P&T News: August 2003
Pharmacy and Therapeutics Subcommittee and the Department of
Pharmaceutical Care
Peer Review Status: Internally Peer
Reviewed
One of the primary communication links between the prescriber, pharmacist, and patient is complete, safe, and accurate prescription writing. Completion of all "essential elements" of a prescription will assure that it is accurately interpreted and not subject to alteration. Attention to detail when writing prescriptions will prevent the need for the Department of Pharmaceutical Care to contact the prescriber to clarify prescriptions and will reduce patient delays. Properly written prescriptions will help ensure continuity of care in the patient's local community.
Duplicate Prescription System
The Duplicate Prescription System at 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 a 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 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,
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 ensure that the intended patient receives, and is billed for, the
correct medication.
B. Name and
Strength of 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, PCN, U, 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.
C. Quantity to Be
Dispensed
The quantity of drug to be dispensed should be indicated. The
quantities dispensed to most patients are generally limited to a
maximum 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.
For Drug Enforcement Administration (DEA) designated controlled substances, including narcotics and anabolic steroids, the quantity should be written in words as well as numbers to prevent alteration of the prescription.
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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. Refill prescriptions may be processed for:
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D. 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).
E. 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 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.
F. 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 (CLP
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.
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 in Iowa.
Assistance in obtaining the application forms for State and Federal registration is available at the Pharmacy Administrative Office, Room CC-101 GH. For additional information, see the on-line Formulary and Handbook -- www.vh.org/Formulary/Form/FedDEARegistrationProcess.html.
G. 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.
H. 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.
I. 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 previous). Prescriptions for these eligible patient groups (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 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 (see next).
J. 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.
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Table 1. Drug Name Abbreviations Approved for Use at UIHC |
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Abbreviation |
Generic Name |
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Medications |
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Intravenous Fluids* |
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* Note: Other combinations of the above abbreviations may be used. |
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Vaccines, Toxoids, Skin Tests |
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Vitamins |
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Standard International Chemical Formulas (e.g., NH3 , KCl) are also acceptable. |
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Handwriting Legibility
Several national organizations, including the American Medical Association, the Institute of Medicine, the Institute for Safe Medication Practices, and the Joint Commission for Accreditation of Healthcare Organizations, have warned healthcare providers about the association between poor prescriber handwriting and medical errors. Prescription orders written hurriedly and illegibly force other care providers to seek order clarifications or inadvertently lead the care provider to erroneously interpret the order and give medication in a manner not intended by the prescriber. To avoid errors caused by illegibly written orders, the following should be observed:
Additional information about safely writing medication orders may be reviewed at the Institute for Safe Medication Practices web site (www. ismp.org).
Electronically Generated Prescriptions
The INFORMIM Patient Record (IPR) allows UIHC prescribers to generate prescriptions electronically by using the Medication List function. Prescriptions can be printed out locally or sent electronically to the ambulatory care pharmacy-of-choice. These prescriptions maintain the duplicate system (original and copy) that has been employed at UIHC for over 25 years.
Several Features of the IPR system are advantageous: 1) prescriptions generated by IPR are later accessible in the patient's profile under Medication List; 2) legibility is clear by virtue of the prescriptions being type-printed; and 3) prescriber signature are "electronically" provided, therefore also legible. The legibility of both the prescription information and the signature promotes patient safety and convenience for patients and results in fewer follow-up phone calls to prescribers.
The system also affords several security features. In addition to the electronic signature, each prescription has its own printed security number. This number is generated by IPR and can later be entered into INFORMM by a UIHC ambulatory care pharmacist to verify the prescription's authenticity. Additionally, the paper stock used is water marked. Finally, outside the pharmacies may call the Department of Pharmaceutical Care (phone number is provided on the prescription) to verify the authenticity of the prescription.
Prescriptions for controlled substances can be generated by the IPR Medication List function, although electronic signatures are prohibited. Prescribers must provide a handwritten signature on the original portion and on the "copy" portion if refills have been indicated. Controlled substance prescriptions cannot be sent electronically to the ambulatory care pharmacies; rather, they must be printed out locally so that the prescriber can sign them.
Discharge Prescriptions for Inpatients
Prescriptions for discharge medication 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 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 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. Payment for prescriptions is required at the time of discharge. Use of generics or most cost-effective therapy is recommended.
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 generated 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 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.
Self-Prescribing Medications
State regulations prohibit practitioners from self-prescribing any prescription for (legend) medication, and from prescribing or dispensing controlled substances to members of the practitioner's immediate family for an extended period of time (this applies to all controlled substances in all DEA Schedules). Another authorized prescriber (with a valid DEA registration number for controlled substances) should write the prescription for the practitioner or members of his/her immediate family, and this should be properly documented in the appropriate medical record.
Prescriptions for House Staff
The UIHC medical care program permits house staff physicians and dentists 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. A clinician may not prescribe for himself/herself in accordance with Hospital Policy 1.21. 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. Failure to acquire any required signatures for 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.
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 see the on-line Formulary and Handbook -- www.vh.org/Formulary/Form/17TakeHome.html .
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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:
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Table 3. State Papers Patients Over-the-Counter Medication Formulary* |
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Open Formulary |
Covered Devices Insulin Syringes Restricted Prescribing Aluminum Hydroxide Capsules (Renal Dialysis) |
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Acetaminophen Tablets, Chewable |
80 mg |
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Acetaminophen Tablets |
325 mg |
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Acetaminophen Oral Suspension |
160 mg/5 ml |
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Acetaminophen Suppositories |
120 mg |
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Bacitracin Ointment |
-- |
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Aspirin Tablets, Chewable & EC |
81 mg |
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Aspirin Tablets |
325 mg |
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Aspirin Tablets, Enteric Coated |
325 mg |
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Aspirin Tablets, Buffered |
325 mg |
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Benzoyl Peroxide Lotion |
5%, 10% |
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Benzoyl Peroxide Gel |
5%, 10% |
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Chlorpheniramine Tablets |
4 mg |
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Clotrimazole Vaginal Cream |
2% |
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Diphenhydramine Capsules |
25 mg |
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Diphenhydramine Oral Soln |
12.5 mg/5 ml |
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Ferrous Sulfate Tablets |
300 mg/325 mg |
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Ferrous Sulfate Oral Drops |
125 mg/ml |
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Ferrous Gluconate Tablets |
300 mg, 325 mg |
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Guaifenesin: Dextromethorphan |
100mg:10mg/5 ml |
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Insulin |
-- |
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Meclizine Tablets |
12.5 mg, 25 mg |
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Miconazole Topical Cream |
2% |
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Niacin Tablets |
50 mg, 500 mg |
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Permethrin Topical Liquid |
1% |
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Prenatal Multivitamins |
-- |
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Pseudoephedrine Tablets |
30 mg, 60 mg |
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Pseudoephedrine Oral Soln |
30 mg/5 ml |
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Senokot Tablets |
187 mg |
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* OTC items not listed above are not covered |
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JCAHO Patient Identification Guidelines
Striving for Quality
Across the nation hospitals report serious medical errors that
are attributed to misidentification of patients. In order to assure
that this important patient right is maintained in the medication and
blood administration processes at UIHC, special attention to checking
two methods of identification is being implemented.
In July 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established its 2003 National Patient Safety Goals. One of the goals is to Improve the Accuracy of Patient Identification. JCAHO recommendations for ensuring compliance include the use of at least two identifiers whenever taking blood or administering medication or blood products.
Inpatient Settings
In the inpatient setting, the two patient identifiers are patient
name and hospital number. The individual performing these functions
must compare and verify each of the two identifiers at the point of
care/bedside.
Medication Administration
Drawing Blood
Use the phlebotomy requisition at the bedside.
Blood Administration
Use the attached blood label at the bedside and follow the usual
blood administration procedures for double-checking all patient
information with a witness.
Outpatient Settings
Ask the patient his/her name and birth date to assure that the
correct patient is identified.
Medication Administration
The individual administering the medication will ask the patient
his/her name and birth date. If the patient is a minor, the parent
will be asked to identify the patient. In situations where the
patient is unable to communicate, sedated, or lacking the ability to
state his/her name and birth date, an ID band will be placed on the
patient that contains the two patient identifiers.
Drawing Blood
The phlebotomist will ask the patient his/her name and birth date
and compare to the phlebotomy requisition.
Blood Administration
Use the attached blood label at the point of care and follow the
usual blood administration procedures for double-checking all patient
information with a witness.
For additional information, reference the UIHC Patient Identifier Policy at http://policies.uihc.uiowa.edu/Governing Body Directives/SectionV/V.35PatientIdentifiers.pdf