P&T News: July 1999
Pharmacy and Therapeutics Subcommittee
Peer Review Status: Internally Peer Reviewed.
Inpatient Medication Orders
Inpatient medication orders are to be written on the structured
medication order form (A-1 a) shown on page 2. The following elements
should be considered when writing inpatient medication orders:
General Guidelines
A ball point pen and a firm writing surface should be used to assure
clarity and legibility. Felt tips and fountain pens do not generate
sufficient pressure to transmit the order to the carbon copy from
which Pharmacy interprets and dispenses.
In accordance with Hospital Bylaws, the pharmacist is authorized to dispense and the nurse is authorized to administer generic brands of drugs approved for stock by the Pharmacy and Therapeutics Subcommittee whether or not it is the same brand specified in the medication order. If the generic medication stocked is not acceptable, the prescriber must note on the A-1a medication order that only the brand specified is acceptable. To obtain the desired brand of medication, the prescriber must also complete an Inpatient Special Order Request for a Non-Stock Drug (described on page 4).
Automatic expiration of medication orders:
1. Medication order durations default to those predefined by the
Pharmacy and Therapeutics Subcommittee at the time the order is
entered into the pharmacy computer system* unless otherwise specified
by the physician. The current predefined order durations include: a)
systemic antibiotics (excluding antiretrovirals) - 7 days; b)
clozapine 7 days; c) ketorolac injection - 5 days; and d) all other
medications - 30 days.
2. Physicians are notified of the impending expiration orders via an Expiring Orders Summary (EOS). The EOS is placed on the patient's chart at least 24 hours prior to the assigned expiration time/date.
3. It is important that medication orders be rewritten in a timely manner before the end of their assigned expiration date. If this is not done, Pharmacy and Nursing staff may be placed in a position of having to make a decision on whether to dispense without authorization or to withhold medication (which may have a deleterious effect on continuity of patient care).
4. Medication orders also expire and must be rewritten when a patient is transferred to a different clinical service or when the patient returns from the operating or delivery room.
Verbal orders for inpatient medications are discouraged except in those instances when a written order cannot be obtained. Verbal orders should be transmitted to a nurse or pharmacist who must immediately transcribe the order into the patient's medical record. The authorized prescriber must then countersign the order within 24 hours.
For selected parenteral antibiotics utilized in adult patients and pediatric patients weighing 20 kg or more, standardized doses have been established. When an antibiotic order is received for a nonstandard dose size, the dose will be rounded to the nearest standard size. The prescriber and the nurse will subsequently be notified. In situations in which the prescriber determines that the patient's dosage requirements cannot be met by a standard dose size, a "PATIENT ORDER FOR NONSTANDARD ANTIBIOTIC DOSES- (Form 602a) must be completed by the prescriber in addition to the usual A-1a Doctors' Orders Form. Upon receipt of this order, the "nonstandard" doses will be prepared and dispensed. Pages 20-21 of the 1999-2000 Formulary and Handbook should be consulted for lists of the standard antibiotic doses.
Medication orders for adult and pediatric parenteral nutrition solution are written on separate medication order forms (A-1a--AVN for Adults; A-1a--PVN for Pediatrics; A-1a--NVN for Neonates). These orders must be written daily.
Parenteral nutrition orders for adult patients (A-1a--AVN for Adults) must be written by 1400 hours so that orders may be received by the Pharmacy no later than 1500 hours daily. Solutions are hung at 2 100 hours.
If there are extremely unusual situations, an order for parenteral nutrition can be compounded up to 2100 hours. Pharmacy requires a minimum of two hours to compound a parenteral nutrition solution. Orders for parenteral nutrition cannot be processed after 2100 hours. In these situations, 10% dextrose with electrolytes should be used until a twelvehour bag of nutrition solution can be prepared for a 0900 hours dose the following morning.
Parenteral nutrition solution orders for pediatric and neonatal patients (A-1a--PVN for Pediatrics. A-1a--NVN for Neonates) must be written daily by 1200 hours so that orders may be received by the Pharmacy by 1300 hours. Solutions are hung at 1800 hours. Orders received after 1300 hours may not be available until after 2100 hours.
If a drug needed for a specific patient is not stocked by Pharmacy, and no alternative stocked drug is suitable, the drug will be acquired on a one-time basis as a Special Order Drug. In order to initiate the acquisition of a Special Order Drug, the prescriber must write a chart order in the usual fashion, indicating that the drug should be special ordered. Additionally, an Inpatient Special Order Request for a Non-Stock Drug (Form 602) stating the reason that the Special Order Drug is needed in lieu of other drugs stocked must be completed, signed by the patient's attending physician, and sent to the Pharmacy. Most Special Order Drugs can be procured within 24 to 48 hours. If unusual circumstances make it imperative that a Special Order Drug be obtained in less than 24 to 48 hours, the prescriber must contact the Pharmacy directly so that emergency measures can be arranged.
There are several drugs that have been approved for stock by the Pharmacy and Therapeutics Subcommittee with specific restrictions on their use. Restricted Stock Drugs are identified by an " (R) " after the generic name in the drug monograph section of the Formulary; the conditions of the restriction are also included in the monograph. Drugs approved for stock by the Pharmacy and Therapeutics Subcommittee for use according to specific criteria are termed Protocol Drugs; they are identified by a " (P) " after the generic name in the drug monograph section of the Formulary.
If patients admitted to the UIHC bring personal medication supplies with them, these drugs are not administered to the patient while at the hospital, but rather are collected by nursing personnel and, preferably, returned to the patient's family, or stored in a secure manner and returned to the patient at the time of discharge. Special circumstances (as defined by the responsible physician or dentist) may indicate that the patient's medications should be administered at UIHC, for example, birth control pills or in the instance of medication which is not available at the UIHC. Under these circumstances, it is the responsibility of the pharmacist to examine the medications for proper identification, labeling, and condition prior to permitting the drugs to be administered to the patient. When it is decided that personal medications brought from home by the patient are to be administered by hospital personnel, the physician or dentist is required to specify this intent in the patient's chart at the time the medication is prescribed.
A pharmacist will review all medication orders, and in those instances in which a consultation about a drug order is required, the pharmacist will discuss the issue directly with the prescriber.
COMPLETION OF DESIGNATED SECTIONS OF THE A-1a DOCTORS' ORDER FORM
(The capital letters at the beginning of each section refer to a specific section of the A-1a Doctors' Order example on page 2)
A. Patient name, address, hospital number, birthdate, patient care unit, and date. This demographic information should be transmitted to the medication order by using the patient's addressograph plate.
B Allergies. Patient's medication allergies should be specified in this space. If there are no known allergies, please check the box next to " NKA-No Known Allergies.
C. Date. As each series of medication orders is written, the date should precede the order. Prescribers are encouraged to include the time when writing medication orders.
D. Medication Column. Medications should be ordered by the generic name, not by the proprietary or trade name. 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, LOC, AAOC, TMP-SMX, and ddI are not acceptable 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 and nurses are authorized to withhold administration of medications ordered via nonapproved abbreviations. The list of drug name abbreviations approved for use at UIHC is provided on pages 48-49 (graycolored section) in the 1999-2000 Formulary and Handbook.
If it is necessary to modify or discontinue a medication order, it is important that this be done on the next open line on the A-1a Doctors' Order Form. Do not alter an existing order which Pharmacy and Nursing have accepted onto their profiles. For example, if the existing order is for digoxin 0. 25 mg PO daily, and you wish to change it to digoxin 0. 125 mg PO daily, on the next open line write: " Discontinue digoxin 0.25 mg. Begin digoxin 0. 125 mg PO daily. "
E. Dose Column. Dosages should be prescribed in the metric system. The number of units of medications (e.g., 2 capsules) is only acceptable for combination products that are commercially available in only one strength. If a single ingredient medication is available in only one strength, it is still important to write that strength on the order. The terms " one tablet, " or " one ampul, " or only the volume amount for oral -liquids, should not be used because the strength or concentration of the dosage unit periodically changes. A zero should always be placed before a decimal expression less than one to prevent misinterpretation of drug orders. From example, .5 mg may be mistaken for 5 mg, especially on carbon copies or when the decimal point is written on the line of the order form. The correct way to express this value is 0.5 mg. The leading zero alerts the pharmacist and the nurse if the decimal point is not visible. Never place a decimal point and zero after a whole number as the decimal point may not been seen. Write 5 mg, not 5.0 mg, as this may be mistakenly interpreted as 50 mg.
F. Route Column. The route of administration is indicated in this column, e.g., PO or IM.
G. Interval and Remarks Column. Indicate the schedule on which the medication is to be administered. This section should also be used when prescribing a specific number of doses or days of therapy. The "PRN" designation should include the medication's purpose (e.g., PRN sleep, PRN pain). The drug administration times at the UIHC are published inside the front cover of the 1999-2000 Formulary and Handbook.
H. Signature. Inpatient medication orders must be signed by authorized prescribers. Medication orders are to include the four-character (alpha-numeric) prescriber's code. Orders written by medical students must be reviewed and co-signed by a licensed physician or dentist. Designated physician assistants and advanced registered nurse practitioners delineated in specific protocols approved by the Hospital and their employing departments may sign orders for medications and treatments. The designation "PA" or "ARNP" must follow the signature of the prescribing physician assistant or advanced registered nurse practitioner on all inpatient medication orders. Physician assistants may not write orders for Schedule II controlled substances which are listed as stimulants or depressants.
*The pharmacy computer system is an on-line patient medication system. The system screens medication orders for dosages, drug interactions, allergies, and therapeutic duplications.
Anti-Infectives:
Others:
The criteria for use of each of these drugs can be found in the drug monograph section of the Formulary as well as on each specific Protocol Drug Order Form.
How to Order a Protocol Drug
To obtain a protocol drug, prescribers are required to forward a
completed Protocol Drug Order Form that designates the indication for
use to Pharmacy along with the usual A-1a Doctors' Order Form. The
Protocol Drug Order Forms may be obtained on each patient care unit
or from the local pharmacy satellite. If a completed Protocol Drug
Order Form is not received by pharmacy within 24 hours of the written
order, the order will be discontinued and subsequent doses will be
withheld until a completed protocol order form has been received. In
the case of doxorubicin liposomal, famotidine, interferon
alfacon-1, celecoxib, or omeprazole, NO drug will be dispensed
until the Protocol Drug Order Form has been received by Pharmacy. Use
of the protocol drugs outside the criteria listed on the form
requires that the indication for use be clearly stated on the form
next to "Other indication" and that the form be signed by the
patient's attending physician.
The protocol drug process is necessary in order to collect accurate information regarding the use of high cost, high risk, and high use drugs. This allows the P&T Subcommittee to evaluate usage patterns of these specific agents in order to meet its charge in assuring the safe and cost-effective use of drug products within UIHC.
The Food and Drug Administration issued a public health advisory to physicians concerning the risks of liver toxicity associated with the use of trovafloxacin/alatrofloxacin (Trovan[R]). This action follows postmarketing reports of rare but severe liver injuries leading to transplants and deaths.
FDA had received reports of over 100 cases of clinically symptomatic liver toxicity in patients receiving trovafloxacin/ alatrofloxacin. Some of these patients developed serious liver injury leading to liver transplant and/or death. At present, FDA is now aware of 14 cases of acute liver failure that it has concluded are strongly associated with the drug. Six of these patients died: five due to liver failure and one of four additional patients who received liver transplants. Three patients recovered without requiring liver transplants, and for the remaining two patients the final outcome is still pending.
In issuing this advisory, FDA is informing physicians that trovafloxacin/alatrofloxacin should be reserved for use only in patients who meet all of the following criteria:
FDA is further informing physicians that, in general, therapy with trovafloxacin/alatrofloxacin should not continue for longer than 14 days. Therapy should be discontinued sooner if the patient experiences any clinical signs of liver dysfunction, including fatigue, loss of appetite, yellowing of the skin and eyes, severe stomach pain with nausea and vomiting, or dark urine.
In addition, the manufacturer has agreed to limit distribution of the product to hospitals and long-term nursing care facilities. The manufacturer will be communicating in the near future with other appropriate pharmacies to provide directions concerning possible return of their present inventories of trovafloxacin/alatrofloxacin.
More information about trovafloxacin/alatrofloxacin, including FDA's public health advisory, is available on the World Wide Web at www. fda. im/cder/news/trovan/default. htm
FDA Talk Paper June 9, 1999
In view of this unprecedented action by the FDA, the Chairman of the Pharmacy & Therapeutics Subcommittee, with the advice of the Antibiotic Advisory Subcommittee, has instructed the Department of Pharmaceutical Care on an interim basis to implement the following:
1) Remove trovafloxacin/alatrofloxacin (Trovan[R]) from the inpatient formulary; it will be available only with a special order by attending staff of the Infectious Diseases Service.2) Remove all samples from the clinic areas.
3) The Ambulatory Care pharmacies will not be filling any new outpatient prescriptions for trovafloxacin/alatrofloxacin.
4) Homegoing prescriptions will be filled; however, total duration of therapy will not be permitted to exceed 14 days.
The recommendation is that all patients at UIHC who are currently on trovafloxacin/alatrofloxacin be changed to alternative antibiotics. Prescribers will be contacted with recommendations for alternatives to trovafloxacin/ alatrofloxacin.
The actions by the FDA are expected to have a minor impact on patient care in this institution because the Antibiotic Advisory Subcommittee has taken precautions since the drug's approval to place restrictions on the use of trovafloxacin/ alatrofloxacin. Due to the prospective actions of the Antibiotic Advisory Subcommittee, we at the UIHC have put a minimal number of patients at risk.