Download I. Policy Statement II. Procedures Stanford Hospital and Clinics

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.