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This policy applies to: LPCH Approval Date: Stanford Hospital and Clinics May 2007 Lucile Packard Children's Hospital Stanford University Name of the Policy: Patient's Own Medications Page 1 of 4 Departments Affected: All Departments I. Policy Statement A patient's own medications from home may not be used at LPCH. Exceptions are allowed for drugs that cannot be acquired by the LPCH Pharmacy and for blood factors and growth hormone. Exceptions may be allowed in outpatient areas. Drug samples will not be accepted for administration to patients. This policy applies to all drugs including prescription drugs, non-prescription drugs (i.e. over-the-counter drugs), homeopathic and herbal remedies, and any botanical products. II. Procedures A. If a patient brings personal medications from home, the nurse will review the physician's order to see if the drugs have been ordered for inpatient administration. B. If the medications have not been ordered for the current admission or if there is no order to use the home supply of medication, the nurse will return the medications to the patient, parents or caregivers to be taken home. C. If a specific medication from home is ordered for this admission, it may be used if ALL the following criteria are met: 1. The medication is NOT available in the pharmacy. 2. The medication is sent to the pharmacy to be examined. The pharmacist must verify the identity of the drug and verify that the drug appears to be stable and uncontaminated. 3. A complete order is entered into the patient's medical record. D. (a) The order must include the drug name, strength or concentration, dosage form, route, dose, and frequency of administration (refer to Hospital Policy "Ordering Drugs"). (b) The physician must designate that the patient’s own supply of medications are to be used. (c) The pharmacist evaluates the appropriateness of medication use (Pharmacy Policy "Drug Distribution: Patient Assessment and Review of Medication Orders") and determines that the order is appropriate. If the above criteria are not met, the home medications may not be administered during the hospitalization. 1. If the medication is available in the pharmacy, the pharmacist will contact the This policy applies to: LPCH Approval Date: Stanford Hospital and Clinics May 2007 Lucile Packard Children's Hospital Stanford University Name of the Policy: Patient's Own Medications Page 2 of 4 Departments Affected: All Departments physician. 2. (a) The physician will write an order to discontinue use of the patient’s own medication. (b) If the medication is a non-formulary drug, the pharmacist will so advise the physician and the physician completes a “Non-Formulary Request” form (available on the LPCH intranet). (c) The pharmacist retains the patient’s home supply of medications until the new order is received. Upon receiving the new order, the pharmacist returns the drug to the nurse. If the home supply of medication appeared contaminated, unstable or not identifiable, the pharmacist will recommend that the nurse advise the patient/family to dispose of the medication. (d) The nurse notifies the patient/family that the home supply of medications cannot be used while at LPCH. The policy and patient safety issues may be discussed with the family. The home medications are returned to the patient/family. If the medication is not available in the pharmacy, but the home supply is not usable (due to contamination, stability, or identity), the pharmacist will consult with the physician regarding other options. (a) The physician writes an order to discontinue use of the home medications. (b) When the new order is received the pharmacist returns the home medications to the nurse. The pharmacist will recommend that the nurse advise the patient/family to destroy the medications because they appear contaminated, etc. (c) The nurse notifies the patient/family that the home supply of medications cannot be used. The policy and patient safety issues may be discussed with the family. The home medications are returned to the patient/family. E. The order is processed in the hospital computer system with the designation that the medications are "Patient's Own Medications". The pharmacist attaches the computer-generated label to the medications. F. After labeling, the patient's home medications will be sent to the nursing unit to be kept under hospital control and will be administered to the patient by hospital licensed personnel who are authorized to administer medications. G. If a patient’s home medication is not currently stocked in the pharmacy, the pharmacy will attempt to procure a hospital supply of the drug. 1. If the medication is a formulary item, the pharmacy will attempt to procure the drug per policy. (Pharmacy Policy: Purchasing and Inventory Control: Procurement of Pharmaceuticals). If the drug can be obtained, the patient will use the hospital supply as soon as it is available. The nurse will then return the patient's own medications to the parents or caregivers to be taken home. 2. If any medication is a non-formulary item, the physician will complete a Non-Formulary Drug Request (see hospital policy Non-Formulary Drugs) and submit it to the This policy applies to: LPCH Approval Date: Stanford Hospital and Clinics May 2007 Lucile Packard Children's Hospital Stanford University Name of the Policy: Patient's Own Medications Page 3 of 4 Departments Affected: All Departments pharmacy. The pharmacist will evaluate the Request and procure the drug per policy. H. Any medications that are not accepted by the parents or caregivers are sent to the pharmacy for destruction. All medications will be disposed of in accordance with state and federal regulations (Pharmacy Policy: Purchasing and Inventory Control: Disposition of Drugs; Controlled Substances: Disposal; and the hospital Medical Waste policy) I. To ensure continuation of therapy with the most appropriate product, patients may bring in their own supply of Growth Hormone or Blood Factor (Hemophilia patients). J. To ensure continuation of therapy in outpatient areas where the patient is treated for an extended period of time (e.g. Day Hospital, Dialysis, specialty clinics), the use of a patient's own prescribed medication is permitted for teaching purposes and in extraordinary circumstances when the following criteria are met: a. The patient or parent will administer the drug. b. The medication is positively identified and documented by a pharmacist or physician prior to administration of the medication by the patient/parent. c. The registered nurse verifies that the prescribed medication is ordered per the patient's plan of care and he/she documents the medication, dose, route, and time that the patient/parent will administer the medication. III. Document Information A.. Legal Authority/References 1. 22 CCR § 70263 (m) 2. Joint Commision Standard MM 2.40 B. Author/Original Date 1. C R. Poole, 1/93 (03.01.08) Distribution 1. This policy resides in the Pharmacy Manual of Lucile Packard Children’s Hospital. D. Review/Renewal History 1. Revised: 3/03, 3/04, 7/04, 8/04, 2/06 (P. Wong); 3/07 (P.Wong) 2. Reviewed: 3/99,6/00,3/02 E. Review Requirements: Every three years F. Approvals This policy applies to: LPCH Approval Date: Stanford Hospital and Clinics May 2007 Lucile Packard Children's Hospital Stanford University Name of the Policy: Patient's Own Medications Page 4 of 4 Departments Affected: All Departments 1. Department of Pharmacy: 4/04; 2/06; 3/07 2. Pharmacy & Therapeutics: 4/04; 4/07 3. Medical Board: 6/04; 5/07 4. Board of Directors: 6/04; 5/07 This document is intended for use by staff of Stanford Hospital & Clinics and/or Lucile Packard Children's Hospital. No representations or warranties are made for outside use. Not for outside reproduction or publication without permission.