis against deep vein thrombosis following
orthopedic surgery. Other uses included instances in which heparin
was deemed not to be the preferred therapy (e.g., pre-existing
coagulopathies, heparin-associated thrombocytopenia, possible heparin
allergy). Dosages were consistent with the manufacturer's
recommendations.
Potential drug interactions occurred in 9 (16%) patients; they included 3 cases in which a concomitant anticoagulant was prescribed, and 6 cases in which concomitant nonsteroidal anti-inflammatory drug (NSAID) therapy was prescribed. One of the patients had a severe hematoma requiring surgical intervention while also receiving ketorolac. Two other patients had bright-red bleeding from bandages while receiving other NSAIDs.
Although routine monitoring of hemostasis factors such as PT and PTT is not recommended by the manufacturer for patients on enoxaparin therapy, these factors were monitored in 10 (18%) patients. Monitoring of hemostasis factors was appropriate in 5 instances based on other patient factors (e.g., thrombocytopenia). The manufacturer recommends periodic complete blood counts, including platelet count, and stool occult blood tests during the course of treatment with enoxaparin injection.
Prescribing Guidelines
The manufacturer's recommended dosing schedule is as follows: 30
mg subcutaneously every 12 hours with the initial dose given as soon
as possible after surgery, but not more than 24 hours
post-operatively. Treatment should be continued throughout the period
of post-operative care until the risk of deep vein thrombosis has
diminished. Up to 14 days of therapy has been well tolerated in
clinical trials, and the average duration is 7 to 10 days.
Enoxaparin is contraindicated in patients with major active bleeding, patients with thrombocytopenia with a positive test for anti-platelet antibody, and in patients with a know hypersensitivity to heparin or pork products. Enoxaparin should be used with care in patients receiving oral anticoagulants, and/or inhibitors, due to the increased risk of bleeding.
Place In Therapy
Current literature suggests that enoxaparin is equivalent to or
superior to heparin in preventing post-operative deep vein thrombosis
following hip replacement. Without anticoagulants, deep vein
thrombosis occurs in about 50% of patients after major orthopedic
procedures. After most other surgical procedures, the incidence is
much lower.5 Cost for a single dose of enoxaparin is $11.38; 5000
units of subcutaneous heparin costs $.066. The acquisition cost for
14 days of therapy for enoxaparin is $318.64, while only $18.48 for
heparin.
Due to a lack of definitive comparative efficacy studies in other settings, and a lack of well-designed cost-effectiveness studies, currently enoxaparin is most useful when limited to the orthopedic surgical settings.
References