P&T News: August 2000

Guidelines for Complete, Safe, and Accurate Discharge and Outpatient Prescription Writing

Pharmacy and Therapeutics Subcommittee
Peer Review Status: Internally Peer Reviewed by Bradley Britigan, MD, Kevin Bebout, RPh, Alan Mutnick, PharmD, Mary Ross, MBA

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.

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.

Outpatient Prescription Medication Supply Limits 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: Patients receiving their on-going primary care from UIHC (i.e., generally local area residents as refills must be picked up from UIHC). Hospital staff and dependents at the same address. Prescriptions for medications which are not commercially available. Prescriptions for verified state paper (indigent) patients (as defined by UIHC policy). These patients are eligible for a maximum of 90-day supply with a single refill of specific maintenance medications.

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 Department of Pharmaceutical Care 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 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 II 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.

F. 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. Prescriptions for this eligible patient group (excluding controlled substances) may be refilled a maximum of 11 times or for 18 months - whichever is less. Prescriptions for DEA controlled substances in Schedules III, IV, and V may be refilled a maximum of 5 times or for 6 months - whichever is less. Prescriptions for Schedule II controlled substances may not be refilled. State-paper eligible patients may receive a single refill of specific maintenance medications.

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. In order to provide optimal service to our patients and minimize the potential for transcription errors, only small groups of prescriptions should be phoned to the pharmacy. Larger groups (more than 4) should be in writing or via the IPR Medications List function.

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 and state law require that prescriptions for controlled substances written for immediate family or personal use must be written and 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.

Prescription Quantity Guidelines for Quota State Paper Patients 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:   Patients must have current (verified) quota state papers. (NOTE: This program excludes patients with county-pay papers.) Prescribers will identify these patients on new prescriptions (or one of a group of new prescriptions) to be filled by the Ambulatory Care Pharmacies. Patients not listed with a status of verified quota state papers on the INFORMM System when prescriptions are presented to the Ambulatory Care Pharmacies are not eligible for this program. Prescriptions must be written by authorized UIHC prescribers on UIHC prescription blanks. A maximum 90-day supply of maintenance medications may be dispensed to patients eligible for this program. The therapeutic categories of medication that may be dispensed for more than 30 days of therapy are limited to those indicated for the treatment of chronic disease (see Table 1). Only medications available on the UIHC Formulary are available for a 90-day supply. Only a 30-day supply of a special order (i.e., nonformulary) medication may be processed for acute conditions if a formulary alternative is not available. Chronic use of nonformulary medications will require a new prescription every 30 days, and hence, a physician visit at least once a month as per current procedures. Formulary medications in the acute category that are being prescribed for a chronic condition must have the specific indication for use documented on the prescription blank in the designated location to be eligible for a 90-day supply. The maximum duration for which a prescription will be valid for this program (including a single refill) is six months. Patients must have a visit with the prescriber or the prescriber's clinical service at least every 180 days (six months). One refill will be processed to complete up to a 180-day supply (if authorized by the prescriber). Refills may be provided by mailout service from the UIHC Ambulatory Care Pharmacies. Only refill supplies will be mailed to patients in the Indigent Patient Care Program. Nonformulary (special order) medications will not be eligible for this service. To avoid stockpiling of medications by patients, refills will only be provided 75 days after the patient last received a supply of the same medication from the UIHC. OTC medications not covered under the UIHC State Paper OTC Formulary will not be provided (see Table 2). Prescribers must include explicit patient directions on all prescription orders to be filled by the Ambulatory Care Pharmacies for this program. Orders with "Take as directed" will not be processed via this program.

Table 1. Medication Dispensing Limits for Patients in the Indigent Patient Care Program Maximum Supply Limits of Medication Which May Be Dispensed No more than a 30-day supply of medication will be dispensed for these medications.
Medications for the treatment of ACUTE (short-term) medical conditions, including:
Alprostadil urethral suppositories (MUSE) (maximum 6 suppositories per month) Anti-infective agents Antineoplastic agents and colony stimulating factors Clozapine Controlled substances Dihydroergotamine nasal spray Erythropoietin Interferons	OTC cough and cold preparations Otic preparations Ophthalmic preparations (for acute conditions) Naratriptan Proton pump inhibitors Rebetron® kits Sedative / hypnotics Sildenafil (Viagra) (maximum of 6 tablets per month) Sumatriptan nasal spray, tablets, and injection Topical preparations (for acute conditions)
Maximum Supply Limits of Medication Which May Be Dispensed 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:
Anticoagulants Anticonvulsants Antihistamines Anti-infective agents (for long-term use, e.g., osteomyelitis, endocarditis, TB, PCP) Arthritis drugs Asthma drugs Cardiovascular drugs, including: Antilipemics Antianginal agents Antiarrhythmics Antihypertensives Calcium channel blockers Diuretics Diabetes drugs	Gastrointestinal drugs (e.g., antacids, mesalamine, sucralfate, sulfasalazine, H2RAs) Glaucoma drugs HIV / AIDS drugs Hormone replacements Oral contraceptives Organ transplantation drugs Parkinson's disease drugs Prostate disease drugs Psychiatric drugs Topicals (for chronic dermatologic conditions) Thyroid drugs Tramadol Vitamins

Table 2. State Papers Patients Over-the-Counter Medication Formulary

Open Formulary Acetaminophen Tablets, Chewable; 80 mg Acetaminophen Tablets; 325 mg Acetaminophen Oral Solution; 160 mg/5 ml Acetaminophen Suppositories; 120 mg Aluminum Hydroxide Oral Suspension; 600 mg/5 ml Aspirin Tablets, Chewable; 81 mg Aspirin Tablets; 325 mg Aspirin Tablets, Enteric Coated; 325 mg Aspirin Tablets, Buffered; 325 mg Benzoyl Peroxide Lotion; 5%, 10% Benzoyl Peroxide Gel; 5%, 10% Bisacodyl Enteric-Coated Tablets; 5 mg Calcium Carbonate: Vitamin D Tablets; 1250 mg:125 I.U. Calcium Carbonate Tablets, Chewable ; 500 mg Capsaicin Topical Cream; 0.025% Chlorpheniramine Tablets; 4 mg Diphenhydramine Capsules; 25 mg Diphenhydramine Oral Solution ; 12.5 mg/5 ml Ferrous Sulfate Tablets ; 300 mg or 324 mg or 325 mg Ferrous Sulfate Oral Solution; 300 mg/ 5ml Ferrous Sulfate Oral Drops; 125 mg/ml Ferrous Gluconate Tablets; 300 mg or 324 mg or 325 mg Ferrous Fumarate Tablets; 200 mg Guiafenesin: Dextromethorphan Oral Soln.; 100 mg:10 mg/5 ml Hydrocortisone Topical Ointment; 1% Ibuprofen Tablets; 200 mg Insulins Magnesium/Aluminum/Simethicone Antacid; High Potency Magnesium Citrate Oral Solution Meclizine Tablets; 12.5 mg Meclizine Tablets, Chewable; 25 mg Miconazole Topical Cream; 2%

Multivitamin Tablets, Prenatal Multivitamin Tablets Multivitamin with Mineral Tablets Niacin (Nicotinic Acid) Tablets; 50 mg, 500 mg Nicotine Polacrilex Gum; 2 mg, 4 mg Nicotine Transdermal Patches; 7 mg, 14 mg, 21 mg Permethrin Topical Liquid (Nix); 1% Pseudoephedrine Tablets; 30 mg, 60 mg Pseudoephedrine Oral Solution; 30 mg/5 ml Senokot Tablets; 187 mg Sodium Chloride Inhalation Solution; 0.9% Triple Antibiotic Ointment, Topical Restricted Prescribing Lactobacillus Capsules; 2.5 billion, 10 billion organisms (diagnosis of antibiotic-associated diarrhea) Bismuth Subsalicylate Tablets; 262 mg (diagnosis of H. pylori ulcer) Bismuth Subsalicylate Oral Suspension; 262 mg/5 ml (diagnosis of H. pylori ulcer) Artificial Saliva Substitute (Radiation Oncology patients) Artificial Tears (prescribing by Ophthalmology) Loperamide Capsules; 2 mg (severe and/or chronic diarrhea) Docusate Capsules; 100 mg (chronic opioid therapy) Devices Insulin Needles Insulin Syringes Blood glucose test strips Lancet

DRUGS ADDED TO STOCK

CADEXOMER IODINE
Topical Gel: 40 g
Cadexomer iodine (Iodosorb®-Health Point) is a starch polymer bead with iodine 0.9% bonded to the polymer. It is indicated for the cleaning of acute and chronic wounds infected/colonized with bacteria sensitive to iodine.

CLARITHROMYCIN EXTENDED-RELEASE TABLETS
Tablet: 500 mg
Clarithromycin extended-release tablets (Biaxin XL® -Abbott) are a once-daily dosing formulation of clarithromycin which is indicated in adult patients for the treatment of acute maxillary sinusitis and acute exacerbations of chronic bronchitis caused by susceptible organisms.

EXEMESTANE
Tablet: 25 mg
Exemestane (Aromasin ® - Pharmacia & Upjohn) is an irreversible inhibitor of aromatase that is indicated for the treatment of advanced breast cancer in post menopausal women who disease has progressed following tamoxifen therapy.

LEVETIRACETAM
Tablets: 250 mg, 500 mg
Levetiracetam (Keppra® - UCB Pharma) is an anticonvulsant unrelated to other currently marketed anticonvulsants. It is indicated as adjunctive therapy in the treatment of partial onset seizures in adults.

LINEZOLID
Injection, Tablets and Oral Suspension: 600 mg
Linezolid (Zyvox® - Pharmacia & Upjohn) is a member of a new class of antimicrobial agents called oxazolidinones. It is generally considered a bacteriostatic agent with clinical utility against aerobic gram-positive organisms. Linezolid is indicated for the treatment of adult patients with the following infections caused by susceptible microorganisms; vancomycin-resistant Enterococcus faecium, nosocomial pneumonia, complicated and uncomplicated skin and skin structure, and community acquired pneumonia.
NOTE: The prescribing of linezolid is restricted to attending staff physicians from the Infectious Diseases Service.

OXCARBAZEPINE
Tablets: 150 mg, 300 mg, 600 mg
Oxcarbazepine (Trileptal® - Novartis) is an anticonvulsant structurally related to carbamazepine that is indicated as monotherapy or adjunctive therapy for the treatment of partial seizures in adults. It is also indicated as adjunctive therapy in the treatment of partial seizures in children ages 4 to 16 years.

PAPAIN/UREA/CHLOROPHYLLIN COPPER COMPLEX
Topical Ointment: 30 g
Papain/urea/chlorophyllin copper complex (Panafil ®-Health Point) is indicated for the treatment of acute and chronic wounds such as varicose, diabetic, and decubitus ulcers; burns; postoperative wounds; pilonidal cyst wounds; carbuncles; and miscellaneous traumatic or infected wounds.

PAPAIN/UREA DEBRIDING OINTMENT
Topical Ointment: 30 g
Papain/urea debriding ointment (Accuzyme ® -Health Point) is indicated for the debridement of necrotic tissue and liquefaction of slough in acute and chronic lesions.

PYROLYTIC CARBON-COATED ZIRCONIUM OXIDE BEADS
Injection: 1ml
Pyrolytic carbon-coated zirconium oxide beads (Durasphere ® -Advanced Uroscience) are indicated for the treatment of adult women with stress urinary incontinence due to intrinsic sphincteric deficiency.
NOTE: The prescribing of Durasphere® is restricted to Urology.

TAMSULOSIN
Capsule: 0.4 mg
Tamsulosin (Flomax® - Boehringer Ingelheim) is an alpha1-adrenoceptor blocking agent that is indicated for the treatment of the signs and symptoms of benign prostatic hyperplasia.

THYROTROPIN ALFA
Injection: 1.1 mg vial
Recombinant human thyroid stimulating hormone (Thyrogen® -Genzyme) is indicated as an adjunctive diagnostic tool for serum thyroglobin testing with or without radioiodine in the follow-up of patients with well-differentiated thyroid cancer.

VERTEPORIFIN
Injection: 15 mg
Verteporfin (Visudyne® - CibaVision) is a light-activated drug indicated for the treatment of age-related macular degeneration in patients with predominantly classic subfoveal choroidal neovascularization.

ADDITIONAL ACTIONS

EPOETIN ALFA (PROCRIT®) INJECTION
A 20,000 unit per 1 ml vial and a 40,000 unit per 1 ml vial have been added to stock.

DRUGS DELETED FROM STOCK

COLLAGENASE (SANTYL®) OINTMENT
Deleted due to low use. Papain/Urea (Accuzyme®) and Papain/Urea/Chlorophyllin (Panafil®) are available.

GRANISETRON 1 mg/ml (KYTRIL®) INJECTION
Ondansetron injection is available.

GRANISETRON 1 mg (KYTRIL®) TABLET
Ondansetron tablets are available.

OMEPRAZOLE (PRILOSEC®) CAPSULES
Lansoprazole is available. Title Page