P&T News: August 1995, Vol. 16, No. 2 Part B
Pharmacy and Therapeutics Subcommittee of the University
Hospital Advisory Committee and the Pharmcy Department
Peer Review Status: Internally Peer Reviewed
Duplicate Prescriptions 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 to obtain 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 depicted in the preceding figure of a UIHC prescription and described below:
A. Patient name, address, hospital number, birthdate 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 53-54 (gray-colored section) in the 1995 Formulary and Handbook; approved medical abbreviations are found beginning on page 157 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 65-67 in the gold-colored section in the front of the 1995 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 institutional prices) must be for inpatient use or for dispensing a limited take-home supply. The following rules must apply: 1. A maximum 30-day supply is authorized on prescription orders. 2. Refill requests may not be processed. 3. Exemption from the above rules:
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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 assistants 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.
Application 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 Federal Poison Prevention Packaging Act of 1970. You may indicate the need for nonsafety closures for a patient for whom childproof containers may cause difficulty by 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 whose 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 of 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 f fled by the Pharmacy Department should be written and forwarded to Pharmacy the day prior to discharge.
Prescriptions for Clinic Patients
Prescriptions forwarded to Pharmacy for patients being seen in the
clinics should note when the patient will call for the prescription
and in what clinic the patient was seen. This allows timely
preparation and clarification if necessary.
Telephoned Prescriptions
Prescription orders for "take home medications" are not permitted to
be telephoned to the Pharmacy Department except in case of an
emergency or at the request of those patients who are enrolled in the
UI Care or UI Select health plans. In emergency situations 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 any 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 prescriptions for a one month or less supply of
medications, stocked at UIHC, if medically necessary, for themselves
and members of their immediate family (defined as a spouse or child
living with the house staff member) at no charge. 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. Prescription
blanks must not be stored in patient examination rooms. 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 Practitioners
Physician assistants and advanced registered nurse 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 discharge and outpatient medications, please consult pages 55 - 68 in the gold colored section of the 1995 Formulary anal Handbook or call the Pharmacy Department at 6-2577.
Drugs Added to Stock
GRANISETRON Tablets: 1 mg Injection: I mg per ml, I ml vial Granisetron (Kytril(R)-SKB) is indicated for the prevention of nausea and vomiting associated with initial and repeat doses of highly or very highly emetogenic cancer chemotherapy. NOTE: Granisetron has been designated as a protocol drug by the Pharmacy and Therapeutics Subcommittee. Guidelines for its use may be found in the pocket-sized "Guide to Antiemetic Use in Oncology Settings." Copies of the pocket guide can be obtained by calling the Drug Use Evaluation Program (6-3870).
METFORMIN Tablets: 500 mg, 850 mg Metformin (Glucophage(R)-BMS) is an oral hypoglycemic agent indicated for the treatment of Type 11 diabetes mellitus.
OFLOXACIN Tablets: 200 mg, 300 mg, 400 mg Injection: 200 mg per 50 ml and 400 mg per 100ml in 5% Dextrose Injection Ofloxacin (Floxin(R))- McNeil) is a quinolone antibiotic. NOTE: Injectable ofloxacin has been designated a protocol drug by the Pharmacy and Therapeutics Subcommittee. It will replace injectable ciprofloxacin and its use will be restricted to: 1) serious gram-negative infection with organisms documented to be resistant to aminoglycosides, third-generation cephalosporins , and extended-spectrum penicillin, and 2) serious gram-negative infection in which there is an intolerance and/or contraindication to aminglycosides, third-generation cephalosporins, and extended spectrum penicillins.
POLYMYXIN B/NEOMYCIN/HYDROCORTISONE Ophthalmic Suspension This product (cortisporin(R)-BW) is indicated for steroid-responsive inflammatory ocular conditions in which bacterial infection, or the risk of bacterial infection, also exists.
Drugs Deleted to Stock
CASTOR OIL, EMULSIFIED Discontinued by all manufacturers. Other laxatives and cathartics are available.
CIPROFLOXACIN (CIPRO(R) IV) INJECTION Ofloxacin injection will replace ciprofloxacin injection as the protocol injectable quinolone antibiotic.
Additional Actions
PEDIATRIC MULTIVITAMIN SHORTAGE There is a developing nationwide shortage of MVI-Pediatric(R) (Astra), the only pediatric parenteral multivitamin product available in the United States. It appears that demand for the product has exceeded the manufacturer's expectations, the shortage is anticipated to last until late fall 1995. After consultation with Dr. E. Ziegler, Director of Pediatric Nutrition, and subsequent approval by the Pharmacy and Therapeutics Subcommittee, the following guidelines for use of MVI-Pediatric(R) have been implemented:
1. MVI-Pediatric(R) will be used in infants receiving parenteral nutrition ordered on the A-la-NVN (Neonatal) order form. This will generally include all patients in the Neonatal Intensive Care Unit and the Intermediate Care Nursery.
2. Adult multivitamins (MVI-12(R) should be used in older pediatric patients receiving parenteral nutrition ordered on the A-la-PVN (Pediatric) or A-la-AVN (Adult) order forms. This will generally include pediatric patients located in all other areas of the hospital, except the 4th Floor General Hospital nurseries. Dosing guidelines for these patients are:
- Use an equivalent volume of MVI-Pediatric(R) to MVI-12(R) daily, to a maximum of 5 ml/day.
- Order 0.2 mg of vitamin K daily. (Vitamin K is included in MVI Pediatric(R) at this daily amount- however, vitamin K is not included in the adult MV1-12(R).)
3. The Pharmacy and Therapeutics Subcommittee has authorized the Pharmacy Department to automatically substitute MVI-12(R) and 0.2 mg/day vitamin K for all MVI-Pediatric(R) orders written on the A-la-PVN (Pediatric) and A-la-AVN (Adult) order forms.