P&T News: August 1999
Pharmacy and Therapeutics Subcommittee
Peer Review Status: Internally Peer Reviewed.
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 Department of Pharmaceutical Care 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, T3, 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 48-49 (graycolored section) in the 1999-2000 Formulary and Handbook; approved medical abbreviations are found beginning on page 176 of the pink-colored section. This information may also be found on the Virtual Hospital version of the Formulary and Handbook.
A separate prescription blank must be used for each drug prescribed. Multiple prescriptions on a single blank are unsafe and greatly increase the potential for medication errors.
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. 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.
1. Supply quantities are generally limited to a 30-day supply except where health plan benefits allow a greater supply. Patients being discharged from the hospital may receive an initial supply of medications. Refills are limited to the cases noted below.
2. Refill prescriptions may be processed for:
[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 prescriber 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. Additionally, Board of Pharmacy rule 657 I.A.C. 8.14(1) requires that the name of the prescriber appear on the prescription label. If the prescriber's signature is illegible and the identity of the prescriber is unknown, the prescription cannot be filled until the prescriber has been identified. This provision in the law will result in telephone calls to your department and delays to patients. 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 (or the UIHC DEA registration number for eligible practitioners) with your personal 4-digit prescriber code 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.
Physician assistants and advanced registered nurse practitioners are authorized to prescribe controlled substances after obtaining a mid-level practitioner's registration from the DEA. However, physician assistants are not authorized to prescribe Schedule 11 substances listed as stimulants or depressants.
Application forms for personal DEA registration at the UIHC and instructions for completion are available at the Pharmacy Administrative Office, Room CC-101 GH.
(D) Drug allergies. The patient's medication 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 Pharmacies.
[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 Department of Pharmaceutical Care ONLY if certain criteria are met (see page 8). Prescriptions for this eligible patient group (excluding controlled substances) may be refilled a maximum of I I times or for 18 months - whichever is less. Prescriptions for DEA controlled substances in Schedules 111, IV, and V may be refilled a maximum of 5 times or for 6 months - whichever is less. Prescriptions for Schedule 11 controlled substances may not be refilled. State-paper eligible patients may receive a single refill of specific maintenance medications (see pages 11 and 12).
[I] Indication for use. The indication for use should be specified in this space for each prescription. This information permits the pharmacist to reinforce physician instructions with the patient and helps the patient understand the purpose for the medications. Federal regulations require the pharmacist to obtain information on the patient's disease state(s) so that appropriate utilization review and counseling can occur.
Discharge Prescriptions For Inpatients
Prescriptions for discharge medications should be in writing as
all patients must be given the option of taking their prescriptions
to their community pharmacy or having an initial supply filled by the
UIHC Ambulatory Care Pharmacies. This should be determined 24 hours
prior to discharge to allow time for the prescriptions to be filled
at the UIHC Ambulatory Care Pharmacies and returned to the patient's
bedside if the patient chooses this option. Failure to determine the
need to have prescriptions filled at UIHC until the day of discharge
can lead to delays in the patient's discharge and dissatisfaction
with their stay. If prescriptions are filled by the UIHC Ambulatory
Care Pharmacies, the patient will be billed by the hospital for the
medications. The patient is responsible for filing any insurance
claims for these take-home medications.
Telephoned Prescriptions
All UIHC physicians, dentists, physician assistants, and advanced
registered nurse practitioners may telephone prescriptions for UIHC
clinic patients to the UIHC Ambulatory Care Pharmacies during normal
clinic operating hours.
The majority of patients being discharged from UIHC will not utilize the UIHC Ambulatory Care Pharmacies as their primary pharmacy and will require a written or verbal prescription for their local pharmacy. Prescriptions for patients being discharged from the hospital must be in writing, as this ensures patients their legal right to choose where to have their prescriptions filled. Should the patient choose to have an initial supply of medications filled at UIHC, the inpatient pharmacist following the patient will review the patient's medication profile and counsel the patient about any prescribed home going medication therapy at bedside before discharge from the hospital.
Registered nurses and pharmacists acting as an agent of a physician may also transmit prescription orders for clinic patients to the UIHC Ambulatory Care Pharmacies.
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
Department of Pharmaceutical Care 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 to a maximum of a 30-day supply of
medications as deemed appropriate based upon the package insert, 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 cost. Only medications on formulary may be
prescribed. All prescriptions must be in writing, except in cases of
an emergency. Certain high-cost medications within specific
therapeutic classes may be restricted, requiring a clinical faculty
signature. Self-prescribing of these agents will result in the house
staff member being billed the acquisition cost of the high-cost
medication. All prescriptions must reflect the name of the patient
for whom the medication is being prescribed. Prescriptions will
be monitored for appropriateness. Hospital policy requires that
prescriptions for Schedule 11 narcotics written for immediate family
or personal use must be signed by another member of the medical staff
who possesses a personal DEA registration number (the hospital DEA
number is not valid for this purpose).
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 lost or 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 Department
of Pharmaceutical Care 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 51-60 in the gold-colored section of the 1999-2000 Formulary and Handbook or call the Department of Pharmaceutical Care.
The Ambulatory Care Pharmacies may fill prescriptions for patients with quota state papers for a greater than 30-day supply according to the following guidelines:
| Table 1. Medication Dispensing Limits For Patients In The Indigent Patient Care Program | |
|
No more than a |
Therapeutic Categories of Medication |
|
Maximum Supply Limits of Medication Which May Be Dispensed 30day supply of medication will be dispensed for these medications. |
Medications for the treatment of ACUTE (short-term) medical conditions, including:
|
|
A 90-day supply of maintenance medications may be dispensed for these medications. |
Medications for the treatment of CHRONIC medical conditions; the patient must be stabilized on a particular drug and dose for at least 30 days. These categories include:
|
Since 1979, the only indigenous cases of poliomyelitis reported in the United States (n = 144) have been associated with use of the live oral poliovirus vaccine (OPV); an additional six imported cases have been reported since 1979, the last of which occurred in 1993. Until recently, the benefits of OPV use (i.e., intestinal immunity, secondary spread) outweighed the risk for vaccineassociated paralytic polio (VAPP) (one case per 2.4 million doses distributed). 1 In 1997, to decrease the risk for VAPP while maintaining the benefits of OPV, the Advisory Committee on Immunization Practices (ACIP) recommended a sequential schedule of inactivated poliovirus vaccine (IPV) followed by OPV.2 Since 1997, the global polio eradication initiative has progressed rapidly, and the likelihood of poliovirus importation into the United States has decreased substantially. In addition, since 1997, the sequential schedule has been well accepted. No declines in childhood vaccination coverage were observed, despite the need for additional injections. 3
On the basis of these data, on June 17, 1999, to eliminate the risk for VAPP, the ACIP recommended an all-IPV schedule for routine childhood polio vaccination in the United States. As of January 1, 2000, all children should receive four doses of IPV at ages 2 months, 4 months, 6-18 months, and 4-6 years.
OPV should be used only for the following special circumstances:
Availability of OPV is expected to be limited in the future in the United States. ACIP reaffirms its support for the global polio eradication initiative and use of OPV as the vaccine of choice to eradicate polio from the remaining countries where polio is endemic.
References
1. MMWR 1997;46:79-83.
2. MMWR 1997;46(No. RR-3).
3. MMWR 1998; 47:1017-9.
Reprinted from: MMWR 1999,48:590
DOSAGE FORMS/STRENGTHS ADDED TO STOCK
AMPRENAVIR (AGENERASE[R]) ORAL SOLUTION A 15 mg per ml oral solution has been added to stock. " dose, 246
ENOXAPARIN (LOVENOX[R]) 80 mg PER 0.8 ml AND 100 mg PER 1 ml INJECTION Two additional syringe sizes have been added to stock. Till I
RITONAVIR (NORVIR[R]) 100 mg SOFT GEL CAPSULE These soft gel capsules are a replacement for the previous capsule formulation that was discontinued by the manufacturer in early 1999 due to stability problems.
SUMATRIPTAN (IMITREX[R]) 0.5 mg PER 0.1 ml NASAL SPRAY A lower strength nasal spray has been added to stock.
URSODIOL (URSO[R]) 250 mg TABLETS The 250 mg strength of the Urso[R] brand was added to stock due to supply problems with the Actigall[R] brand. co
DRUGS DELETED FROM STOCK
TUBERCULIN PPD SKIN TEST I TEST UNIT per 0.1 ml and 250 TEST UNITS per 0.1 ml Discontinued by the manufacturer. A 5 test units per 0. 1 ml skin test is available.
The Centers for Disease Control and Prevention (CDC) recommends postponing administration of the rotavirus vaccine (Rotashield[R] 0 ) to children scheduled to receive the vaccine before November 1999, including those who have already begun the rotavirus vaccine series.
The CDC has received reports of intussusception (a type of bowel obstruction that occurs when the bowel folds in on itself) among some infants who received rotavirus vaccine. As of July 7, 1999, the Vaccine Adverse Event Reporting System (VAERS) has received 15 reports of intussusception. The rate of intussusception among children receiving the rotavirus vaccine appears to be increased in the first 2 to 3 weeks after vaccination. Parents and caretakers of infants should contact their health care provider if the child develops symptoms of intussusception (persistent vomiting, bloody stools, black stools, abdominal bloating or severe colic pain). Health care providers should be aware of the possible increased risk and consider this diagnosis among children presenting these symptoms.
Although intussusceptions occur among infants who have not received rotavirus vaccine, CDC will be collecting additional data in the next several months that may indicate more clearly whether the rotavirus vaccine increases the risk of intussusception. The recommendation to postpone vaccination is being made with the consideration that rotavirus season is still 4 to 6 months away in most parts of the United States.
In studies done before the Food and Drug Administration (FDA) licensed rotavirus vaccine for use in the United States, intussusception was noted among 5 of approximately 10,000 vaccine recipients. This number was not significantly higher than among placebo recipients in the studies. However, the Advisory Committee on Immunization Practices (ACIP), in its recommendation for routine rotavirus vaccination of infants, indicated that postlicensure surveillance was needed for intussusception and any other rare adverse events that might occur following receipt of the vaccine.
Rotavirus is the most common cause of severe diarrhea in children in the United States. Virtually all children have one or more rotavirus infections in the first 5 years of life. Each year in the United States, rotavirus is responsible for approximately 500,000 physician visits and 50,000 hospitalizations. Severe diarrhea and dehydration occur primarily among children 3 months to 35 months of age. It is a seasonal disease in the United States with the vast majority of the disease occurring in the winter and spring months.
Because of the CDC action, the Pharmacy in collaboration with UIHC Pediatrics and Family Medicine Medical Staff has quarantined all rotavirus vaccine and staff will not be administering the vaccine until the CDC gives a final recommendation in the late fall.
The full document can be found at:
http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4827al.htm
Summarized from MMWR 1999; 48:516-8.