Download Pharmacist Training Manuel

Pharmacist Training & Reference Manual 1 MISSION The mission of Unity Health System is to make a positive difference in the lives and health status of individuals in the city of Rochester and will educate our community, our providers, and future health care professionals in order to offer the highest quality care to all members of our community, especially those who are underserved and most vulnerable. OUR HOSPITAL SYSTEM Unity is a 681-bed health care network serving the city of Rochester and western Monroe County. A wide range of specialty programs and services are available at Unity Hospital, the Unity St. Mary's Campus, and multiple sites across Monroe County. The primary clinical site will be at Unity Hospital which is a 360-bed community teaching hospital. Pharmacists at Unity work with physicians, nurses, and other supportive personnel to provide cost-effective care through medication selection, preparation, focused monitoring, outcome evaluation, and implementation of practice guidelines. Other responsibilities of pharmacists at Unity include working on process improvement projects, providing education to other health care professionals, and severing on selected hospital committees. 2 Current Project Team Leaders:  Bob Adams  Leo Cai  Shashi Patel Contributing Team Members  Jill Graham  Susan Kang  Andrea Smith Acknowledgement for Help and Input throughout Development:  Hamied Alkamil  Pete Chakos  Kevin Conlon  Lisa Cringoli  Paul Dahler  Mavis Jasmine  Jeff Kasten  Cynthia Marx  Natalie Kremer  Patnawon Thung Updated July 8, 2008 3 Table of Contents I. II. III. IV. V. General Hospital Information  Pharmacy Department Organizational Chart 5  Map of Park Ridge Campus 6  Hospital Floors/Units/Departments 7  Pharmacy Staff 9  PAs, Hospitalists, Residents 11  When to page who 14 Pharmacist Duties  Overall Checking Procedures 15  Medication Order Entry / Work Flow 16  Park Ridge Satellite  AM Shift 17  Afternoon Shift 19  Evening Shift 20  Main (basement) 21  St. Mary’s 24 Protocols  Auto Substitute 26  TPN 32  PPN 36  PDQ Delivery 39  PRCD After hour delivery 39  Standard Narcotic Concentration 40  41 IV Manufacturing Standards Professionalism  Articles “Believing what we know: Pharmacy provides value” “Pharmacy does provide value, but is the profession built to last?” Misc. 43  Cerner Short Codes / order sets 58  Pyxis FAQs 60  Computer Resources / Links 61  Cerner/Label/Mars Printers 62  IVF with Potassium 63  IV Push Policy 64  Fax Downtime procedures 65  Meds Not Loaded Policy 66  Policy 9.11 Antineoplastic/Cytotoxic Drugs 67  Unity Health High Alert Medications 76  Unity Health look-a-like sound-a-like Drug list 77  Joint Commission Educational Booklet (See Pharmacy Shared Folder)  Chempack Handbook (See Pharmacy Shared Folder) 4 Pharmacy Department Organizational Chart James Della Rocco, RPh, J.D. Director of Pharmacy Services Lisa Cringoli Administrative Assistant Vaccant Director of Operations James Rapp, RPh SP Park Ridge Apothecary vacant System Administrator Shashi Patel, PharmD Director of Clinical Services Pharmacists Larry Green, RPh SP St. Mary’s Apothecary Pamela Dunning Purchasing Agent Technicians 5 6 Hospital Phone Numbers Place 2100 2100 Clinical Nurse Leader Nadine Knapp 2200 2200 Clinical Nurse Leader Monty Cox 2300 2300 Clinical Nurse Leader Mary R. 2400 2400 Clinical Nurse Leader Trish McCann 3100 3100 Clinical Nurse Leader (Chemo) Linda Hagan 3200 3200 Clinical Nurse Leader Lisa Ladowski 3300 3300 Clinical Nurse Leader Donna Soles 3400 3400 Clinical Nurse Leader Vicki Wray 4100 4300 5100 Charge NurseRenee Jenkins or Pamela Daniels Director of 5100 Ivy Shelby 6300 Cardinal Emergency PR Apothecary SM Apothecary Admitting Chief Resident Pager System Administrator vacant Dialysis (3500) ED Charge Nurse Extension 1100 4490 1200 Fax 7200 Place 2nd PACU Extension 1233 Fax 7848 7375 PACU Ext Stay PACU Ext Stay 4156 7186 4491 1300 7395 PACU Ext Stay PACU Ext Stay 1707 5024 4492 1400 7409 Pamela (purchasing) Patty Miller (narcotics) 7328 7333 4493 5100 7478 Pharmacy Main Pharmacy Main 7330 7336 7047 7047 4494 5200 7271 Pharmacy Main Pharmacy Satellite 7331 7310 7047 7848 4495 5300 Pharmacy Satellite Pharmacy Satellite 1312 2340 1940 7309 7332 7734 Pharmacy IV Room PRCD Medication Room (evening hours ext.) 4496 5400 4497 3919 3600 3270 263-8001 3540 375-4455399 7340 3928 5895 240-5500 7970 4295 7270 3918 3915 3649 PRCD PA, Richard Wilson PRCD PreAn 4034 306-8318 5477 7955 PreAn 1188 PreAn Resident Float Evenings/Nights 1429 Respiratory Rochester General SCU Security 7849 240-5500 7176 Shashi Patel 922-4481 7702 7745 x: 4164 pg: 3060097 Southside Apoth. SPD St. Mary's 271-7141 7157 3395 3397 7 ED ED ED ED ED Quickcare Environmental Services Help Desk Help Desk after hours Highland Hospital 1029 7070 1770 1288 5190 7145 3375 7417 341-6790 7045 Strong Hospital (inpatient) Strong Hospital (outpatient) Surgical PA Float pager TCU TCU James Della Rocco Walk-in Care Center 7141 275-5213 275-4931 220-7880 1696 7132 x: 7337 pg: 2394829 3531 7392 PDQ 475-0033 8 Hospice Hospice ICU-S ICU-S ICU-S ICU-C ICU-C ICU-C ICU-N ICU-N ICU-N Jim Finucane (pyxis) Kevin Conlon (Cerner) Lakeside Hospital Leo Cai LDRP Lisa Cringoli Maintenance MOU Night Nursing Supervisor Nursery OR Main Desk OR Tech OR Recovery PACU PACU 3540 3565 1425 1095 7090 1079 7397 1056 1409 7017 1417 7348 4951 395-6047 x: 7829 pg: 3230049 4020 7283 5888 7279 5021 4030 7975 or 7191 320-0206 1194 7186 5024 Acct # 8580 Pharmacy Acct # 17178 Cost Center #108200 Courier Pick-ups 1-800-220-3146 Pyxis Support 1-800-727-6100 Customer #311 7226 4019 Pharmacy Department Name Abel, Theresa Adams, Bob Alkamil, Abedalhamied Biletskiy, Roman Boland, Jennifer Extension 7310 7310 7310 7310 fax pager 220-5280 Home Phone 467-5812 563-7183 359-3461 458-0316 Cell 259-8085 455-2448 703-1017 820-1389 469-5123 9 Cai, Leo Carnevale, Joyce 7829 4952 7047 323-0049 Chakos, Pete Clark, Jim Conlon, Kevin Coots, Alex 7310 323-0021 / 2405540 7310, 4951 220-5333 7237047 Cringoli, Lisa 7283 Csati, Jordan Dahler, Paul 7310 7310 323-0030 Della Rocco, Jim Diep, Tuong 7337 7310 239-4829 Dockrell, Tom Dunning, Pamela Fafinski, Kristine Finocchio, Jacklyn Finucane, Jim Graham, Jill Halpin, Kevin Hayward, Amanda Hosenfeld, Andrew Jackson, Jennifer 7337 7328 7310 7310 7348 7310 7310 7310 7310 7310 Jasmine, Mavis Kang, Susan Kasten, Jeffrey Kokanowich, Kate Kremer, Natalie Letendre, Michael Lessard, Lyn Lewish, Erik Lewish, Katie Marble, Lucas McElroy, Richard Miller, Patty Moore, Jeremiah Munawar, Daud Nasim, Muhammad Patel, Shashi 7310 7330 7310 7310 7310 7310 7310 7310 7310 7310 7310 7333 7310 7310 7310 4164 227-7751 225-5356 716-8338653 414-4116 425-8141 723-0717 413-0747 859-8063674 943-8441 269-8813 506-2185 716-9233212 586-9551 240-3777371 334-3942 7237047 278-4405 453-2350 320-0208 323-0219 720-9519 259-8447 429-6971 247-6299 671-8402 392-5856 320-0206 (OR Tech) 220-7355 752.9266 507-7871 455-6056 330-8105 750-0231 208-9235 716-9083887 415-3491 594-0503 314-6900 802-6422 462-0033 921-0052 306-0097 269-9284 247-8953 473-4844 473-4844 723-9224 227-0230 889-5636 662-3738 244-9885 381-5313 442-2505 766-1813 697-4967 721-7520 613-5180 415-3115 749-3501 733-7446 10 Scalzo, Joyce Scorgie, Kevin Sifain, Evelyn Smith, Andrea 429-6394 7310 1993 Stevenson, Rabia 7310 Thung, Patnawon 7310 Ulrich, Mary 7310 Vogt, Joan Vora, Priya 7310 Vuciterna, Bukurijue 1993 White, Debbie 7310 ***St. Mary's RPh Pager 238-0049*** MEDICAL - PA/NP BAILEY, JULIE CARL, LEAH CASTRO, SARA CAVEN, JOHN 802-9591 964-7029 486-4217 220-3943 238-0081 964-8607 227-6419 208-0822 716-4002182 305-8347 322-3493 414-6166 320-0206 (OR Tech) 663-8937 865-7327 PAGER # 263-8060 220-5371 306-9277 306-9271 11 CUPOLO / TIFFANY / POPIELARZ / TUTTLE FARLEY, DOREEN HERNBERG, KRISTIN IGBOELI, ADAOBI KENYON, ELIZABETH PARKER, MARY POPIELARZ, CHRIS RICH, JANET SAPORITO, BRENDA SCHULTZ, PATRICIA SIFAIN, CLAUDINE TRAN, NHUNG TUTTLE, KIM WOOSTER, JENNIFER STUDENT PAGER as of 12/19/07 238-0147 238-0184 220-5697 291-0160 291-0011 306-9273 238-0776 240-0486 306-9274 306-9278 220-5573 306-9272 220-5575 323-0267 238-0083 291-1403 SURGICAL HOUSESTAFF Pager #s: Home #s: Dr. Cardin…………….. 220-9677……. 899-9813 Dr. Golijanin………….. 220-4562…….c-507-9529 Dr. Grieger……………. 240-6478……c354-3135 Dr. Madeb…………….. 220-4573…….. 244-3641 Dr. Marshall…………... 220-9678…….. 442-5212 12 Dr. Nicholson………… 220-4551…….. 670-0437 Dr. Patel………………. 220-5300…….. 414-6376 Dr. Polomsky………... 220-7605…….. 571-4306 Dr. Singer…………….. 220-2646……c. 278-8743 Catie Benjamin, PA… 240-6594..c.1-716-481-9367 Kendra Bigham, PA…. 291-2568……c-259-1691 Kelly Burgess, PA…… 291-2596……c-747-5136 Katie Ciurca, PA……… 240-1364…….. 271-5089 Timothy Crowe, PA…. 320-2443………473-9984 Kristi Edmunds, PA…. 240-0408…1-315-383-5353 Theresa Garbach, PA.. 306-0119………217-8641 Jennifer Kuhner, PA... 291-2595.......c737-3032 Candi Napolitano, PA.. 323-0206…….. 455-8352 Dan O’Hara, PA........… 320-2430..…… 387-9982 David Perry, PA........ 291-2592..……. 338-2705 Tina Reinhardt,PA… 291-2598..1-716-863-3534 Sue Sargent,PA……….306-0142………442-6467 Debra Smith, PA.......... 291-2593..……. 889-7061 Leslie Sonders, PA…. 306-0107………749-3075 Christine Tensley,PA...291-2591………313-2576 FLOATER PAGER – X-4788 PAGING THE FLOOR TEAMS: In an effort to aid communication to the resident team on-call, we have instituted “Team Pagers”.  From 7:30 a.m. to 5:00 p.m. please call the team pager # listed below.  After 5:00 p.m. please page 306-8497. This applies on both weekdays and weekends. 13 BLUE TEAM: GREEN TEAM: ORANGE TEAM: PURPLE TEAM: RED TEAM: YELLOW TEAM: 220-7407 220-7400 220-7408 220-7409 220-5354 220-7101 PLEASE DO NOT page residents (unless for emergency) during the following times:  Noon Conference: Mon-Fri: 12 N-1:00 P.M.  Grand Rounds: Tuesdays: 8:00 A.M. – 9:00 A.M.  Attending Rounds: Mon/Wed/Fri: 10:00 A.M. – 11:30 A.M.  Specialist Rounds: Thursdays: 10:00 A.M. – 11:30 A.M. If you have any questions, please contact the Chief Resident at ext. 4037. This person can also be very helpful if for some reason your pages are not being returned, for example if a resident is not aware that his/her pager is not functioning. WHEN TO PAGE WHO ORDER WRITTEN BY TIME ORDER WRITTEN Medical PA 7am – 7pm 7pm – 7am (Night Float PA) LOCATION OF PATIENT PAGER ED,TCU, 2nd floor 238 – 0147 3rd floor 238 – 0184 14 Surgical PA TCU PA 7am – 5pm 5pm – 7am 220 – 7880 or X4788 Daytime Call TCU X1696, ask sec to tx to PA covering Night 238 – 0147 EOU/SCU PA Resident EOU/SCU X4294 or X4797 All locations 306 – 8497 ICU Call ICU x1079, sec will tx to resident line 7am – 5pm 5pm – 7am ICU Resident Resident Teams LDRP Order written by PA Blue: 220-7407 Green: 220-7400 Orange: 220-7408 Purple: 220-7409 Red: 220-5354 Yellow: 220-7101 LDRP 240 – 7834 Order written by NP, other Call LDRP X4020, sec can often tx to NP on floor II. Pharmacist Duties CHECKING PROCEDURES IV’s  Patient name  Drug name  Drug dose Homemade IV’s  Syringe tech used to prepare IV  Diluents Patient Specific Meds.  1 patient name per zip-lock bag  Verify dose in bag 15     Frequency Solution Rate Exp. Date (especially frozen)          Drug IV fluid Patient name Drug name Drug dose Frequency Solution Rate Exp. Date     with dose on label Drug name Drug dose Frequency Being sent appropriately vs. being loaded in Pyxis Pyxis  Drug name and strength (careful-solumedrol and depomedrol)  Dosage form  Quantity Prepacking  Drug name and strength-refer to regular med bottle  Expiration date  Lot number  Quantity (especially narcotics)  Narcotic label must have NDC number and schedule (II,III, IV, V)  Make sure each packaged med is fully sealed Satellite  Patient name (make sure each bag has labels for the same patient  Check both sides of bag  Patient rm number  Drug name  Drug strength  Dosage form  Directions  Expiration date  Quantity (how much to send where) o SCU/EUO – 2 day o ED – 1 day o Floors – load most medications into pyxis o Final list for IVs in the basement is printed at 2:30- when sending initial MEDICATION ORDER ENTRY / WORK FLOW doses of IVs before 2:30 make sure enough doses are sent to get patient through until around 5 (when meds are delivered); when sending initial doses of IVs after 2:30 send a 24 hour supply Orders Arrive in Satellite Pharmacy  Via fax  Via door Techs retrieve and sort orders Sorted orders placed in Pharmacist Order Entry Bin  STAT  New Admits 16  Floors   Order Entry Find Patient – based on MRN or Floor + Patient Name Scan order for potential problems No Problems Found Enter Order Medication Stocked in Pyxis Information transferred to pyxis and nursing staff may retrieve medication from floor Pyxis terminal Medication Not Stocked in Pyxis  Pharmacist changes Qty to 0 or appropriate Qty if not being loaded into Pyxis  Label Prints in Satellite  Techs Load Medication into Pyxis or Deliver to Pharmacy Bins in Med Room at Units Pharmacist Checks  Patient Specific Medication  Meds-Not-Loaded Park Ridge Satellite   Problem Found Enter Orders that can be entered Problem Solved If Pharmacy Intern present then pass problem along to Pharmacy Intern to follow-up No Intern Then…  Page Provider (if provider Known) o Take Verbal Order  If Provider Not Known o Call Floor to find out coverage  Fill out green Nursing Communication sheet and send to floor AM Shift (7:00-3:30) Techs Deliver / Load Medications DailyatPharmacy Top and Middle of every Hour Starting 8:00 AM Operations 7:00 AM STATs when completed and checked by Pharmacist o Check Night Log Book for orders – verify that all meds that were taken match up with a valid order, if not contact the night nursing supervisor before she leaves and place night log book back in cabinet o Remove orders from the fax machine 17 o Sort/prioritize orders (techs generally retrieve and sort) 1. Admissions a. EOU & MOU b. ICU c. All others 2. Single orders a. STATs b. Antibiotic c. EOU & MOU d. ICU e. All others o Check Cerner for admitted patients held in the E.D. (E.D. boarders). If not all of the orders have been received, contact the E.D. Clinical Leader at x7270 7:30-12:00 o Enter orders o Print patient MARs in satellite for new admits except for TCU (no MARs). Labor and delivery, PRCD, 4100 and 5100 MARs should all be printed to the specific unit printer. o Check patient meds and pyxis meds loaded o Check IV hood o Check IV compatibilities and answer other phone related problems o Check any Vancomycin 1st time doses and record in Antibiotic review chart o Fax down any TPN orders to main pharmacy and also call down to verify receipt of TPN orders Lunch – Start lunch rotation 12:00-3:30 o Enter orders o Print patient MARs in satellite for new admits except for TCU (no MARs). Labor and delivery, PRCD, 4100 and 5100 MARs should all be printed to the specific unit printer. o Check patient meds and pyxis meds loaded o Check IV hood o Check IV compatibilities and answer other phone related problems o Check any Vancomycin 1st time doses and record in Antibiotic review chart o Fax down any TPN orders to main pharmacy and also call down to verify receipt of TPN orders o Discuss any unresolved problems with night pharmacists Notes: 18 Afternoon Shift (1:00 – 9:30) Daily Pharmacy Operations 1:00 – 5:00 o Enter orders o Print patient MARs in satellite for new admits except for TCU (no MARs). Labor and delivery, PRCD, 4100 and 5100 MARs should all be printed to the specific unit printer. 19 o o o o o Check patient meds and pyxis meds loaded Check IV hood Check IV compatibilities and answer other phone related problems Check any Vancomycin 1st time doses and record in Antibiotic review chart Discuss any unresolved problems with AM pharmacists Dinner - start covering dinner with night pharmacists 5:00-9:30 o Enter orders o Print patient MARs in satellite for new admits except for TCU (no MARs). Labor and delivery, PRCD, 4100 and 5100 MARs should all be printed to the specific unit printer. o Check patient meds and pyxis meds loaded o Check IV hood o Check IV compatibilities and answer other phone related problems o Check any Vancomycin 1st time doses and record in Antibiotic review chart o Check Pyxis tech (around 7ish but pyxis tech will call when ready) o Pull Narcotics (around 7ish – pyxis tech will call when ready for check) o Make any Narcotic drips or pull meds for Narcotic drips to be made in the satellite Notes: Evening Shift (3:30 – 12:00 Monday-Friday & 2:30-11:00 on weekends) Daily Pharmacy Operations 3:30 o Receive report from AM shift about any unresolved problems or potential issues that may come up during the evening shift 20 3:30-12:00 o Enter orders o Print patient MARs in satellite for new admits except for TCU (no MARs). Labor and delivery, PRCD, 4100 and 5100 MARs should all be printed to the specific unit printer. o Check patient meds and pyxis meds loaded o Check IV hood o Check IV compatibilities and answer other phone related problems o Check any Vancomycin 1st time doses and record in Antibiotic review chart o Pull Narcotics (around 10:30 Make any Narcotic drips or pull meds for Narcotic drips to be made in the satellite o Sort Pink Buckets if time permits o Group problem orders by prescriber o Make sure problem orders are clear to the person reading them. o Put out Night log book o Turn off light o Make sure pharmacy door is locked o Check pharmacy on call list Notes: Main (basement) Pharmacy (7:30-4:00) Daily Pharmacy Operations 7:30 am o Unlock doors (front and back) o To open door ______ o To unlock _______ o Tech code 3532 21 o Take phones off of forward o press CheckFW then CanclFw on phone o Check for Chemo orders o If chemo confirm with patient nurse before compounding ANY chemo o Check Voice Mail (Top of phone blinks red when you have Voice Mail) o Dial: 7749 o Login: 7336# o Password: 7336# o Follow prompts 7:30-12:00 o Check OR tech meds o Check TPN rm numbers/call remind floors/nurses/providers to write TPN order o Check IV room (9:30ish) o Check Pyxis meds (10ish) o Check Narcotics o Check PRCD pyxis o Compound any Narcotic drips or chemo orders o Remember to verify need and time with patient nurse before compounding o Enter TPN o Enter Orders (if possible call satellite to see if they need help and enter some of those orders) o Check Pre-packing meds, especially narcotics and return to vault o Natrecor drips o EP lab order/drips Take lunch when you are caught up 12:30-3:00 o Check o Check o Check o Check TPNs IV room refrigerated meds (IV tech delivers cart by 3:30-3:45) IV room updates afternoon Pyxis meds 3:00-4:00 o Check anesthesia kits and put back in vault when finished o Check code carts (if any – do not leave code carts in pharmacy over night) o Check Pre-pack meds (if needed) 4:00 (Closing) o Forward Phones o 6 phones – pharm desk phone, 2 tech phones, checking counter phone, pyxis phone and pre-pack checking counter phone 22 o o o o o o o Hit Forward then 7310 then done Turn off light in Vault, close gate and shut vault door Turn off lights in IV room Log off computer Back up TPN files Turn off fax machine Lock door o Code _________ MISC: o Make protonix suspension o Make other compounds as needed from compounding manual On the weekends o Pull narcotics once in the am and once in the pm. o Order entry for St. Mary’s (4100, 4300 and 5100) o Pkwy Tech carries the “ Pyxis pager” (220-5171) during shift (Felicia’s pager) o PR Inpatient pharmacist enters an order for St. Mary’s and prints at Zebra printer in Parkway Apothecary break room. (printer is: PHARZEB5) o PR Pharmacist pages Pkwy Tech with notification of new order/label via code: 1111 o Cut off time for orders/labels to print at Pkwy Apothecary is 1pm. o Pkwy Tech will check the printer hourly for labels. o Pkwy Tech will prepare meds, Pkwy pharmacist will check, tech will deliver. If needed meds are not available at Parkway or must be delivered after 1pm, Inpatient Pharmacy staff will contact PDQ for delivery to specific unit at St. Mary’s Campus. PDQ phone #: 475-0033 Acct #: 8580 Notes: 23 St. Mary’s Pharmacy (8:30-5:00) Daily Pharmacy Operations ***See chemo product reference in Pharmacist Area*** 8:30-12:00 o Check Voice mail (if light on phone is blinking) o Dial: 7749 24 o o o o o o o o o o o Login: 3395# o Password 1234# o Follow prompts Turn on Chemo clinic pager (clinic phone #3404) Run IV labels for St. Mary’s floors Enter orders (watch for Chemo orders) Print patient MARs to floor for new admits Check patient meds and pyxis tech meds Check IV compatibilities and answer other phone related problems Pull Narcotics (around 10ish) Enter Chemo orders Clean chemo hood Compound Chemo orders and deliver to infusion center (either you deliver or have a tech run it over) Take Lunch when all caught up 12:30-5:00 o Check Voice mail (if light on phone is blinking) o Dial: 7749 o Login: 3395# o Password 1234# o Follow prompts o Enter orders o Print patient MARs to floor for new admits o Check patient meds and pyxis tech meds (around 4ish) o Check IV compatibilities and answer other phone related problems o Pull Narcotics (around 4ish) o Enter Chemo orders o Compound Chemo orders and deliver to infusion center (either you deliver or have a tech run it over) o Order replacement chemo products and supplies – see chemo supply order sheet on the S:drive in the St. Mary’s folder o Clean chemo hood at end of shift and turn on antimicrobial UV light o Enter Pass meds (if any) o Fax Clozaril Patient MonitoringNotes: form (on Fridays only) o Narcotic Monthly Inventory 25 III. Protocols APPROVED THERAPEUTIC SUBSTITUTION ANALGESICS Lortab® (hydrocodone/acetaminophen): The following tablets will be substituted as indicated below: IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE: ADMINISTERED DOSE OF SUBSTITUTION MEDICATION: Any (tab/cap) combination of: 26 Hydrocodone 2.5mg w/ APAP 500 Hydrocodone 5mg w/ APAP 500 Hydrocodone/APAP 5/500 (Hydrocodone/APAP) 5/500 Hydrocodone 7.5mg w/ APAP 500 Hydrocodone 10mg w/ APAP 500 ( Vicodin ) (vicodin ) Hydrocodone/APAP 5/500 Hydrocodone/APAP 10/650 ½ tablet 1 tablet 1 1/2 tablet (Lorcet) 1 tablet Percocet® & Tylox® (oxycodone/acetaminophen): The following Percocet® tablet(s) and Tylox® capsules will be substituted as indicated below: IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE: ADMINISTERED DOSE OF SUBSTITUTION MEDICATION: Tylox® 5/500 Percocet® 5/325 1 tablet Percocet® 2.5/325 Percocet® 5/325 ® ® Percocet 5/325 ½ tablet Percocet 5/325 Percocet® 5/325 1 tablet 1 and ½ tablets Perlocet® 5/325 2 tablets THERAPEUTIC SUBSTITUTION WILL BE: Percocet® 7.5/325 Percocet® 7.5/500 Percocet® 10/325 ® Percocet 10/650 Ultracet® (Tramadol/Acetaminophen): Ultracet® will be substituted as indicated below: IF MEDICATION ORDERED AS: Ultracet® Tramadol 50 mg ADMINISTERED DOSE OF SUBSTITUTION MEDICATION: 1 tablet (Tramadol 37.5mg/Acetaminophen 325mg) Acetaminophen 325 mg 1 tablet ANTACIDS: The following antacids will be substituted as indicated below: IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE: Any liquid aluminum/magnesium combination Any liquid aluminum/magnesium w/simethicone Maalox Regular Strength Mylanta Alu-Tab Alternagel 600 mg/5ml Amphogel Alternagel 600 mg/5ml Riopan Maalox Riopan Plus Mylanta Calcium Carbonate Tums Dicarbosil Tums Titralac Liquid Tums ( 2 tabs) Gaviscon Liquid/Tab Gaviscon Tab CALCIUM SUPPLEMENTATION PREPARATIONS: IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE: Calciday-667 Tums 500 Os-Cal 500 Os-Cal 500 Oyst-Cal 500 Os-Cal 500 Oystercal 500 Os-Cal 500 Oyster Shell Calcium-500 Os-Cal 500 Cal-Plus Os-Cal 500 27 Caltrate 600 Os-Cal 500 Gencal 600 Os-Cal 500 Nephro-Calci Os-Cal 500 Caltrate, Jr. Tums Calci-Chew Os-Cal 500 Oysco 500 Os-Cal 500 Citracal Tums 500 Cal-Guard Softgels Os-Cal 500 Florical Tums 500 Calcium Carbonate 600mg + Vitamin D Caltrate 600mg/Vit D 200 units Calcium 600 + D Caltrate 600mg/Vit D 200 units Posture D Tablets Caltrate 600mg/Vit D 200 units Caltrate 600 + D Tablets Caltrate 600mg/Vit D 200 units Caltrate Plus Tablets Caltrate 600mg/Vit D 200 units Super Calcium ‘1200’ Softgels Caltrate 600mg/Vit D 200 units Calcium 600 with Vitamin D Tablets Caltrate 600mg/Vit D 200 units Calel D Tablets Caltrate 600mg/Vit D 200 units Desert Pure Calcium Caltrate 600mg/Vit D 200 units Os-Cal 500 + D Caltrate 600mg/Vit D 200 units Oyster Calcium 500mg + D Tablets Caltrate 600mg/Vit D 200 units Oyster Calcium Tablets Caltrate 600mg/Vit D 200 units Citracal Caplets + D Caltrate 600mg/Vit D 200 units Caltro Tablets Caltrate 600mg/Vit D 200 units Os-Cal 250 + D Caltrate 600mg/Vit D 200 units Oysco D Tablets Caltrate 600mg/Vit D 200 units Oyst-Cal-D Tablets Caltrate 600mg/Vit D 200 units Oystercal-D 250 Caltrate 600mg/Vit D 200 units Amino-Min-D Capsules Caltrate 600mg/Vit D 200 units Femcal Caltrate 600mg/Vit D 200 units Calcet Tablets Caltrate 600mg/Vit D 200 units Super CalciCaps Tablets Caltrate 600mg/Vit D 200 units Dical-D Wafers Caltrate 600mg/Vit D 200 units Dical-D Tablets Caltrate 600mg/Vit D 200 units Dical Cap Tabs Caltrate 600mg/Vit D 200 units Diostate D Tablets Caltrate 600mg/Vit D 200 units Viactiv Calcium Chews Caltrate 600mg/Vit D 200 units CalciCaps Tablets Caltrate 600mg/Vit D 200 units Bone Meal Tablets Tums 500 IRON SUPPLEMENTS: IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE: Fergon all strengths Ferrous sulfate 324 mg/325 mg trade/generic (Feosol, lFerodan, Slow Fe, Fero-grad ) Ferrous Gluconate 300 mg tab Ferrous Sulfate 325 mg tab Fer-In-Sol drops Ferrous Sulfate 75 mg/0.6 ml solution Ferrous sulfate 300 mg/5 ml elixir Ferrous Sulfate 300 mg/5 ml elixir 28 ESTROGEN PATCHES: IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE: Estraderm (Estradiol)-b/w 0.05/0.1 mg/24 hr Vivelle & Vivelle Dot (Estradiol) 0.05, 0.075, 0.1 Climara (Estradiol) 0.05 mg/24 hr weekly 0.075 mg/24 hr 0.1 mg/24 hr weekly Alora 0.05, 0.07, 0.1 twice a week Climara equivalent dose once a week Esclim 0.05, 0.075, 0.1 twice a week Climara equivalent dose once a week HYPNOTIC/SLEEPING AIDS: IF MEDICATION ORDERED AS: Eszopiclone (Lunesta) THERAPEUTIC SUBSTITUTION WILL BE: Zolpidem (Ambien) 5 mg) Zolpidem (Ambien CR) Ramelteon (Rozerem) INSULINS: IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE: Novolog (Insulin Aspart) Humalog (Insulin Lispro) GASTROINTESTINAL AGENTS: Laxatives: IF MEDICATION ORDERED AS: Fibercon , Fiberall ( 500 mg,625,1000 mg). (Polycarbophill ) Citrucel ( methylcellulose ) Citrucel ( methylcellulose ) THERAPEUTIC SUBSTITUTION WILL BE: Metamucil ( psyllium ) 1 gm powder HISTAMINE2 ANTAGONISTS: The following H2 antagonists will be substituted as indicated below unless otherwise prescribed as “do not substitute”: IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE: Ranitidine (Zantac) 150 mg oral QD Famotidine (Pepcid) 20 mg oral HS  Ranitidine (Zantac ) 150 mg oral BID Famotidine (Pepcid) 20 mg oral BID  Ranitidine (Zantac ) 300 mg oral QD Famotidine (Pepcid) 40 mg oral HS Ranitidine (Zantac) 300 mg oral BID Famotidine (Pepcid) 40 mg oral BID  Famotidine (Pepcid) 20 mg IV HS  Ranitidine (Zantac ) 50 mg IV BID Famotidine (Pepcid) 20 mg IV BID Ranitidine (Zantac) 50 mg IV TID Famotidine (Pepcid) 20 mg IV BID Ranitidine (Zantac ) 50 mg IV QD  Ranitidine (Zantac ) 150 mg IV Q24H Consult Prescriber  Ranitidine (Zantac ) all other regimens Consult Prescriber Nizatidine (Axid) 150 mg oral QD Famotidine (Pepcid) 20 mg oral HS Nizatidine (Axid) 150 mg oral BID Famotidine (Pepcid) 20 mg oral BID  Nizatidine (Axid ) 300 mg oral QD Famotidine (Pepcid) 40 mg oral HS PROTON PUMP INHIBITORS: The following Proton Pump Inhibitor will be substituted as indicated below unless otherwise prescribed as “do not substitute”: IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE: Omeprazole (Prilosec) 10 mg QD  Pantoprazole (Protonix®) 40 mg QD Omeprazole (Prilosec ) 20 mg QD Pantoprazole (Protonix®) 40 mg QD Omeprazole (Prilosec) 20 mg BID Pantoprazole (Protonix®) 40 mg QD Omeprazole (Prilosec) 40 mg QD Pantoprazole (Protonix®) 40 mg QD 29 Omeprazole (Prilosec) 40 mg BID Pantoprazole (Protonix®) 40 mg BID ® Pantoprazole (Protonix®) 40 mg QD Rabeprazole (AcipHex ) 20 - 40 mg QD  Lansoperazole (Prevacid ) 15 mg QD Pantoprazole (Protonix®) 40 mg QD Lansoperazole (Prevacid) 15 mg BID Pantoprazole (Protonix®) 40 mg QD  Pantoprazole (Protonix®) 40 mg QD  Lansoperazole (Prevacid ) 30 mg BID Pantoprazole (Protonix®) 40 mg BID Esomeprazole (Nexium) 20-40 mg QD Pantoprazole (Protonix®) 40 mg QD Lansoperazole (Prevacid ) 30 mg QD Patients with a feeding tube will be switched to Pantoprazole suspension. TOPICAL ANTIFUNGAL POWDERS: IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE: Nystatin Miconazole Brand I Generic inhaler ordered Brand I Generic formulary substitution (non-formulary) (approved by the Drug Usage Committee) Advair 100/50 Pulmicort ( Budesonide) respules via neb. 0.25 mg bid (Fluticazone 100 mcg/ Salmeterol 50 mcg) or and Foradil ( Formoterol ) 1 inhalation ( 12 mcg ) bid Advair 250/50 (Fluticazone 250 mcg/ Salmeterol 50 mcg) Dose: 1 inhalation bid Pulmicort ( Budesonide) respules via nebulizer 0.5 mg bid Advair 500/50 (Fluticazone 500 mcg/ Salmeterol 50 mcg) and Dose: 1 inhalation bid Foradil ( Formoterol) 1 inhalation ( 12 mcg ) bid Serevent (Salmeterol 50 mcg) Foradil ( Formoterol ) 1 inhalation ( 12 mcg ) bid Dose: 1 inhalation bid or q 12 hours Atrovent inhaler (Ipratropium 18 mcg) Spiriva (Tiotropium ) 1 inhalation ( 18 mcg ) q day Dose: 2 inhalation qid Albuterol neb via nebulizer 2.5 mg qid Combivent inhaler (albuterol 90 mcg/ ipratropium 18 mcg) Except ventilator patients and Dose: 2 inhalation qid Spiriva (Tiotropium ) 1 inhalation ( 18 mcg ) q day Albuterol inhaler 2 inhalations (180 mcg) Albuterol 2.5 mg nebulizer solution Dose: Dose: TOPICAL CORTICOSTEROIDS: LOW POTENCY Aclometasone/Dexamethasone/Fluoromethalone MEDIUM POTENCY Desoximetasone,fluocinolone,fluticasone, hydrocortisone valerate &butyrate LOW POTENCY Hydrocortisone Cream/Ointment 0.5% / 1% / 2.5% MEDIUM POTENCY Triamcinolone Cream/Ointment 0.025% / 0.1% HIGH POTENCY HIGH POTENCY Fluocinonide/Halcinonide 30 Amcinonide/Dexoximetasone VERY HIGH POTENCY Diflorasone,Betamethasone dipropionate Betamethasone 0.05% Cream/Ointment VERY HIGH POTENCY Clobetasol 0.05% Cream/Ointment Halobetasol 0.05% Cream/ointment VAGINAL ANTIFUNGALS: IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE: Mycostatin (Nystatin Cream) Monistat-7 (Miconazole Cream Gyne-Lotrimin (clotrimazole Supp),Mycostatin supp Vagistat-1 (tioconazole) cream Monistat-3 (Miconazole Supp) Mycelex-3 (butaconazole) Monistat-7 (Miconazole Cream Monistat-7 (Miconazole Cream VITAMINS IF MEDICATION ORDERED AS: Abdec One-A-Day Plus Iron One-A-Day + Minerals Allbee with C Optilets-500 Allbee C-800 Plus Iron Allbee-T Optilets-M-500 Becotin with C Probec-T Berocca Protegra Sigtab Berocca Plus Stress Caps Cefol Stresstab-500 w/Iron Stresstabs-600 Centrum Stresstabs 600 w/ Zinc Folbesyn Tabs Surbex-750 w/Iron Fero-Folic 500 Stuartinic Ferosol-Plus Surbex-C Fortespan Surbex-T Fumatinix Surbex 750 w/ Zinc Geritol Tablet Theragran Hematinic Theragran-Z Ger-I-Bon Tablets Thera-M Hepicebrin Therapeutic B&C Hexavitamin Theravitamin “High-Potency Multivitamin” Unicaps Iberet-500 Unicap-T Iberol Unicap-M Micebrin Unicap Plus Iron Micebrin-T Vigram tab Multicebrin Via-Daylin tab Multivitamin Vicon-C Multivitamin + Iron Multivitamin w/ Minerals Multivitamin w/ Zinc Myadec Vicon Forte Ocuvite Z-Bec One-A-Day Zentinic Chromagen Nephrocap Trinsicon Nephro-Vite THERAPEUTIC SUBSTITUTION WILL BE: THERAGRAN M Multivitamin Multivitamin Liquid Prenatal Vitamin Vicon Plus Xymacap Nephrovite Rx. 31 'Statin' Automatic Therapeutic Substitution June 2007 Automatic therapeutic substitution to Simvastatin approved by the Drug Usage Committee: *Pravachol will be substituted with Simvastatin with the EXCEPTION OF PATIENTS ON POTENT INHIBITORS OF CYP3A4: Cyclosporine Antifungals Erythromycin Clarithromycin HIV protease inhibitors Nefazodone Gemfibrozil (particularly with high doses Of Vytorin and Simvastatin) Atorvastatin ( Lipitor) Pravastatin ( Pravachol ) Simvastatin ( Zocor ) *see exception 10mg 40mg 20mg 20mg 80mg 40mg > 20 mg No substitution Lovastatin (Mevacor) 10mg 20 mg 40 mg 80 mg Simvastatin ( Zocor ) 5 mg 10 mg 20 mg 40 mg TPN ORDER ENTRY *High Alert Medication* New Patient 1. Make a folder with the following: (in this order) a. Patient Name b. MRN # c. FIN# 32 2. 3. 4. 5. 6. 7. 8. 9. d. DOB e. Room # f. Date patient was started g. Allergies (if known) h. Note Central or Peripheral line i. Not if patient is NOT to receive Vitamin K on Mondays Check Cerner to see if TPN is in profile and the patient was charged today if not add TPN to patient profile (which will charge the patient) Log on to TPN computer Hit F2 for patient data Hit Insert Add the patient info (use folder for reference) Verify Central or Peripheral Line F10 to accept F9 to exit patient data screen Entering Order: Note:  Watch for “Standard Formulas” as these are “Per Liter” not per 24 hours and do not contain any fat.  Should contact provider when the lipid field is blank to verify no fat. o Select patient o Hit enter until box appears with type of TPN o Choose formula o Or F2 (continue as previous solution then type the number of the previous solution) o Verify Central or Peripheral Line o Enter TPN components o Chloride/Acetate: to change Anion Part hit F3, Balance is 5 and 50 %, min or max choose accordingly use 2% b/c computer does not allow 0 – F10 to accept changes o Double Check o F10 to print label o Check again o Write E (enter), C (checked) and M (mixed) at the bottom of the label o Initial next to the “E” Formulation problems: Document all changes 1. Check most recent patient labs against the order each day and make sure the electrolytes chosen by the provider are appropriate. The ranges listed below each electrolyte on the order form are not absolutes; they are recommendations as to what the normal range of most orders will be. For example, if you receive an order for a patient with a potassium level of 5.7 mmol/L, potassium should 33 not be included in the bag even though the range on the worksheet is (60-150) mEq. Keep in mind that the provider may be managing the patient’s electrolytes with methods other than the TPN. It may be appropriate for a patient with a low K+ level to have only 60 mEq of K+ in the bag if the provider is also following an electrolyte protocol or infusing potassium runs. Use your clinical judgment when evaluating these orders. 2. Look back at previous orders to make sure orders are being completely rewritten every 3 days. Many times providers will check off that the date of last order written was the previous day, even if the order that day was just a “continue previous order”. Evaluating the effects that previous TPN formulations have had on the patient’s electrolytes can also be helpful in determining the appropriateness of the current order. 3. Check to see if patient is on warfarin, as per order form all patients on warfarin will not receive vit K on Mondays (whether or not box is checked). 4. When evaluating calcium levels, remember to calculate the “corrected calcium”. This will provide a more accurate level than the serum calcium in patients with low serum albumin. The formula for calculating a corrected calcium level is: Total serum calcium (mg/dL) = measured serum calcium (mg/dL) + 0.8*(4 – measured serum albumin (g/dL)) 5. Before contacting the provider, test out whatever recommendations you may have by entering the TPN formula you will recommend into the computer to rule out any formulation problems. 6. Contact/page Provider who wrote the order 7. Write up verbal order form (only if absolutely necessary) make a photo copy of verbal order and staple to original order. 8. Make changes to original order, initial and note to see verbal order. 9. Send original verbal order to floor with TPN bag 10. Contact floor if provider does not return page Patient Discontinued 1. Write D’cd on folder with name of nurse or copy of order and date 2. Put TPN folder in box next to pharmacy desk with other D’cd TPN orders 3. Remove patient from active list. a. Hit F2 patient date b. Find and select patient c. Change the Y to an N 34 d. F10 to accept e. F9 to exit f. Patient should not appear on the active list if they are still active try to remove patient again. Patient “On-Hold”  Leave patient in computer  Leave folder with the rest of the active folders  Note on folder: Hold & date Backup TPN: Must be done everyday  Exit out of TPN entry field  Double click TPNPC backup icon  Select appropriate floppy disk (for odd or even days of the week)  Hit “ok”  Takes 2-3 minutes  Take out of computer  Leave computer on and disk nearby Misc: Calculating Osmolarity of PPN 1. Multiply grams of protein per liter by 10  i.e. 40g x 10 = 400 mOsm/L 2. Multiply grams of dextrose per liter by 5  i.e. 100g x 5 = 500 mOsm/L 3. Lipids are isotonic, therefore do not contribute to osmolarity 4. Electrolytes would further add to osmolarity  Na+ 2 mOsm per mEq  K+ 2 mOsm per mEq 5. Add together #1 and #2 plus a rounded number of 200 for eletrolytes and divide by the number of liters to find the PPN solution Osmolarity 6. Limit final PPN Solution Osmolarity to <900 mOsm/L 7. Max Dextrose Load per patient: 5mg/kg/min 8. Max lipid rate: 2.5g/kg/day Notes: 35 Total Parenteral Nutrition Order Form (Central Line Required) **Orders must be sent to Pharmacy by 2pm** ⁭ Initial Orders (phone Pharmacy @ x7330) ⁭ Formulation/Rate change (Please rewrite form with ALL requirements to be administered) ⁭ Continue previous order as of (date of last full form completion) __/__/__ ALL orders must be re-written once every 3 days ⁭ Discontinue (taper rate at least one hour, or replace with D10) Indication for TPN (Total Parenteral Nutrition) : 36 ⁭ Non-availability of enteral route ⁭ Supportive parenteral nutrition with chemotherapy and/or ⁭ Anticipation of non-availability of enteral route >7 days radiation therapy when GI tract cannot be used ⁭ Complete bowel rest for therapeutic/supportive purpose ⁭ Recommendation of Registered Dietitian based on complete assessment Estimated Needs**see back Height: ______Weight: _____kg Caloric Need: ________Protein Need: ________Fluid Need: ________ Administration Total Volume =______________ ml/24 hours ⁭ Continuous Infusion @ __________ml/hour ⁭ Cyclic Infusion @ ___________ml/hour x __________ hours Tapered to ___________ml/hour x __________ hours Standard TPN Formula ⁭ Standard Central Formula(40 gm amino acids, 200 gm dextrose/liter) No lipids unless ordered below. Custom Formula Amino Acids (4kcal/gm) Dextrose (3.4kcal/gm) Lipids (10kcal/gm) ⁭ 50 gm/24hours ⁭ 200 gm/24 hours ⁭ Three-in-one ________gm/24 hr ⁭ 75 gm/24 hours ⁭ 300 gm/24 hours ⁭ No lipids ⁭ 100 gm/24hours ⁭ 400 gm/24 hours ⁭______gm/24 hours ⁭ 500 gm/24 hours ⁭______gm/24 hours ⁭ Standard Electrolytes/24 Hours Na 113 mEq K 89mEq Ca 11.25mEq Mg 12.5mEq PO4 30mmol CI-balanced MVI 1 vial Trace Metals (M.T..E.) 1ml ⁭ Custom Electrolytes/24 Hours Na_____ mEq (60-150) K___mEq (60-150) Ca___mEq Mg____mEq (10-20) (8-30) Regular Insulin __________Units/bag PO4____mmol CI-minimu MVI 1 vial Trace Metals (M.T.E.) 1ml (15-50) maximum balanced (Circle one) Vitamin K: 5 mg added Monday unless box checked ⁭ (Will be omitted in patients receiving Warfarin) Additional additives/medications:_________________________________________________ Recent Labs Standing Orders ⁭Custom Orders-see chart (unless custom orders are provided) (MD must write orders on Physician Order Form) Date _________ Na__________ K___________ Cl___________ CO2________ BUN________ Cr___________ Glu__________ Mg__________ Phos_________ Corrected Ca________ Day # 0; then every Mon.: Prealbumin, Triglycerides Day # 1; then every Mon.:Chem 14, CBC/diff, PT, APTT Day # 2 and # 3; then every Thurs.: Chem 8 Capillary BG @ initiation: every 6 hours x 48 hours Mandatory Weigh daily Nutrition consult Intake and Output every shift Temperature every 4 hours Provider Signature _____________________ MD/PA/NP Pager # ____________ Date: ____________Time: _______ RN Signature _______________________________________________ PS # 200066 05/07 Date: _________________ Time: _____ Refer to back of sheet for practice guidelines and indications for parenteral nutrition FAX TO PHARMACY 723-7047 Peripheral Parenteral Nutrition (PPN) Order Form **Orders must be sent to Pharmacy by 2pm** o o o o Initial Orders (phone Pharmacy @ x7330) Formulation/Rate change (Please rewrite form with ALL requirements to be administered) Continue previous order as of (date of last full form completion) __/__/__ ALL orders must be re-written once every 3 days Discontinue (taper rate at least one hour, or replace with D10) Indication for PPN: o Non-availability of enteral route o Supportive parenteral nutrition with chemotherapy and/or o Anticipation of non-availability of enteral route o radiation therapy when GI tract cannot be used 37 o Complete bowel rest for therapeutic/supportive purpose o Recommendation of Registered Dietitian . based on complete assessment PPN Standard Formulas 0 1560 mL/24 hr @ 65mL/hr 0 2400 mL/24 hr @ 100mL/hr 0 3000 mL/24 hr @ 125mL/hr 40 gm amino acids/24 hours 75 gm amino acids/24 hours 90 gm amino acids/24 hours 120 g m dextrose/24 hours 200 gm dextrose/24 hours 280 gm dextrose/24 hours 40 g m lipids/24 hours 55 g m lipids/24 hours 65 gm lipids/24 hours O No lipids O No lipids O No lipids O Standard Electrolytes/24 Hours Na 113 mEq K 89 mEq Ca 11.25 mEq Mg 12.5 mEq PO4 30 mmol CI-balanced MVI 1 vial Trace Metals (M.T.E) 1 ml O Custom Electrolytes/24 Hours Na____mEq (60-150) K___mEq Ca____mEq Mg_____mEq (60-150) (10-20) (8-30) Regular Insulin __________Units/bag PO4_____mmol CI-minimum MVI 1 vial Trace Metals (M.T.E.) 1ml (15-50) maximum balanced (Circle one) Vitamin K: 5 mg added Monday unless box checked O (Will be omitted in patients receiving Warfarin) Additional additives/medications: _____________________________________________________________ Recent Labs Standing Orders o Custom Orders-see chart Date __________ Na__________ K___________ Cl___________ CO2________ BUN________ Cr___________ Glu__________ Mg__________ Phos_________ Corrected Ca___________ (unless custom orders are provided) (MD must write orders on Physician Order Form) Day # 0; then every Mon .: Prealbumin, Triglycerides Day # 1; then every Mon.:Chem 14, CBC/diff, PT, APTT Mandatory Day # 2 and # 3; then every Thurs.: Chem 8 Weigh daily Capillary BG @ initiation: every 6 hours x 48 hours Nutrition consult Intake and Output q shift Temperature every 4 hours Provider Signature ________________________________________ MD/PA/NP Pager # ____________________ Date: _____Time: __________ RN Signature _______________________________________________ _________________ Date: _________________ Time: Refer to back of sheet for practice guidelines and indications for parenteral nutrition FAX TO PHARMACY 723-7047 PS # 200067 05/07 Practice Guidelines & Indications For Parenteral Nutrition Total parenteral nutrition is indicated if the small intestine is dysfunctional, obstructed, or inaccessible or the colon is severely dysfunctional or obstructed and this condition is expected to continue a minimum of 7 days. The following are examples of indications for Parenteral Nutrition: Intractable vomiting---e.g., severe acute pancreatitis, hyperemesis gravidarum, chemotherapy. Severe diarrhea---(>500ml of stool) or malabsorption, e.g., severe, acute flare of inflammatory bowel disease, graft versus host disease, severe sprue or sprue-like conditions, short-bowel syndrome (<50-60cm of remaining bowel), radiation enteritis with weight loss. 38 Severe mucositis/esophagitis---e.g., chemotherapy, graft versus host disease. Ileus---e.g., severe trauma/major abdominal surgery or pseudo-obstruction, when enteral nutrition, including feeding jejunostomy cannot be used for at least 7 days. Small bowel or colon obstruction---e.g., cancer, adhesions, infectious, pseudo-obstruction. “Bowel Rest”---e.g., enterocutaneous or entero-enteric fistula, anastomotic leak. Crohn’s disease of the small intestine. Preop---e.g., only in cases of severe malnutrition, otherwise surgery should not be delayed. Peripheral Parenteral Nutrition provides hydration and initiates calorie and protein replenishment. Peripheral Parenteral Nutrition is not appropriate for long-term use. It does not usually meet total caloric requirements for the patient or provide an appropriate balance of carbohydrate, protein and fat. If a patient has a PICC line with confirmed central access, use the Total Parenteral Nutrition Order Form. When a patient has a functional GI tract but is unable to in gest adequate nutrients orally, enteral feedings are indicated. Estimation of Nutrition Needs Ideal Body Weight Female: 5 ft @ 100 lbs + 5 lbs for every inch above 5 ft Male: 5 ft @106 lbs + 6 lbs for every inch above 5 ft To determine weight in kilograms, divide weight in pounds by 2.2 For actual weight >125% of the ideal body weight, adjustments will be made by the Registered Dietitian (R.D.) Caloric Needs No/Mild Nutrition Impairment Moderate Nutrition Impairment Severe Nutrition Impairment 25-28 Kcal/kg Body Weight/day 28-32 Kcal/kg Body Weight/day 30-35 Kcal/kg Body Weight/day Protein Needs No Nutrition Impairment Mild Nutrition Impairment Moderate Nutrition Impairment Severe Nutrition Impairment 0.8-1.0 gm/kg Body Weight/day 1-1.2 gm/kg Body Weight/day 1.2-1.3 gm/kg Body Weight/day 1.3-1.5 gm/kg Body Weight/day Fluid Needs Normal Requirements Dehydration Renal/CHF needing fluid restriction 30 mL/kg Body Weight/day 35 mL/kg Body Weight/day 25 mL/kg Body Weight/day PDQ Delivery If needed… Call: 585-475-0033 Acct #: 8580 o Place objects to be delivered in Satellite Pharmacy for pick up and inform the techs and pharmacists in the satellite of the planned pick up. 39 PRDC After Hours Delivery o Label a 24 hour supply o Call Security to deliver medication to PRCD o Leave a not for PRCD tech to load medication in Pyxis the next day Standard Narcotic Concentrations Note: Narcotics- must fill out narcotic request form (“Controlled Substance Order Form”) CADD pumps o only send to 3100 NO EXCEPTIONS 40 o Expiration date is 7 days for all CADD pumps  Morphine : 10:1 , 5:1, 25:1 o Type in “CADD” at drug search  Dilaudid (hydromorphone): 10:1, 5:1 o Type in “CADD” at drug search Narcotic drips o enter under continuous , rate as “per protocol”, but use infusion rate to calculate 24 hour supply     Versed (midazolam): o 1:1 – 100 mg midazolam in 100 mLs of saline Morphine drip: o 1:1 – 100 mg of morphine in 100 mLs of saline o 1:5 – 50 mg of morphine in 250 mLs of saline Fentanyl (available premixed, will not generally have to make): o 10:1- 2000 mcg of fentanyl in 200 mLs of saline (remove 50 mLs from 250 mL bag) o 20:1- (only do for ICU – will ask for double-concentrate fentanyl); 2000 mcgs of fentanyl in 100 mLs of saline Ativan (lorazepam) drips: need to use EXCEL (clear plastic) bags o 1:1- The PAB bag is 50 ml + 7 ml overfill= 57 ml total. Remove 27 ml to give 30 ml volume. Add lorazepam 60 mg/30 ml to the bag.= 60 mg/60 ml. Use 0.22 micron filter on the label. o Cerner short code: lora60d5w Try searching ICUIV under drug search for all of these Epidurals o See compounding recipes IV Manufacturing Standards In an effort to standardize procedures, an IV manufacturing card file is maintained in the satellite. Please check against the appropriate drug card when checking/making IVs. This card file is a work in progress. If an IV needs to be made which is not in this file, make the IV according to the appropriate literature and submit the information that was used to Shashi to be verified and added to the file. These files 41 may also be used in the future for “batch manufacturing”. The following example illustrates the format used for the cards: Caspofungin 70 mg/250 mL NS Drug (source bottle concentration/volume): 70 mg single use vial Diluent (s): 10.5 mL NS or SWFI Volume from bag removed (if any):n/a Volume of drug injected into bag: 10 mL Infuse over: 1 hour Expiration: 24 hours at room temp, 48 hours if refrigerated. Misc. info: 1) Allow vial to come to room temperature before reconstituting 2) 70 mg dose CANNOT go in 100 ml 3) After reconstitution vial is good for one hour when stored ≤ 77 deg F. (25 deg C) IV. Professionalism 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 V. Miscellaneous Current Order Sets in Cerner (Bold sets are most useful) *subject to change* ACS AMI Albunsneb Alcohol Am10d Am5d Asa325d Asa81d A25d A50d cadd AIV CIV Cosopt CVA darvct Dig.125d Dig.25d Dss100bid Ecasa325d Ecasa81d Epidural F325bidm F325dm F325tidm F20d F40d Fi40d Hctz12.5d Hctz25d Hctz50d Heppicc Hepcvl HSC8 HSC12 HospPR hospStM Icuiv Kcl10b Kcl10d Kcl20bid Kcl20d Kcl30d Acute Coronary Syndrome Acute MI Order Set Albuterol/NS neb combo Alcohol Withdrawal Order Set Amlodipine 10 mg daily Amlodipine 5 mg daily Aspirin 325 mg daily Aspirin 81 mg daily Atenolol 25 mg daily Atenolol 50 mg daily CADD pumps Common antibiotic order sets (use this whenever possible as there are prebuilt notes pertaining to each med included) Common IV order sets (this includes Protonix I.V.) Cosopt components CVA order set Darvocet N-100 order set Digoxin 0.125mg daily Digoxin 0.25 mg daily Docusate 100mg bid Enteric coated aspirin 325 mg daily Enteric coated aspirin 81 mg daily Epidural/spinal order set Ferrous sulfate 325 mg bid w/meals Ferrous sulfate 325 mg qday w/meals Ferrous sulfate 325 mg tid w/meals Furosemide 20 mg PO daily Furosemide 40 mg PO daily Furosemide 40 mg IV daily HCTZ 12.5 mg daily HCTZ 25 mg daily HCTZ 50 mg daily Heparin flush for open-ended PICC Heparin for CVL flush Heparin SC q8h Heparin SC q12h Hospice – park ridge order set Hospice – St. Mary’s order set ICU IV order set Kcl 10 meq po BID Kcl 10 meq po qday Kcl 20 meq po bid Kcl 20 meq po qday Kcl 30 meq po qday 58 Lorcetset momqhsprn Mvid Nausea Nebs Nebstcu Nephd Nsfpicc P40bid P40d PCA Percocet P124 P126 Plav300 Plav75d Pneumonia Csection JOINT PTCA Labor PRCD PSY Sennbid Sennd Senn2bid Senn2d Sensbid Sensd Sens2bid Sens2d Tcujoint Tele T100hs T50hs Tq4hpf Tq4hpp Tq6hpf Tq6hpp Vanco Vicodin Lorcet order set Milk of magnesia 30ml po qbedtime prn Multivitamin daily Nausea order set Nebulizers for hospital patients Nebulizers for TCU patients Nephrovite daily NS flush for close-ended PICC Pantoprazole 40 mg bid Pantoprazole 40 mg daily PCA order set Percoset order set Phenergan 12.5mg IV q4hr prn n/v Phenergan 12.5 mg IV q6h prn n/v Plavix 300 mg x1 dose Plavix 75 mg daily Pneumonia order set Post-op C-section Post-op joint order set *has many flaws use with caution* Post-PTCA/stent Post-vaginal delivery PRCD admission orders Psychiatry admission orders Senokot 1 tab bid Senokot 1 tab daily Senokot 2 tabs bid Senokot 2 tabs daily Senokot-S 1 tab bid Senokot-S 1 tab daily Senokot-S 2 tabs bid Senokot-S 2 tabs daily Tcu joint admissions order set Telemetry order set Trazodone 100mg po qbedtime Trazodone 50mg po qbedtime Tylenol 650mg po q4h prn fever Tylenol 650mg po q4h prn pain Tylenol 650mg po q6h prn fever Tylenol 650mg po q6h prn pain Vancomycin order set Vicodin order set 59 FAQs re: Pyxis Access 1. New Nurse Hires at Unity Health System: New nurse hires must pass an exam before receiving access to Pyxis medstation(s). Consequently, only Clinical Education staff can authorize Pyxis access for a newly hired Unity Health System nurse. Cindy Marx (or designee) forwards access. 2. Agency Nurses (e.g. Nurse Finders, InteliStaf): Employee name is provided by agency via email request.  If contracted to a specific nursing unit, Cindy Marx (or designee) forwards Pyxis access info to Nurse Manager. Nurse Manager disseminates to nurse. Access expires at end of contract. (Agency contacts Cindy Marx with any contract extensions/renewals.)  If contracted as a floater, agency nurse contacts NM, Clinical Leader, or Charge Nurse at beginning of each shift to be assigned temporary user Pyxis status. 3. EMS Techs (ambulance):  The Office of Pre-Hospital Care sends Cindy Marx a written request for EMS tech Pyxis access. No access is provided without this request. If an EMS tech calls the Pharmacy for access, refer him/her to the Office of Pre-Hospital Care or to Cindy (585-723-7970).  If needed, provide EMS tech with info for Office of Pre-Hospital Care: Sheri Strollo, BSN, EMT-P telephone: 585-273-3961 4. How to find information about kits in the Pyxis console? 1. 2. 3. 4. log in click “System Setup” Click “Formulary Management” Click “Kits” Nurse Managers, Charge Nurses, and Clinical Nurse Leaders have the ability to create temporary users in Pyxis. Instructions to Add a Temporary User:  Log in to Pyxis medstation  Choose: User Menu  Choose: Activate User  Choose: Add Temp User (at bottom of screen) To that end, Pharmacy personnel should not provide initial or additional areas to a current Pyxis account at the request of the employee. Instead, speak to the Nurse Manager, Charge Nurse, or Clinical Nurse Leader and ask them to provide temporary access. Contact Jim Finucane (7237348) during the next business day with any questions/ concerns. 60 Computer Resources S: Drive – A place for shared documents and folders items saved on the S: drive are visible by all Pharmacists H: Drive – A place to store materials that only you have access to. http://gateway.nlm.nih.gov/gw/Cmd http://hivinsite.ucsf.edu/ http://medem.com/MedLB/medlib_entry.cfm http://online.factsandcomparisons.com/ o Login: unityhealth o Password: Pharmacy http://unitynet/Documents/Medical/Formular... http://unitynet/Documents/Medical/Vancomyc... o Unity Vancomycin 1st Dose formula http://unitynet/Documents/Unitdose/ http://unitynet/MedDirNews/Protocols/HIT%2... http://www.cdc.gov/ http://www.emedicine.com/ http://www.epocrates.com/ http://www.globalrph.com/ http://www.healthfinder.gov/ http://www.healthweb.org/ http://www.mayoclinic.com/ http://www.medterms.com/script/main/hp.asp http://www.nih.gov/ http://www.nlm.nih.gov/ http://www.statref.com/ http://extranetcitrix.viahealth.org/Citri... http://w3prqs01/OBLink_Login.asp http://www.acmlis.com/opquery/ http://www.theidegroup.com/ http://www.utdol.com/utd/content/search.do The National Women's Health Information Center -- 1-800-994-9662 61 Cerner/Label/MAR Printers Med Labels IV Room: Main: Satellite: St. Mary’s: PHARZEB1 PHARZEB2 PHARZEB3 and PHARZEB4 PHARZEB5 MARs Printers  Print MARs in Satellite to be delivered to floors, however, sometimes the floors will ask to print directly to their printer.  Exceptions 4100, 5100, PRCD, labor and delivery (LDRP) need to be printed to the floor printers. Satellite: PSATP1 Central: PHARUNET1 2100: PN21P1 2200: PN22P1 2300: PN23P1 2400: PN23P1 ICU: PICUC1 3100: PN31P1 3200: PN32P1 3300: PN33P1 3400: PN34P1 3500: PN35P1 MOU: PSPRP1 LDRP: PLDRP1 Nursery: PLDRP1 TCU: Do not print MARs for TCU 4100: SN41P1 St. Mary’s 4300: SN43P1 St. Mary’s 5100: SN51P1 St. Mary’s PRCD Adol: PGRCP3 PRCD Adult PGRCP3 62 IVF with POTASSIUM D5 ½ NS D5 NS D5 NS 10 X 20 X X X X 30 X X 40 X X X X These are the pre-mixed IVF with Potassium. If the fluid you need is not on the chart, it will need to be ordered from Pharmacy. Please double check label on IV bag to ensure you have the correct solution 63 Drug Bumetamide Chlorthiazide Dexamethasone Digoxin Dihydroergotamine Diphenhydramine Droperidol D50W Ethacrynate Sodium Famotidine Furosemide Heparin Hydrocortisone Sodium Hydromorphone Ketorolac Lorazepam Meperidine Methylprednisolone Metoclopramide Morphine Sulfate Nalbuphine Naloxone Phenobarbital Prochlorperazine Promethazine Torsemide ++ CAUTION ++ IV PUSH DRUGS CHECK POLICY Dose Frequency 1 mg Q2h 1 Gm MDD 2 GM 40 mg 0.25 mg 2 mg MwD 6 mg 50 mg Q4-6h 1.25 mg TELEMETRY ONLY 25 Gm MR x 1 50 mg 20 mg MDD 40 mg 200 mg MDD 600 mg 10 Mu 2 Gm 1 mg Q4h MR q30min x 2 Max 3 mg / 4 hours Rate 1 mg over 2 min 30 mg Q6h 5 day max 2 mg ETOH Protocol 4 mg 75 mg Q3-4h 2 Gm 10 mg 3 mg Q2-4h 20 mg Q3-6h 0.4mg 3 dose max 240 mg MR x 1 10 mg MDD 40 mg 12.5 mg Q4-6h MR x 1 100 mg MDD 200 mg 64 Fax Downtime Procedure Pharmacy Technicians are to pick-up medication orders from units when Pharmacy fax machine is not receiving faxes (see table below with unit assigned fax line). Only stat orders will be faxed to the fax machine that is operating. Due to Park Ridge Chemical Dependency and St. Mary’s being off-site they will be called and informed that they are to fax to x1940. x1940 x7848 2nd floor 1st floor 3rd floor Park Ridge Chemical DependencyMon – Fri, 430pm – 12am Sat & Sun, 430pm – 11pm TCU St. Mary’s CampusMon - Fri, 5pm – 12am Sat, 430pm - 8am Sun, 430pm - 11pm 65 Ordered Meds Not Loaded This procedure is effective 8/27/07 and applies only to Unit Dose Meds in Patient Profile Medstations at Unity Campus, exception: EOU and St. Mary’s Campus When a label prints, that is the “trigger” that a med must be loaded in Pyxis. The RPh will always generate label with zero (0) doses so that you will not have to credit patient. Load a three (3) day supply unless the RPh advises otherwise. Max = three (3) day supply; Min = one (1) day supply. Patches – load two (2) each TCU – load meds in both medstations Never load chemo meds. Non-Formulary meds cannot be loaded. Contact Jim Finucane for operational issues; Tom, Shashi or Leo with clinical questions. Instructions Log into Pyxis Click Inventory, select Floor Click Select or hit Enter Click on Assign New Med Tab Find desired med, click Select or hit Enter Select available Pocket Enter max & min and click on outdate tracking tab Do not click the standard stock tab click save -ORIf No Available Pockets Log into Pyxis Click Inventory, select Floor Highlight a med that does not have an S (standard pyxis med) or O (active order) If there are no meds listed without S or O, see the charge RPh for instructions Click new med tab in upper right corner Find desired med, click select or hit enter Enter max (three day supply) & min (one day supply) and click on outdate tracking tab Do not click the standard stock tab Click save this will P (pend) the med Unloading Meds No Longer Being Used (this report shows S meds) Log into Pyxis Choose Reports Choose Run Report Choose Inventory Choose Meds Without Removal Choose Unit Choose No Removals Since: first enter date of 6 months in past; if nothing, then 4 months Report will show which cubies can be freed. Review of Inventory will show the S and O meds Log into Pyxis Choose Inventory 66 9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS PREAMBLE: The increasing use of antineoplastic drugs and the growing awareness of potential hazards requires special attention to the procedures utilized in the handling, preparation and administration of these drugs. Equally important is the proper disposal of chemical residues and wastes. Policies are intended to provide information for the protection of personnel participating in the clinical process of chemotherapy. The mutagenic and carcinogenic potential of many antineoplastic agents is well established and is a possible hazard to the health of exposed individuals. It is the responsibility of institutional and private health care providers to adopt and use appropriate procedures for protection and safety. Policies and procedures provide the basis for safe handling of antineoplastic agents. There is no substitute for individual awareness and consistent application of the highest standard of performance regarding personnel protection. POLICY: A pharmacist shall compound antineoplastic-cytotoxic drugs in the Department of Pharmacy in accordance with accepted professional standards and as promulgated and approved by the Executive Committee of the medical staff to insure patient and professional employee safety through proper handling, compounding, delivery, administration and disposal of these compounds. Pregnant females, or those intending to become pregnant, will not be allowed to compound antineoplastic medications due to potential hazard to the fetus. In the out-patient clinic, a certified Oncology Nurse under the direction of the Oncologist may prepare the antineoplastic agents utilizing the same guidelines and standards as listed above in the unlikely event that the pharmacist is unavailable. PROCEDURE: 1. Orders written for antineoplastics at Park Ridge Hospital will be carefully reviewed and entered into the computer system by the pharmacist. a. Pharmacist will confirm the chemotherapy regimen and the patient identification with the chemo nurse. b. Pharmacist will enter the chemotherapy order in the Cerner computer system. c. A second pharmacist will check the orders and the label. d. The first pharmacist will prepare the chemo; following compounding procedure. e. Pharmacist will package chemo in chemo spill bags. f. Pharmacy Technician will deliver the chemo directly to chemo nurse. At the Genesee Street Campus, the orders will be handed directly to the pharmacist. 67 9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d) 2. Compounding of antineoplastics for hospitalized patients and the patients at the Oncology Center at Genesee Street Campus shall be done in the pharmacy or in the Outpatient Oncology Center utilizing the Vertical Laminar Flow Hood by pharmacists or certified oncology nurses in the out-patient oncology center under the supervision of the oncologist 3. Preparation and supplies,reference, and registry protocol information shall be available in the pharmacy and at the Genesee Street Campus. 4. Disposable chemo safety gloves must be worn for all procedures involving antineoplastic drugs. Double gloving is recommended for cleaning up spills. 5. Disposable protective barrier garments should be worn for all procedures. These garments should have a closed front, long sleeves, and closed cuff (either elastic or knit). Disposable protective garments and chemo gloves should only be worn while preparing neoplastic agents. 6. A manual will be located on selected units, in the pharmacy, and in other areas as designated which will include a simple summary of policies, procedures, and protocol. 7. Special aseptic techniques and precautions must be utilized because of the vertical (downward) airflow. 8. No other IV admixture should be prepared in Biological Safety Cabinets designated for the mixing of antineoplastic agents. 9. The Biological Safety Cabinets will be certified by qualified personnel annually, or any time the cabinet is physically moved. 10 The biological Safety Cabinet must be operated with blower on for at least 5 minutes prior to using the hood. 11 Drug preparations shall be performed only with the viewing window at the required access opening. 12 Compounded cancer drugs shall be sent/taken to the floor at Park Ridge, properly labeled and packaged. This will include a green "antineoplastic material” caution sticker and the use of a chemotherapy drug ziplock bag. In the GSC Oncology Clinic, chemo preparations remain in the Biohazard hood until the administering Nurse verifies the preparation. The Nurse then removes the chemo preparation and administers it directly to the patient. 68 A comprehensive protocol is available to the Department of Pharmacy and in designated areas. See following expanded information. 69 9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d) SAFE HANDLING AND DISPOSAL OF CHEMOTHERAPEUTIC DRUGS INTRODUCTION Current practices in the preparation, storage, administration and disposal of the widely used group of antineoplastic (anti-new growth; anti-cancer) drugs, also called cytotoxic drugs (CDs) because they are toxic to cells, may expose pharmacists, nurses, physicians, and other health care workers to high environmental levels of these drugs. 1. Although little research has been done on the long-term risks at the levels of exposure encountered by unprotected health care workers, these drugs have been associated with human cancers at high (therapeutic) levels of exposure and are carcinogens and teratogens in many animal species. 2. Under current work practices, CDs have demonstrated the ability to cause elevations in sister chromatid exchanges and chromosome breakage in circulating lymphocytes and mutagenic activity in urine. 3. In addition, many of these drugs have been shown to cause a variety of acute effects in humans, such as localized skin necrosis after surface contact with abraded skin or damage to normal skin. These drugs were known to be potentially harmful to workers dealing with them. The nitrogen mustard drugs are extremely irritating to mucous membranes, eyes and skin. Other agents developed later on, such as fluorouracil, also have well-known topical effects. Spills of agents such as doxorubicin onto abraded skin can lead to severe soft-tissue injury, such as necrosis and sloughing of exposed areas as well as possible effects on the fetus. Symptoms such as lightheadedness, dizziness, nausea, headache, and possible allergic reaction also have been described in nurses after the preparation of antineoplastic drugs, and their subsequent administration, in unventilated areas. The potential for harmful effects developing over a longer term is also well-known. Most CDs either bind directly to genetic material, in the cell nucleus, or affect cellular protein synthesis, and may therefore damage growth and reproduction of normal cells as well. 70 9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d) The risks to workers handling CDs are a combined result of the drugs’ inherent toxicity and the extent to which workers are directly exposed to CDs on the job. The main routes of exposure are through the inhalation of drug dusts or droplets, absorption through the skin, and ingestion through contact with contaminated food or cigarettes. Opportunity for exposure may occur at many points in the handling of these drugs. Long term risks are uncertain with low level exposure to drugs known to be mutagenic, carcinogenic and teratogenic. Therefore, precautionary measures as defined below are recommended for the particular drugs of concern. I. DRUG PREPARATION GUIDELINES Access to preparation area should be limited to authorized personnel. Eating, drinking, smoking, chewing gum, applying cosmetics, and storing food in or near the preparation area should be forbidden. A. Biological Safety Cabinets • • • • • • • All mixing of neoplastic drugs shall be performed in a vertical Laminar Flow Biological Safety Cabinet. Special aseptic techniques and precautions must be utilized because of the vertical (downward) airflow. No other I.V. admixtures should be prepared in Biological Safety Cabinets designated for the mixing of antineoplastic agents. The Biological Safety Cabinets should be certified by qualified personnel annually, or any time the cabinet is physically moved. The Biological Safety Cabinet must be operated with blower on at least 5 minutes prior to using the hood. Drug preparations shall be performed only with the viewing window at the required access opening. All I.V. bags must carry the following label to identify contents as a Chemotherapy Agent. This is in addition to the regular I.V. label. —CAUTION— Antineoplastic Material Handle Properly 71 9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d) B. Gloves and protective gowns • • • • Disposable surgical latex gloves or special chemo safety gloves must be worn for all procedures involving antineoplastic drugs. Double gloving is recommended when cleaning up spills. Disposable protective barrier garments should be worn for all procedures. These garments should have a closed front, long sleeves and closed cuff (either elastic or knit). Disposable protective aprons may be worn as a barrier in lieu of closed front garments. A disposable mask should be worn when exposure to particles is anticipated such as when compounding in areas other than that specified under “A. Biological Safety Cabinets”, i.e., when BSC is not available. All potentially contaminated garments must not be worn outside the work area. C. Compounding Techniques • • • • • • • • • • Hands must be washed thoroughly before gloving and after removal. Care must be taken to avoid puncturing of gloves and possible self-inoculation. Syringes and I.V. sets with luer-lock fittings should be used whenever possible. Syringes should always be large enough so that they are never more than threefourths full. The work surface should be thoroughly cleaned before daily use and after any spillage. Vials should be vented to eliminate internal pressure on vacuum. Before opening ampules, care should be taken to insure that no liquid remains in the tip of the ampule. A sterile gauze sponge should be wrapped around the neck of the ampule while opening. Final drug measurement should be performed prior to removing the needle from the stopper of the vial. A non-splash collection vessel should be available in or next to the Biological Safety Cabinet to discard excess drug solution. The external surface of final I.V. containers should be wiped with alcohol soaked sponges prior to removal from the Biological Safety Cabinet. Special procedures should be followed for major spills or acute exposures. 72 9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d) D. Disposal Recommendations • • • All disposable items that have potentially come in contact with antineoplastic drugs during compounding or administration must be disposed of in specifically designated containers. These are plastic “Biohazard” or “Contaminated Material” buckets. Care must be taken to insure that the lid and the vial opening are securely closed before the buckets are removed for disposal. All hazardous waste containers shall be collected for disposal by housekeeping staff (environmental policy procedure). General cleaning of the work area must be performed using dust containment procedures. E. Personnel Policy Recommendation • • • • • • All personnel must receive special training in working with antineoplastic agents. The number of personnel working with these agents should be minimized. Eating, drinking, smoking, application of cosmetics, or similar activities are not permitted during compounding or drug administration procedures. Access to the compounding area must be limited to only necessary authorized personnel. The personnel working with these agents should be observed regularly by supervisory personnel to insure compliance. Acute exposure episodes must be documented. The employee must be referred for professional examination. II. ADMINISTRATION OF CHEMOTHERAPEUTIC AGENTS ON PATIENT UNITS Proper handling of drugs is important to minimize contact to skin, mucus membranes and eyes for nurses and for patients. • • • Wash hands with soap and water before and after changing bags or tubing. Disposable surgical latex gloves are required to be worn when changing bags and tubing. Syringes and I.V. sets with luer-lock fittings should be used whenever possible. 73 9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d) • • To prime I.V.set at Genesse campus,use compatible solution and double clamp the iv tubing. Add the chemo to the base solution. To prime I.V.set at Park Ridge Campus,chemo nurse back primes primary solution of D5W or NS into drip chamber of chemotherapy secondary tubing by lowering chemotherapy bag and unclamping tubings.Reclamp when primed. III. STORAGE AND TRANSPORT A. Storage Areas • Access to areas where CDs are stored should be limited to authorized personnel B. Receiving Damaged CD Packages • • Damaged cartons should be opened in an isolated area by an employee wearing the same protective equipment as is used in preparation without a hood. Broken containers and contaminated packaging mats should be placed in a punctureresistant receptacle and then in CD disposal bags, which should be closed and placed into appropriate receptacles. C. Transport • • • Within the medical facility, drugs should be securely capped or sealed and properly packaged. Personnel involved in transporting CDs should be cautioned and trained in the necessary procedures should a spill occur, including sealing off the contaminated area and calling for appropriate assistance. All drugs should be labeled with a warning label and clearly identified as cytotoxics. IV. DRUG SPILLAGE A. Skin Contact • Immediate thorough washing of area with soap and water. 74 9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d) B. Eye Contact • • Flush affected eye with copious amounts of water. Seek medical attention immediately. C. Floor Drug Spillage • • • • • • Open a “Spill Kit”, put on gloves, gown, etc., goggles and mask are also available and should be used for large spills. Absorbent materials are also available. After spill is absorbed, the contaminated materials should be disposed of in the plastic biohazard recepticles and the area washed as indicated below. When a “Chemo Spill Kit” is not immediately available, apply two pair of latex gloves. (Surgical gowns and masks are recommended for large spills to minimize skin/clothing/vapor contact.) Use paper towels to wipe up spill. Follow by rinsing area with water to remove any excess drug. Dispose of all materials as contaminated material. If linen is involved, it should be changed as soon as possible. The patient should be protected from skin contact with the spill until the linen is changed. Linen should be double bagged and marked as contaminated. D. Spills in Hoods • Decontamination of all interior hood surfaces may be required after the above procedures have been followed. If the HEPA filter of a hood is contaminated, the unit must be labeled “Do not use — Contaminated”, and the filter must be changed and disposed of properly as soon as possible by trained personnel wearing protective equipment. Protective goggles should be cleaned with an alcohol wipe after the cleanup. V. DISPOSAL OF MEDICATION AND RELATED SUPPLIES A. All supplies, including syringes, needles, I.V. bags and tubing, alcohol swabs, gloves, paper towels, etc., should be treated as “contaminated,” i.e., placed in red plastic trash buckets marked for contaminated materials. B. Medication remaining in vial or ampule after preparation is also disposed of in the plastic trash buckets. (See above) C. I.V. bags containing chemo medication should be clamped off (i.e., leave tubing attached with tubing clamps closed) and disposed of by placing in containers, double bagged and marked for “contamination or biohazard.” D. Disposable containers may be placed in patient rooms for the disposal of such drugs and related supplies. 75 9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d) VI. MANAGEMENT OF PATIENT EXCRETA 1. Precautions are recommended particularly on those specific days the patient has received chemotherapy (see list of drugs VII). 2. Wear gloves to dispose of urine and stool. 3. Hand washing is essential following contact with or without gloves. 4. In emptying and rinsing containers, use toilet, avoiding spray of contents onto toilet seat, skin or eyes. Clean all areas of possible contact after rinsing the container. 5. For peritoneal drainage containing chemotherapy, the system must be kept closed and discarded intact. VII. THE PARTICULAR DRUGS OF CONCERN INCLUDE: A. I.V. Drugs Bleomycin Carboplatin Doxorubicin Etoposide Mitoxantrone Paclitaxel Carmustine Fludarabine Plicamycin Chlorozotocin Ifosfamide Streptozotocin Cisplatin Investigational drugs Thio TEPA Cytatabine Mechlorethamine Vinblastine Cyclophosphamide Mercaptopurine Vincristine Dacarbazine Methotrexate Vinorelbine Daunorubicin Mitomycin (5-FU does not require special precautions other than good hand washing) B. Oral Drugs Busulfan Etoposide Melphalan Chlorambucil Hydroxyurea Methotrexate Cyclophosphamide Lomustine Procabazine revised:6/26/03 Revised:6/1/07 reviewed:3/31/06 76 Unity Health System High Alert Medications High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error with these medications are clearly more devastating to patients. Based on literature, ISMP Medication Errors Reporting Program and Unity Health System Medication Safety Reporting Program, a comprehensive list of identified high-alert medications has been constructed. Specific Medications  IV amiodarone  Colchicines injection  Heparin, low molecular weight, injection  Heparin, unfractionated, IV  Insulin, subcutaneous and IV  IV lidocaine  Magnesium sulfate injection  Methotrexate, oral, non-oncologic use  Nesiritide  Nitroprusside, sodium, for injection  Potassium chloride for injection concentrate  Potassium phosphates injection  Sodium chloride injection, hypertonic, more than 0.9% concentration  Warfarin Classes, categories of medications Adrenergic agonists, I.V. (e.g., epinephrine)  Adrenergic antagonists, I.V. (e.g., propranolol)  Anesthetic agents, general, inhaled and I.V. (e.g., propofol)  Antidiabetic agents, oral  Cardioplegic solutions  Chemotherapeutic agents, parenteral and oral  Dextrose, hypertonic, 20% or greater  Dialysis solutions, peritoneal and hemodialysis  Epidural or inrathecal medications  Glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide)  Inotropic medications, I.V. (e.g., digoxin, milrinone)  Liposomal forms of drugs (e.g., liposomal amphotericin B)  Moderate sedation agents, I.V. (e.g., midazolam)  Narcotics/opioids, I.V. and oral (including liquid concentrates, immediate-and sustained-release formulations)  Neuromuscular blocking agents (e.g., succinycholine)  Radiocontrast agents, I.V.  Thrombolytics/fibrinolytics, I.V. (e.g., alteplase) May 2006 77 UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST HOSPITAL LIST Potential Problematic Drug Names Generic (lowercase) and Brand Name(s) (uppercase) Potential Errors and Consequences Specific Safety Strategies * Safety Strategies in place at Unity Hospital Concentrated liquid morphine products vs. conventional liquid morphine concentrations. Concentrated: ROXANOL, MSIR Concentrated forms of oral morphine solution (20mg/ml) have been confused with the standard concentration (listed as 10mg/5ml or 20mg/5ml), leading to serious errors. Accidental selection of the wrong concentration, and prescribing/labeling the product by volume, not milligrams, contributes to these errors, some of which have been fatal. For example, “10mg” haw been confused with “10ml”. If concentrated product is used, this represents a 20-fold overdose. Concentrate solutions are dispensed in unit dose to the Pyxis. Not available in Pyxis unless patient specific. ephedrine and epinephrine ADRENALIN (epinephrine) Dispense concentrated oral morphine solutions only when ordered for a specific patient (not as unit stock). Segregate the concentrated solution from the other concentrations wherever it is stored. Purchase and dispense concentrated solutions in dropper bottles (available from at least two manufacturers) to help prevent dose measurement errors and differentiate the concentrated product from the conventional products. Verify that patients and caregivers understand how to measure the proper dose for self-administration at home. For inpatients, dispense concentrated solutions in unit doses. See general recommendations below. Do not stock sufentanil in patient care units outside OR/PACU settings. Do not store these agents near one another if both products are available (e.g., pharmacy, anesthesia supplies). Medication name printed using tall man lettering. Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels. Conventional: Morphine oral liquid ephedrine fentanyl and sufentanil SUBLIMAZE (fentanyl) SUFENTA (sufentanil) Updated: 5/2008 Reviewed: 5/2008 The names of these two medications look very similar, and their clinical uses make storage near each other likely, especially in obstetrical areas. Both products are available in similar packaging (1ml amber ampuls and vials). The products are not interchangeable. Confusion has resulted in episodes of respiratory arrest due to potency differences between these drugs. Some errors occurred when using sufentanil during drug shortages of fentanyl. Ephedrine in vial. Stored in Pharmacy under generic name on separate shelves. Epinephrine ampoule. Medications labeled with sound alike look alike labels. 78 UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST Potential Problematic Drug Names Generic (lowercase) and Brand Name(s) (uppercase) Potential Errors and Consequences Specific Safety Strategies * Safety Strategies in place at Unity Hospital hydromorphone injection and morphine injection DILAUDID (hydromorphone) Some health care providers have mistakenly believed that hydromorphone is the generic equivalent of morphine. However, these products are not interchangeable. Fatal errors have occurred when hydromorphone was confused with morphine. Based on equianalgesic dose conversion, this may represent significant overdose, leading to serious adverse events. Storage of the two medications in close proximity to one another and in similar concentrations may contribute to such errors. Confusion has resulted in episodes of respiratory arrest due to potency differences between these drugs. Similar names, strengths and concentration ratios of some products (e.g., 70/30) have contributed to medication errors. Mix-ups have also occurred between the 100 units/ml and 500 units/ml insulin concentrations. Stock specific strengths for each product that are dissimilar. For example, stock units with hydromorphone 1mg unit dose cartridges, and morphine in 2mg unit dose cartridges. Ensure that health care providers are aware that these two products are not interchangeable. Medication name printed using tall man lettering. Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels. Limit the use of insulin analog 70/30 mixtures to just a single product. Limit the variety of insulin products stored in patient care units, and remove patient-specific insulin vials from stock upon patient discharge. For drug selection screens, emphasize the word “mixture” or “mix” along with the name of the insulin product mixtures. Consider auxiliary labels for newer products to differentiate them from the established products. Also apply bold labels on atypical insulin concentrations. Only Stock: Lantus Humulin 70/30 Humalog Humulin N Humulin R Medications labeled with sound alike look alike labels. Insulin stored in individual labeled containers in the medication refrigerators on patient floors and in Pharmacy. ASTRAMORPH, DURAMORPH, INFUMORPH (morphine) Insulin products: Lantus and Lente Humalog and Humulin Novolog and Novolin Humulin and Novolin Humalog and Novolog Novolin 70/30 and Novolog Mix 70/30 LANTUS (insulin glargine) LENTE (insulin zinc susp) HUMULIN (human insulin products) HUMALOG (insulin lispro) NOVOLIN (human insulin products) NOVOLOG (human insulin aspart) Updated: 5/2008 Reviewed: 5/2008 79 UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST Potential Problematic Drug Names Generic (lowercase) and Brand Name(s) (uppercase) Potential Errors and Consequences Specific Safety Strategies * Safety Strategies in place at Unity Hospital Lipid-based amphotericin products vs. conventional forms of amphotericin Lipid-based: Many drugs now come in liposomal formulation indicated for special patient populations. Confusion may occur between the liposomal and the conventional formulations because of name similarity. The products are not interchangeable. Lipid-based formulation dosing guidelines differ significantly from conventional dosing. Conventional amphotericin B desoxycholate doses should not exceed 1.5mg/kg/day. Doses of the lipid-based products are higher, but vary from product to product. If conventional amphotericin B is given at a dose appropriate for a lipid-based product, a severe adverse event is likely. Confusion between these products has resulted in episodes of respiratory arrest and other dangerous, sometimes fatal outcomes due to potency differences between these drugs. Staff involved in handling these products should be aware of the differences between conventional and lipid-based formulations of these drugs. Encourage staff to refer to the lipid-based products by their brand names and not just their generic names. Stop and verify that the correct drug is being used if staff, patients or family members notice a change in the solution’s appearance from previous infusions. Lipidbased products may be seen as cloudy rather than a clear solution. Storage of lipid-based product in patient care areas and automated dispensing cabinets is highly discouraged. To reduce potential for confusion, consider limiting lipid-based amphotericin B products to one specific brand. Medications labeled with sound alike look alike labels. Stored in Pharmacy under generic name on separate shelves in refrigerator. AMBISOME (amphotericin B liposomal) ABELCET (amphotericin B lipid complex) AMPNOTEC (amphotericin B. cholesteryl sulfate complex for injection: Conventional: AMPHOCIN, FUNGIZONE INTRAVENOUS (amphotericin B desoxycholate) Updated: 5/2008 Reviewed: 5/2008 80 UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST Potential Problematic Drug Names Generic (lowercase) and Brand Name(s) (uppercase) Potential Errors and Consequences Specific Safety Strategies * Safety Strategies in place at Unity Hospital Avandia and Coumadin AVANDIA (rosiglitazone) Poorly handwritten orders for Avandia (used for type II diabetes) have been misread as Coumadin (used to prevent blood clot formation), leading to potentially serious adverse events. Mixups originally occurred due to unfamiliarity with Avandia – staff read the order as the more familiar Coumadin. However, mix-ups between these two products continue to occur. Neither medication is safe without appropriate monitoring that is specific to the drug. Patients affected by a mix-up between these three drugs may experience a decline in mental status, lack of pain or seizure control, or other serious adverse events. See general recommendations below. Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels. High Alert label on Coumadin. See general recommendations below. Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels. The generic name for clonidine can easily be confused as the trade or generic name for clonazepam. See general recommendations below. Stored in separate areas in the Pharmacy. Medications labeled with sound alike look alike labels. COUMADIN (warfarin) Celebrex and Celexa and Cerebyx CELEBREX (celecoxib) CELEXA (citalopram hydrobromide) Clonidine and clonazepam (Klonopin) CEREBYX (fosphenytoin) CATAPRES (clonidine) KLONOPIN (clonazepam) Updated: 5/2008 Reviewed: 5/2008 81 UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST Potential Problematic Drug Names Generic (lowercase) and Brand Name(s) (uppercase) Potential Errors and Consequences Specific Safety Strategies * Safety Strategies in place at Unity Hospital Lamisil and Lamictal LAMISIL (terbinifine hydrochloride) Patients with epilepsy who do not receive Lamictal due to an error would be inadequately treated and could experience serious consequences. Conversely, patients erroneously receiving Lamictal would be unnecessarily subjected to a risk of potential side effects (including serious rash) and would miss important antifungal therapy. Name similarity has resulted in frequent mix-ups between Zyrtec, an antihistamine, and Zyprexa, an antipsychotic. Patients who receive Zyprexa in error have reported dizziness, sometimes leading to a related injury from a fall. Patients on Zyprexa for a mental illness have relapsed when given Zyrtec in error. See general recommendations below. Pharmacy does not stock Lamisil. Medications labeled with sound alike look alike labels. See general recommendations below. Medication name printed using tall man lettering. LAMICTAL (lamotrigine) Zyprexa and Zyrtec ZYPREXA (olanzapine) ZYRTEC (cetirizine) Updated: 5/2008 Reviewed: 5/2008 82 UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST CHEMO LIST Potential Problematic Drug Names Generic (lowercase) and Brand Name(s) (uppercase) Potential Errors and Consequences Specific Safety Strategies * Practices in place at Unity Hospital Cisplatin and carboplatin PLATINOL (cisplatin) Similarity in names can lead to confusion between these two products. Doses appropriate for carboplatin usually exceed the maximum safe dose of cisplatin. Severe toxicity and death has been associated with accidental cisplatin overdoses. Install maximum dose warnings in computer systems. A boxed warning notes that cisplatin doses greater than 100mg/m² once every 3 to 4 weeks are rarely used and that the package insert should be consulted for further information. Use safe handling recommendations and safety stickers for cisplatin as provided by manufacturer. Do not store these agents next to each other. Use generic names when prescribing and not chemical names or abbreviations. Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels. Maximum dose warning in Cerner system. High alert medication labeling. Dispensed chemo medications are clearly labeled with “Cytotoxic Dispose of Properly”. Dispensed and secured in special chemo bags. PARAPLATIN (carboplatin) Updated: 5/2008 Reviewed: 5/2008 83 UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST Potential Problematic Drug Names Generic (lowercase) and Brand Name(s) (uppercase) Potential Errors and Consequences Specific Safety Strategies * Safety Strategies in place at Unity Hospital Lipid-based daunorubicin and doxorubicin products vs. conventional forms of daunorubicin and doxorubicin. Lipid-based: Many drugs now come in liposomal formulations indicated for special patient population. Confusion may occur between the liposomal and the conventional formulation because of name similarity. The products are not interchangeable. Lipid-based formulation dosing guidelines differ significantly from conventional dosing. For example, a standard dose of doxorubicin liposomal is 20mg/m² given at 21 day intervals, compared to doses of 50 to 75mg/m² every 21 days for conventional drugs. Doses of liposomal daunorubicin are typically 40mg/m² repeated every 2 weeks, while doses of conventional daunorubicin vary greatly and may be administered more frequently. Accidental administration of the liposomal form instead of the conventional form has resulted in severe side effects and death. Staff involved in handling these products should be aware of the differences between conventional and lipid-based formulations of these drugs. Encourage staff to refer to the lipidbased products by their brand names and not just their generic names. Stop and verify that the correct drug is being used if staff, patents or family members notice a change in the solution’s appearance from previous infusions. Lipid-based products may be seen as cloudy rather than a clear solution. Storage of lipid-based products in patient care areas and automated dispensing cabinets is highly discouraged. Include specific method of administration for these products. Medication name written using tall man lettering. Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels. Maximum dose warning in Cerner system. High alert medication labeling. Dispensed chemo medications are clearly labeled with “Cytotoxic Dispose of Properly”. Dispensed and secured in special chemo bags. DOXIN (doxorubicin liposomal) DAUNOXOME (daunorubicin citrate liposomal) Conventional: CERUBIDINE (daunorubicin, conventional) ADRIAMYCIN, RUBEX (doxorubicin, conventional) Updated: 5/2008 Reviewed: 5/2008 84 UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST Potential Problematic Drug Names Generic (lowercase) and Brand Name(s) (uppercase) Potential Errors and Consequences Specific Safety Strategies * Safety Strategies in place at Unity Hospital Taxol and Taxotere TAXOL (paclitaxel) Confusion between these two drugs can result in serious adverse outcomes since they have different dosing recommendations and use in various types of cancer. Install maximum dose warnings in computer systems to alert staff to name mix-ups during order entry. Do not store these agents near one another. Fatal errors have occurred, often due to name similarity, when patients were erroneously given vincristine intravenously, but at the higher vinblastine dose. A typical vincristine dose is usually capped at around 1.4mg/m² weekly. The vinblastine dose is variable but, for most adults, the weekly dosage range is 5.5 to 7.4mg/m². Install maximum dose warnings in computer systems to alert staff to name mix-ups during order entry. Do not store these agents near one another. Staff involved in handling these products should be aware of the differences. Use brand names or brand and generic names when prescribing and do not use abbreviations for these drug names Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels. Maximum dose warning in Cerner system. High alert medication labeling. Dispensed chemo medications are clearly labeled with “Cytotoxic Dispose of Properly”. Dispensed and secured in special chemo bags. Medication name written using tall man lettering. Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels. Maximum dose warning in Cerner system. High alert medication labeling. Dispensed chemo medications are clearly labeled with “Cytotoxic Dispose of Properly”. Dispensed and secured in special chemo bags. TAXOTERE (docetaxel) Vinblastine and Vincristine  VELBAN (vinblastine) Oncovin (vincristine) These safety strategies are not inclusive of all possible strategies to reduce name-related errors. Also see General Recommendations for Preventing Drug Name Mix-ups. Updated: 5/2008 Reviewed: 5/2008 85 UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST General Recommendations for Preventing Drug Name Mix-ups What prescribers can do:      Maintain awareness of look-alike and sound-alike drug names as published by various safety agencies. Clearly specify the dosage form, drug strength, and complete directions on prescriptions. These variables may help staff differentiate products. With name pairs known to be problematic, reduce the potential for confusion by writing prescriptions using both the brand and generic name. Include the purpose of medication on prescriptions. In most cases drugs that sound or look similar are used for different purposes. Alert patients to the potential for mix-ups, especially with known problematic drug names. Advise ambulatory care patients to insist on pharmacy counseling when picking up prescriptions, and to verify that the medication and directions match what the prescriber has told them.  Encourage inpatients to question nurses about medications that are unfamiliar or look or sound different than expected.  Give verbal or telephone orders only when truly necessary, and never for chemotherapeutics. Include the drug’s intended purpose to ensure clarity. Encourage staff to read back all orders, spell the product name, and state its indication. What organizations and practitioners can do:  Maintain awareness of look-alike and sound-alike drug names as published by various safety agencies Regularly provide information to professional staff.  Whenever possible, determine the purpose of the medication before dispensing or drug administration. Most products with look or sound-alike names are used for different purposes.  Accept verbal or telephone orders only when truly necessary, and never for chemotherapy. Encourage staff to read back all orders, spell the product name, and state it’s indication.  Consider the possibility of name confusion when adding a new product to the formulary. Review information previously published by safety agencies.  Computerized prescribing. Use preprinted orders or prescriptions as appropriate. If possible, print out current medications daily from pharmacy computer system and have physicians review for accuracy.  When possible, list brand and generic names on medication administration records and automate dispensing cabinet computer screens. Such redundancy could help someone identify an error. Updated: 5/2008 Reviewed: 5/2008 86 UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST  Change the appearance and look-alike product names on computer screens, pharmacy and nursing units shelf labels and bins (including automated dispensing cabinets), pharmacy product labels and medication administration records by highlighting, through bold face, color, and/or tall man letters, the part of the names that are different (e.g. hydroxyzine, hydralazine).  Install and utilize computerized alerts to remind providers about potential problems during prescription processing.  Configure computer selection screens and automated dispensing cabinet screens to prevent the two confused drugs from appearing consecutively.  Affix “name alert” stickers to areas where look or sound-alike products are stored.  Store products with look or sound-alike names in different locations in pharmacies, patient care units, and in other settings, including patient homes. When applicable, use a shelf sticker to help locate the product that has been moved.  Continue to employ independent double checks in the dispensing process (one person interprets and enters the prescription into the computer and another reviews the printed label against the original prescription and the product prior to dispensing).  Encourage reporting of errors and potentially hazardous conditions with look and sound-alike product names and use the informationto establish priorities for error reduction. Also maintain awareness of problematic product names and error prevention recommendations provided by ISMP, FDA and USP. References: 1. ISMP. What’s in a name? Ways to prevent dispensing errors linked to name confusion. ISMP Medication Safety Alert! 7(12) June 12, 2002 2. JCAHO, Sentinel Event Alert. Issue 19-May 2001 Updated: 5/2008 Reviewed: 5/2008 87

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