P&T News: August 2004
Kevin L. Bebout, R.Ph., Administrative Pharmacy Practice
Specialist, Department of Pharmaceutical Care
Peer Review Status: Internally Peer
Reviewed
The Pharmacy and Therapeutics Subcommittee, the Joint Office for Compliance, and the Department of Pharmaceutical Care would like to review several key strategies to prevent errors during the prescribing of "take-home" supplies of medications for ambulatory care patients. This review is important for both new and seasoned prescribers since medication therapy is an important part of treatment for ambulatory care patients.
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 order will ensure that it is accurately interpreted and not subject to alteration. Attention to detail when writing prescriptions will prevent the need for the filling pharmacist to contact the prescriber to clarify ambiguous orders and will also reduce patient delays.
The medical literature, as well as several patient safety organizations and regulatory / accrediting agencies, has extensively reviewed multiple issues associated with the safe ordering of medications. The goal, of course, is to ensure that physicians, dentists, and other authorized prescribers write complete, clear, and safe prescription orders that are accurately interpreted by a pharmacist and ultimately carried out properly at home by the patient or care giver.
Duplicate Prescription System & Electronically Generated
Prescriptions
Ambulatory care prescriptions are written on the duplicate
prescription blank provided by the Department of Pharmaceutical Care
or in a format compatible with the UIHC computer-based patient record
for on-line generation of prescriptions. The duplicate prescription
system produces an original and an exact copy of the medication
order. These duplicate blanks are designed to permit the Department
of Pharmaceutical Care at the UIHC to dispense an initial supply of
medication to the patient and also return the original prescription
to the patient for obtaining continuing supplies in the local
community. (The use of other, nonstandard prescription blanks is
not authorized.)
The INFORMM Patient Record (IPR) also allows UIHC prescribers to generate prescriptions electronically by using the Medication List function. Prescriptions can be printed out locally or sent electronically to the UIHC Ambulatory Care Pharmacy-of-choice. These prescriptions maintain the duplicate system (original and copy) that has been employed at UIHC for many years.
Several features of the IPR system are advantageous: 1) a record of the prescriptions generated by IPR are accessible in the patient's profile under Medication List; 2) legibility is enhanced since the prescription is being type-printed; and 3) prescriber signatures are "electronically" provided (where permitted by law), therefore, they are 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 IPR 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 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 UIHC Ambulatory Care Pharmacies; rather, they must be printed out locally so that the prescriber can manually sign them.
Handwriting Legibility
Several national organizations, including the American Medical
Association, the Institute of Medicine, the Institute for Safe
Medication Practices (ISMP), and the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO), 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 provide 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).
Hospital policy and JCAHO 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 and others such as HCTZ, AZT, T3, and PCN are dangerous, may be misinterpreted, and have been associated with medication errors. Such abbreviations may not be used to order medications at UIHC.
In addition, the Pharmacy and Therapeutics Subcommittee and the Health Information Management Subcommittee have approved a list of dangerous medical abbreviations that may not be used in patient care communications at UIHC:
Medication orders that contain unapproved drug name abbreviations or dangerous medical abbreviations are not valid. Pharmacists are authorized to withhold dispensing of medications ordered via unapproved abbreviations.
Similarly, chemotherapy drug name abbreviations are never permitted to be used. The following abbreviations are particularly prone to misinterpretation if used in written or printed communications and must always be avoided: 2-CDA, 5-FU, 6-MP, CPT-11, IL-2, VP-16, CDDP, MTX.
Prescribers will be notified to clarify any orders using these dangerous abbreviations.
Essential Elements of a Prescription Order
Attention to detail when writing prescription orders obviates the
need for the filling pharmacist to contact the prescriber to clarify
orders; this care also enhances safety and reduces patient
inconvenience. 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. The
following elements should be provided on each prescription blank
generated by the prescriber:
1. Patient Demographics
Patient name, address, hospital number, birth date, and date prescription is written should be written on the face of the prescription.
2. Name and Strength of Drug
Medications should be ordered by the generic name, not by the proprietary or trade names. The dosage form (such as tablet, capsule, suspension) and the strength or concentration of the dosage form must be specified. The prescriber must also specify when the delayed-release dosage form for a medication is desired.
3. Quantity to Be Dispensed
Quantity of ingredients in a prescription must be expressed in the metric system. A zero should always be placed before a decimal expression less than one to prevent misinterpretation of the prescription. When prescribing drugs with varying dosage (such as "1 to 2 tablets") or prescribing "as needed" dosing, an exact numerical quantity should be specified rather than writing "30-day supply" on the quantity line.
4. Directions to the Patient
Writing clear and concise directions on the prescription will assist the patient in appropriate use of the medication. "Take as directed" should be avoided. The patient may forget or confuse verbal directions or lose a separate note. The "PRN" designation should include the medication's purpose (e.g., PRN sleep, PRN pain).
5. Indication for Use
An "Indication for Use" must be designated on the face of the UIHC prescription blank by the prescriber.
6. Signature, Printed Name, Physician Code
In addition to signing the prescription, the prescriber should print his/her name legibly below the signature along with a UIHC 4-digit prescriber code, and indicate practitioner status by circling the appropriate initials to the right of the signature line.
7. DEA Number
The prescriber's personal Drug Enforcement Administration (DEA) registration number (or for House Staff members the UIHC's institutional DEA number along with the prescriber's unique Clinical Provider Number [CLP] as a suffix) must be included on all prescriptions for drugs classified under the Federal Controlled Substances Act of 1970.
8. 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. Refills provided by the UIHC Ambulatory Care Pharmacies are limited to the following:
9. 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."
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
patients and minimize the potential for transcription errors, only
small groups of prescriptions should be phoned to the pharmacy.
Larger groups (more than four) should be in writing or generated via
the IPR Medications List function. Registered nurses and pharmacists
acting as agents of a UIHC physician may transmit telephone orders
for UIHC clinic patients.
1. Prescriptions for patients being discharged from the hospital must be in writing or generated by the IPR medication list function where available.
2. Consistent with the UIHC policy on clinician self-treatment, medications may not be ordered or prescribed by a clinician for himself or herself.
3. Verbal prescription orders which include refills can be accepted for those patients who will utilize UIHC's Ambulatory Care Pharmacies as their primary pharmacy (employees, local area residents, verified State Papers patients). If patients cannot return monthly to pick-up their medications, they should obtain refills in their local community. For patients with four or more prescriptions, prescribers should write or enter into the IPR the prescriptions rather than telephoning.
4. To minimize the potential for miscommunication regarding the medication, and to meet federal OBRA regulations, the indication for use of each prescription must be communicated.
5. Orders for Schedule C-III, C-IV, and C-V controlled substances may be received; such orders will require a personal DEA registration number. Orders for Schedule C-II controlled substances may not be received.
6. To ensure the validity of all prescription orders called in to the Ambulatory Care Pharmacies, the pharmacist who receives the verbal order will:
Antineoplastic Orders
To maximize safety, the University of Iowa Hospitals and Clinics
will maintain standardized policies and procedures for the
prescribing, preparation, and administration of antineoplastic (or
chemotherapy) agents. An attending physician, fellow, resident,
physician assistant, pharmacist, nurse, or research assistant may
write outpatient prescriptions for chemotherapy. All such
chemotherapy prescriptions require the signature of a fellow or
attending physician. Each division will establish policies on
which fellows are authorized to prescribe chemotherapy. Verbal orders
are only acceptable in the case of a dose modification. Prescriptions
for antineoplastic agents that are signed by non-oncology staff or
fellow physicians are restricted to that physician's area of
specialty.
Write Prescriptions 24 Hours Prior to Discharge
Prescribers are encouraged to write discharge prescriptions which
are to be filled by the UIHC Ambulatory Care Pharmacies 24 hours
prior to the patient's discharge in order to avoid delays in the
patient's departure. The patient must be given the option of having
an initial supply filled by UIHC or of taking his/her prescriptions
to a community pharmacy. 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 the stay.
Summary
Prescribers are encouraged to review the complete UIHC policy
which covers all aspects of prescribing medications for ambulatory
care patients. The UIHC Formulary and Handbook is also a
valuable electronic reference for prescribers. The full text of the
Formulary and Handbook can be located on a hospital computer by going
into either:
This site is updated with additions, deletions, and changes in restriction status of stocked medications on a weekly basis. If you have any problems accessing the on-line Formulary and Handbook, please contact the Drug Information Center at 6-2600. Questions about prescribing medications for ambulatory care patients may also be directed to the UIHC Ambulatory Care Pharmacies at 384-6800.
1 The list of approved drug name abbreviations which may be used at UIHC for inpatient and outpatient medication orders is provided: http://www.vh.org/formulary/Form/16ApprovedDrug.htmlThe list of approved medical abbreviations which may be used at UIHC for inpatient and outpatient medication orders is provided: http://www.vh.org/formulary/Hand/11MedAbbr.html
The list of dangerous medical abbreviations which may NOT be used at UIHC is provided: http://www.vh.org/formulary/Form/dangerousmedicalabbrev.html
ADDITIONAL ACTIONS
ACETIC ACID 2% OTIC SOLUTION
Replaces acetic acid 3% otic solution that was extemporaneously
compounded.
ARIPIPRAZOLE (Abilify®)
A 10 mg tablet was added to stock.
Note: Restricted to Psychiatry.
AGALSIDASE BETA INJECTION (Fabrazyme®)
A 5 mg vial was added to stock.
Note: Restricted to Pediatric Hematology/Oncology.
NELFINAVIR (Viracept®)
A 625 mg tablet was added to stock.
Note: The cost following each monograph is the UIHC inpatient
acquisition cost.
DRUGS DELETED FROM STOCK
ALMOTRIPTAN TABLETS
Replaced with sumatriptan, naratriptan, or eletriptan tablets.
AMPRENIVAR
Replaced with fosamprenavir.
BRETYLIUM INJECTION
Discontinued by manufacturer. Other antiarrhythmic agents are
available.
CODEINE ORAL SOLUTION
Discontinued by the manufacturer. Codeine tablets and morphine oral
solution are available.
DICLOFENAC 0.1% OPHTHALMIC SOLUTION (Voltaren®)
Discontinued due to low use. Ketorolac ophthalmic solution is
available.
DICLOXACILLIN ORAL SUSPENSION
Discontinued by the manufacturer. Dicloxacillin capsules are
available.
HYDROCORTISONE URETHRAL INSERTS
Deleted due to low use.
HYDROXYPROPYLMETHYLCELLULOSE 1% OPHTHALMIC SOLUTION (Ultra
Tears®)
Discontinued by the manufacturer. Hydroxyethylcellulose 1.6%
ophthalmic solution is available.
MESORIDAZINE
Discontinued by the manufacturer. Chlorpromazine and thioridazine are
available.
OFLOXACIN 0.3% OPHTHALMIC SOLUTION (Ocuflox®)
Replaced with levofloxacin, moxifloxacin, and gatifloxacin ophthalmic
solutions.
RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN INJECTION
Discontinued by the manufacturer. Palivizumab is available.
The Standards for Privacy of Individually Identifiable Health Information (Privacy Rule) establish standards for protection of health information as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Privacy Rule protects all individually identifiable heath information in any form or medium, whether electronic, paper, or oral. Individually identifiable health information is information, including demographic data, that relates to:
To help insure that pharmaceutical company representatives (PCR) do not have access to our patients' protected health information, the following guidelines are in place:
It is the responsibility of all UIHC staff to ensure that PCR are not knowingly or inadvertently provided with protected health information or that PCR do not have access to protected health information because of their location within UIHC. PCR who are in patient care areas or other areas where protected health information is accessible should immediately, but politely, be asked to leave the area.
If you have questions regarding HIPAA regulations or need to report a potential HIPAA violation, contact the Compliance Helpline.