Download Medication Safety - Maine Quality Counts

Medication Safety: Sampling
Identify the Safety Risk
The use of samples leads to prescribing and use
which may not be the most effective or efficient for
patients: sample drugs represent potential risks as
pharmacists are eliminated from the dispensing
process. There is an increased risk of documentation
errors, use of non-formulary drugs, outdated
medications and drug interactions.
It is recommended that clinics eliminate sampling
of all prescription pharmaceutical products
supplied by manufacturers. Clinics choosing to stock
and dispense sample medications must follow safe
medication practices consistent with JCAHO
standards. HealthPartners identifies sampling of
prescription pharmaceuticals as inconsistent with
the six aims of quality, primarily due to concerns for
patient safety.
·
Create labels for the samples and attach them
prior to giving to the patient.
·
Provide educational handouts on each drug
within the sample space and make sure
adequate copies are available and easily
obtainable for each sample. Place a copy of the
education piece given to the patient in the log
and in the medical record.
·
Make pharmaceutical representatives aware of
your protocol and their roles in ensuring safe
sample distribution. Consider a sign in/out log
for pharmaceutical representatives to use during
every visit. Enter a name, medication(s)
delivered, lot numbers, quantity and expiration
date. Clinic staff who remove samples should
sign them out on the same log.
·
Assessments for hidden caches of samples
within physician offices or exam rooms should
be done regularly, perhaps every quarter to
every six months.
Suggestions for Improvement
·
Eliminate sampling.
·
Review or implement a sample drug protocol in
your clinic. Form a work group to assess the
protocol (providers, nurses, medical assistants).
·
·
(Gunderson 22)
Sample Forms
Figure 8: Pharmaceutical Sampling Policy
Implement protocol. If sampling is not yet
eliminated, set a future date and goal for
elimination.
Other Resources - Links
Determine which samples should be maintained,
where they should be maintained and the level
of security necessary. All samples should be
locked in a secure place.
·
Eliminate drug samples from exam rooms and
doctors’ offices and store them in a secure
location in clear view of a nursing station.
·
Create a written documentation and monitoring
system for samples and include duplicate written
instructions to keep in the
·
·
AHRQ: Data Collection
·
AHRQ: Selecting a Sample
·
Harvard Education/Patient Safety Strategies
Works Cited
The Ambulatory Patient Safety Toolkit is the copyrighted work of
the Gunderson Lutheran Medical Center, developed for the
Safety Collaborative for Outpatient Environment (SCOPE)
Project, funded by the American Medical Group Association
(AMGA) in 2003. Portions of the Ambulatory Patient Safety
Toolkit are reproduced with permission of the Gunderson
Lutheran Medical Center and will be referenced whenever used
in this toolkit.
log and to give to the patient. Include expiration
date and drug details.
Track the total starting number of samples per
drug, the number distributed with the date
distributed and the number of sample drugs
remaining with a date.
HealthPartners | Ambulatory Patient Safety Toolkit
6
Medication Safety: Therapeutic
Monitoring
Identify the Safety Risk
Certain medications require annual monitoring due
to increased risk of harm from drug side-effects and
drug toxicity. Therapeutic monitoring of patients is
essential to prevent avoidable adverse drug events
related to specific high-risk drugs (e.g., Coumadin
and Amiodarone monitoring).
Ongoing provider monitoring will include the Health
Plan Employer Data and Information Set (HEDIS)
measure Annual Monitoring for Patients on
Persistent Medications. Performance information
will provide meaningful and useful information to
clinicians for therapeutic decision making and
management.
This measure now includes
- ACE inhibitors and combination products
- ARBs and combination products
- Digoxin
- Diuretics
- Anticonvulsants
Suggestions for Improvement
· Create or implement a protocol on therapeutic
monitoring for patients on persistent
medications.
·
Incorporate the protocol to align with your use
of the HealthPartners registry monitoring
system. Access to the registry data is available
through healthpartners.com.
·
Form a work group to assess the policy and
include providers, nurses, and medical
assistants.
·
Evaluate HEDIS results for this measure.
·
Review the HealthPartners measurement
summary of the HEDIS Annual Monitoring for
Patients on Persistent Medications (Figure 9).
Sample Forms
Figure 9: HealthPartners Clinical Indicator: Annual
Monitoring for Persistent Medications
Figure 10: HPMG&C Amiodarone policy (example
only – HealthPartners health plan does not endorse
HealthPartners Commercial HEDIS Rates
Annual Monitoring for Patients on
Persistent Medications:
2011
2012
Results
Results
2010 DOS 2011 DOS
ACE Inhibitors or
ARBs
84.25%
84.1%
Digoxin
84.49%
86.5%
Diuretics
84.84%
84.4%
Anticonvulsants
71.59%
69.6%
Total
84.2%
83.9%
this specific protocol)
Other Resources -Links
·
American Association for Clinical Chemistry
·
FDA Safety and Drugs
Works Cited
The Ambulatory Patient Safety Toolkit is the copyrighted work of
the Gunderson Lutheran Medical Center, developed for the
Safety Collaborative for Outpatient Environment (SCOPE)
Project, funded by the American Medical Group Association
(AMGA) in 2003. Portions of the Ambulatory Patient Safety
Toolkit are reproduced with permission of the Gunderson
Lutheran Medical Center and will be referenced whenever used
in this toolkit.
HealthPartners | Ambulatory Patient Safety Toolkit
7
Medication Safety: Do Not Use
Abbreviations
·
Identify the Safety Risk
(Gunderson 10)
HealthPartners and Regions Hospital are part of a
metro area-wide effort to eliminate unsafe
prescribing practices and reduce medication errors.
Our efforts are part of the Safest in America (SIA)
and JCAHO initiatives to eliminate dangerous
abbreviations, acronyms and symbols. We provide
this information to encourage the elimination of
unsafe prescribing practices in all clinical settings.
Sample Forms
Figure 11: Medication Discharge Sheet
Figure 12: Clinic Pharmacy Prescription Sheet
Figure 13: ISMP List of Error Prone Abbreviations
Other Resources - Links
Suggestions for Improvement
·
Establish a protocol and eliminate all hand
written prescriptions.
·
Perform an audit of prescriptions written in the
clinic on 20 records to monitor for compliance
with your clinic’s protocol. If 100 percent
compliance is not seen, share results with
providers and set goals for improvement.
Member interviews and pharmacy reports are
additional resources to use in monitoring and
validation checks.
·
HealthPartners Policy and Attachments: Do Not
Use Error Prone Abbreviations
·
Harvard Education/Patient Safety Strategies
·
Joint Commission Do Not Use List
Works Cited
The Ambulatory Patient Safety Toolkit is the copyrighted work of
the Gunderson Lutheran Medical Center, developed for the
Safety Collaborative for Outpatient Environment (SCOPE)
Project, funded by the American Medical Group Association
(AMGA) in 2003. Portions of the Ambulatory Patient Safety
Toolkit are reproduced with permission of the Gunderson
Lutheran Medical Center and will be referenced whenever used
in this toolkit.
·
Continue to monitor for compliance. Consider
additional initiatives with providers if 100
percent compliance is not seen.
·
Obtain examples of poor prescription writing
from pharmacies and have them block out the
names to protect patient confidentiality. You can
show these to providers as examples.
·
Assess prescription writing practice by assigning
a nurse to review all of the prescriptions written
in a day as patients exit the clinics (Figure 11).
·
Collaborate with a pharmacy and provide them
with standards and a chart to track a clinic’s
prescriptions. Ask them to assess every
prescription for one week or one month and give
feedback. Review at least 20 prescriptions.
Generate provider specific data and give
feedback with suggestions for improvement. We
suggest monitoring every 3 to 6 months once
standards are in place.
·
If a medical practice has an electronic medical
record, an electronic prescription writing
platform may already be in place. Create a
monitoring system (through EMR data reports)
to check for accuracy.
HealthPartners | Ambulatory Patient Safety Toolkit
8
Medication Safety: Medication
Reconciliation
review their medication list tool and compare it
to the list in the chart (Figure 15).
Identify the Safety Risk
Medication reconciliation is the process of
comparing a patient's medication orders to all of the
medications that the patient has been taking. This
reconciliation is done to avoid medication errors
such as omissions, duplications, dosing errors, or
drug interactions. It should be done at every
transition of care in which new medications are
ordered or existing orders are rewritten.
HEDIS instituted a new measure in 2009 (2008 data
year) regarding “Medication Reconciliation PostDischarge”. The specification from CMS requires that
medication reconciliation occur within 30 days postdischarge from an inpatient facility. Even though this
measure has a restricted population, the standard of
care should apply to any member with complex
medical care needs on multiple medications
(Gunderson 4)
·
Develop scripting messages around medication
reconciliation to promote consistency, assure a
high level of service, help staff to handle difficult
situations, and set clear expectations. Scripts
also promote a verbal commitment and compel
people to follow through. Commitment
influences behavior and may increase
compliance.
·
Try to include “Elements of Influence” in the
scripting (Cialdini)
-
Suggestions for Improvement
·
·
·
Establish a spot in the medical record where the
current medication list is stored. This should be
accessed upon opening a medical record or on
the encounter page in an electronic medical
record (EMR).
Implement a process for obtaining and
documenting a complete list of each patient’s
medications upon admission to clinic and
hospital. Establish a communication method (fax
or EMR) where an inpatient facility provides the
patient’s current list of medications upon
discharge from an inpatient facility.
Develop a tool for the member to use and carry
with them to bring for each visit to keep
medications up to date (Figure 15).
·
Consider a pre-visit or a post visit phone call to
review medications with the patient.
·
Establish an audit review system to check
accuracy in the data provided between inpatient
and outpatient systems. (i.e., do a comparative
audit of 20 records each quarter).
·
Assign a nurse/medical assistant to choose 20
patients over several days each quarter to
-
Reciprocity exits: give before receiving
Commitment: greater consistency
Social proof: ‘everyone’s doing it’
Recognition of legitimate authority
Scarcity of opportunity: makes us want it
more
Provide a reason for the request
It helps if they know and like you
·
Include a statement in scripting about how the
patient’s provider gives recognition of legitimate
authority. For example, “Dr. X wants to know
your medications and would like you to know
them too”.
·
Consider personal reciprocity in your scripts - be
nice to people and they will feel obligated to be
nice to you. Use words like “will you please…”,
and always give the patient the opportunity to
respond.
·
Once you have developed the medication
reconciliation script with input from front line
staff, test it in a small group. Make changes as
needed.
HealthPartners | Ambulatory Patient Safety Toolkit
9
Medication Reconciliation
Sample Forms
Figure 14: Medication List and Allergy List Accuracy
Test
Figure 15: My Medicine List Tool
Figure 16: Sample Pill Box Distribution Policy
Figure 17: HEDIS 2010: Medication Reconciliation
Other Resources - Links
·
AHRQ
·
NIH Seniors and Medication
·
Joint Commission Alert/Medication
Reconciliation
·
Joint Commission Alert/Anticoagulants
Works Cited
Cialdini Robert B., Influence: The Psychology of
Persuasion (New York: William Morrow and
Company), 1984, 1993. Note: supported by ICSI
The Ambulatory Patient Safety Toolkit is the copyrighted work of
the Gunderson Lutheran Medical Center, developed for the
Safety Collaborative for Outpatient Environment (SCOPE)
Project, funded by the American Medical Group Association
(AMGA) in 2003. Portions of the Ambulatory Patient Safety
Toolkit are reproduced with permission of the Gunderson
Lutheran Medical Center and will be referenced whenever used
in this toolkit.
HealthPartners | Ambulatory Patient Safety Toolkit
10
Medication Safety: Protocols for Use
of Hazardous Drugs
Identify the Safety Risk
Coumadin, Amiodarone, Insulin and controlled
substances are the most common potentially
hazardous drugs prescribed in the outpatient setting.
Research demonstrates that standardized
prescribing of these medications may improve
safety.
Protocols for a Coumadin prescription, along with
standing orders for INR determination are available
through multiple sources, including the product
manufacturer. Clinics should have standing orders
that allow nurses to renew or alter doses based on
lab test results or changes in the patient’s
circumstances. Standing orders that require regular
assessment of INR should also be in place.
Sliding scales for Insulin have improved care by
allowing those at the actual point of contact with the
patient to modify medication orders based on point
of care testing. Protocols, guidelines and standing
orders should be developed to allow nurses to
provide the greatest level of patient care in the
safest manner.
Use of chronic opioid therapy for chronic
nonmalignant pain (CNMP) has increased
substantially; therefore effective management is
considered a major problem in both primary care
and out-patient medicine. It presents a major
challenge for both the patient and health care
provider. Opioids are associated with potentially
serious harms, including adverse effects and
outcomes related to the abuse potential.
Suggestions for Improvement
· Establish protocols for the use of hazardous
drugs in your clinic. Make sure that the protocol
addresses standardized daily dosing algorithms,
monitoring and management plans. Include
details on lock up and sign out procedures for
certain medications.
·
Form an improvement group of providers to
review the current methods of providing safe
care to patients who are on anticoagulants and
for patients who are diabetic. Evaluate the
results and implement change if improvement is
needed.
·
Update protocols and standing orders as needed
to be in compliance with guidelines.
·
Perform an audit of 20 records to compare with
each of the medication guidelines and orders in
your protocol(s). Review compliance outcomes
with your clinic’s quality team.
·
Continue to monitor for compliance against the
clinic protocols for hazardous drugs.
·
If you use an electronic medical record, and as
computers become more common in exam
rooms, incorporate the guidelines, standing
orders and other safety tools into the work flow
of patient care.
·
Review the HPMG & C Amiodarone policy
(Figure 10)
(Gunderson 25)
Sample Forms
Figure 10: Amiodarone Monitoring Policy
Does your clinic have protocols in place and standing
orders for Coumadin, Amiodarone, Insulin and
controlled substances (CS)? Are CS locked in a safe
place with a sign out procedure? How complete are
the protocols for hazardous drugs? Have you
compared them to guidelines? How well are the
protocols and standing orders followed in your
clinic?
Figure 18: Warfarin Therapy Protocol
Figure 19: Provider Letter: Controlled Medication
Figure 20: Exceptional Use Program
HealthPartners | Ambulatory Patient Safety Toolkit
11
Protocols for Use of Hazardous Drugs
Other Resources - Links
·
ICSI Guidelines: Antithrombotic Therapy
Supplement, Diabetes
·
AHRQ
·
AAEM Position
·
OSHA list of hazardous medications
·
MN Pharmacy Board: Prescription Monitoring
Program
·
Clinical Guidelines for Opioid
Therapyhttp://download.journals.elsevierhealth.c
om/pdfs/journals/15265900/PIIS1526590008008316.pdf
Works Cited
The Ambulatory Patient Safety Toolkit is the copyrighted work of
the Gunderson Lutheran Medical Center, developed for the
Safety Collaborative for Outpatient Environment (SCOPE)
Project, funded by the American Medical Group Association
(AMGA) in 2003. Portions of the Ambulatory Patient Safety
Toolkit are reproduced with permission of the Gunderson
Lutheran Medical Center and will be referenced whenever used
in this toolkit
HealthPartners | Ambulatory Patient Safety Toolkit
12
Medication Safety: Antibiotic
Prescribing
Identify the Safety Risk
Sample Forms
To reduce risk, monitor the overuse (multiple
dispensing) of antibiotics and/or inappropriate use
of antibiotics. Some potent antibiotics, while very
effective against certain types of infections, have a
high risk for toxicity. This risk is even greater with
patients who have impaired renal function.
Figure 21: Pearl of Knowledge: Acute Bronchitis
When using antibiotics that have a high risk of
toxicity, such as aminoglycosides and vancomycin,
use protocols or other standardized dosing
guidelines to assist prescribers in selecting
appropriate doses based on clinical condition and
renal function.
Ongoing provider monitoring completed by
Minnesota Community Measurement includes the
following measures:
Other Resources - Links
·
Appropriate Treatment for Children with Upper
Respiratory Infections
·
Appropriate Testing for Children with Pharyngitis
·
Avoidance of Antibiotic Treatment in Adults with
Acute Bronchitis
·
AHRQ Antibiotic Report
·
AAP Guidelines
·
Pediatric Abstract article
·
NY Dept of Health
·
ICSI Guideline Respiratory Illness
·
HealthPartners and Flu Shots
Performance information will provide meaningful
and useful information to clinicians for therapeutic
decision making and management.
Suggestions for Improvement
·
Develop a protocol to follow with antibiotic
prescriptions.
·
Review the Minnesota Community
Measurement provider monitoring for the
measures listed above.
·
Use existing guidelines and protocols with
appropriate criteria to meet before ordering an
antibiotic. If possible, implement these
guidelines into your EMR or patient work flow to
use when prescribing antibiotics.
·
Consider creating a tool with criteria to check for
quarterly chart audits on children and adults
who have received antibiotics. Review results
and try to identify if greater action is needed for
appropriate use of antibiotics.
HealthPartners | Ambulatory Patient Safety Toolkit
13
Medication Safety: Prescription
Refills
Identify the Safety Risk
All providers will have a process for prescription
refills to insure patients receive approvals in a timely
and safe manner. Providers should develop a
standing order policy and procedure regarding
frequent medication refills.
Research studies have proven the effectiveness of
automated or electronic prescription writing
programs to reduce errors in handwritten
prescriptions. Examples of electronic prescription
tools include palm pilots, intranet, electronic
formulary, or online drug information database. EPrescribing allows for clear, concise, and legible
instructions. HealthPartners encourages the
adoption of E-prescribing in all clinical settings.
Electronic prescribing can offer enhanced safety
features for patients. Prescriptions are legible, and
pharmacists can eliminate worries over
misunderstood phone messages for a prescription or
refill of a medication consisting of a sound alike
name.
Online prescription refills is another technology that
can reduce errors and improve prescription
processing efficiency. With online refills, patients can
submit their refill requests electronically.
Suggestions for Improvement
·
Convert your refill process into an e-prescribing
system.
·
Create or implement a protocol on prescription
refills for your clinic. This could be incorporated
into an electronic medical record or an on-line
refill system.
·
·
Integrate the clinic protocol parameters into the
assessment. Complete a random audit of 20
members with refills. Use the assessment sheet
to track audit results.
·
Form a work group to assess the audit data
(providers, nurses, medical assistants). Compare
data to the policy parameters. If parameters
were not met, evaluate if changes are needed in
the policy.
·
Review and analyze the other data results. Is
there an area where improvement is needed in
the refill process? If so, have the work group
develop an improvement initiative.
·
Once the initiative is implemented, evaluate
quarterly until improvement is seen, or until
other changes are made.
·
Continue to monitor for compliance with your
clinic’s prescription refill protocol on an ongoing
basis.
·
Consider implementing a refill reminder system
to increase compliance.
(Gunderson 34)
Sample Forms
Figure 22: Medication Refill (Behavioral Health)
Standing Order policy.
Figure 23: Medication Refill (Non-Behavioral Health)
Standing Order policy.
These policies are for reference only. Please review
and adapt to make your own policy.
Create an assessment sheet for auditing
purposes. The assessment could include how the
refill was provided, by what provider, who
picked up the order, what pharmacy refilled the
prescription, did the member need to be seen
prior to the refill, and, if so, was the member
seen?
HealthPartners | Ambulatory Patient Safety Toolkit
14
Prescription Refills
Other Resources - Links
·
AHRQ Article
·
e Health Initiative-Electronic Prescribing
·
NPSF Pharmacy Safety Consumer Fact Sheet
Works Cited
The Ambulatory Patient Safety Toolkit is the copyrighted work of
the Gunderson Lutheran Medical Center, developed for the
Safety Collaborative for Outpatient Environment (SCOPE)
Project, funded by the American Medical Group Association
(AMGA) in 2003. Portions of the Ambulatory Patient Safety
Toolkit are reproduced with permission of the Gunderson
Lutheran Medical Center and will be referenced whenever used
in this toolkit
HealthPartners | Ambulatory Patient Safety Toolkit
15
Medication Safety: Generic
Prescribing
Identify the Safety Risk
Generics are a safe, effective alternative to many
branded drugs. Generic drugs, because they have
been on the market for a long time, have well known
side effects and a longstanding record making them
a more reliable and safe choice compared to newly
introduced drugs.
Prescription drugs can be a costly medical expense,
especially for older people and those who are
chronically ill. However, each state has a law that
lets pharmacists substitute less expensive generic
drugs for many brand-name products. Generic drugs
are less expensive because generic manufacturers
don't have the investment costs that the developer
of a new drug has.
New drugs are developed under patent protection.
The patent protects the investment - including
research, development, marketing and promotion by giving the company the sole right to sell the drug
while it is in effect.
As patents near expiration, manufacturers can apply
to the FDA to sell generic versions. Because those
manufacturers don't have the same development
costs, they can sell their product at substantial
discounts. Also, once generic drugs are approved,
there is greater competition, which keeps the price
down.
Generic Drug Use in Primary Care and in Specialty
Care are Clinical Indicator measures. The rate
represents the percentage of all prescriptions filled
with generic drugs for HealthPartners members with
a drug benefit. For prescriptions filled the first half of
2011, the generic drug use rate for primary care is
81.7 percent. The generic drug use rate for specialty
care ranged from 75.7 percent to 93.6 percent.
·
Identify patients and target to move them
toward generic conversion from the brand name
drug to the equivalent generic.
·
Perform an audit to identify patients who are on
the drugs and run a cost summary of the past
year. The summary should include cost of the
drug and cost to the patient.
·
Create a generic education sheet and describe
the medication conversion you are focusing on.
·
Identify 20 patients and flag their medical record
to focus on conversion to a generic equivalent
on their next office visit.
·
Make a follow-up phone call to the patient three
to five days after the prescription was written
for conversion.
·
Submit a questionnaire to check on satisfaction
and send to patients two months after
conversion. Review the satisfaction outcomes
and determine if you can broaden the
conversion program.
·
Re-run the cost analysis data in three to six
months and again in one year and compare that
to the brand cost data.
Other Resources - Links
·
FDA Generics
·
HealthPartners.com/formulary
·
HealthPartners Clinical Indicators Report
Suggestions for Improvement
·
Create a generic drug protocol in your clinic.
·
Choose one common brand name drug to focus
on in your clinic.
HealthPartners | Ambulatory Patient Safety Toolkit
16
FIGURE 8
HealthPartners/GHI
Subject
Pharmaceutical Sampling
Key words
Drug samples, pharmaceutical sampling, drug dispensing, pharmacy
Category
Environment of Care, Work Service (EC)
Attachments
Yes
No
Number
GHI EC HPMG Ops 03
Effective Date
11/09
Manual HealthPartners Medical Group and Clinic Operations Manual
Last Review Date
11/09
Issued By
HPMG Pharmacy Committee; HPMG Medical Council
Next Review Date
11/12
Applicable
HPMG and clinic staff
Origination Date
11/90
Retired Date
Review Responsibility
HPMG Pharmacy Committee; HPMG Medical Council and clinic operations
Contact
Dir. of Pharmacy
I.
PURPOSE
To ensure patient safety as it relates to drug samples.
II.
POLICY
Individual clinics or care units wishing to continue or initiate storage and distribution of free drug samples
must apply to the HPMG Pharmacy Committee for pharmaceutical sampling privileges.
Clinics must provide a detailed written plan on how they will comply with outlined procedures.
Applications will be reviewed and approved or denied by the Pharmacy Committee. The Chief of
Professional Services or Department Head will be responsible for the implementation and compliance of
the Pharmaceutical Sampling Policy for his/her clinic and/or department.
III.
PROCEDURE(S)
Proposal Guidelines:
1. Identify the requesting physician and chief or department head (approving MD).
2. Identify the designated coordinator (oversight for daily operations).
3. Identify the clinic location and specific sample location within the clinic.
4. Describe the purpose for providing pharmaceutical samples.
5. Describe how the proposed sampling practice will meet with the following principles for drug
dispensing/distribution:
 Safety—the use of pharmaceutical services/agents within our systems will not pose a threat to
our patients/members.
 Effective—patients/members will receive the most appropriate pharmaceutical interventions,
avoiding underuse and overuse.
 Equitable—pharmaceutical services/agents will be consistent and fair to all patients/member.
Individual personal characteristics will only guide pursuit of optimal outcomes.
 Patient Centered—pharmaceutical services/agents will be respectful of individual
patient/member needs, preferences and values.
 Timely—the delivery of pharmaceutical services/agents will eliminate unnecessary waits and
@[email protected]
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FIGURE 8
harmful delays to both patients/members and providers.
Efficiency—pharmaceutical services/agents will be guided by wise stewardship of resources,
avoiding waste and inefficiencies.
Develop written proposed procedures that are consistent with JCAHO Requirements on Sampling
(see below) and includes these at a minimum:
 A list of proposed sample medications.
 Identify responsible individual “designated coordinator” that will meet with Pharmaceutical
representatives, maintain sample inventory, and implement policy.
 Provide approach of how to ensure proper storage and disposal of samples, secure locked
storage, limited accessibility, and method to dispose of outdated, damaged, recalled drugs.
Note: All out dated or discontinued samples are considered hazardous waste and must be
placed in the black hazardous waste container in the clinic.
 Provide procedure for proper dispensing of drugs, including clarification on who will dispense,
labeling of samples, written patient information, documentation in patient’s medical record.
 Provide approach to assure quality control of pharmaceuticals, including process to manage
drug recalls, process to check for expired drugs, and process for self-audit. Process for
documenting lot number and expiration dates will be in a log book.
 Specify exact location (s) where samples will be stored.
 Designate person in clinic responsible to assure overall compliance with sample program
within this clinic.
 Outline communication plan to notify all staff of sample procedures and expectations.
Forward all applications to the Chair of the HPMG Pharmacy Committee.
Any additions/deletions/changes to the Sample Plan and the list of drugs must be provided to the
Pharmacy Committee quarterly.
Application renewal must be requested annually.

6.
7.
8.
9.
JCAHO DRUG SAMPLES REFERENCE
There is a system for the control, accountability, and security of all drug samples throughout the
organization. This process should adhere to FDA and other laws and regulations regarding
distribution of drug samples, and should be consistent with other organization policies and
procedures for medication use.
The drug samples are properly stored. Storage of drug samples are under proper conditions of
sanitation, temperature, light, moisture, ventilation, segregation, and safety according to
manufacturer’s specifications and law and regulation (e.g. USP and OSHA requirements). Products
that require refrigeration should be refrigerated. Stored drug samples should be organized to allow
for easy retrieval yet segregated to prevent medication errors. All samples of the same drug should
be stored together in the same sample storage area, although multiple storage areas for samples are
allowed.
Although not required, it is recommended that samples be stored by therapeutic class rather
than alphabetically, since the chances of a serious dispensing error are less likely. In any
case, throwing all samples of various types into a drawer is not acceptable. Also, OSHA
requires that cytotoxic agents (e.g. cancer chemotherapy, gancyclovir, etc) be stored separately from
non-cytotoxic drugs with special labeling of the storage area.
Drug sample storage areas are routinely inspected. This inspection checks for expired and
deteriorated sample medications; samples stored in the wrong place; drugs which can no longer be
identified for name, strength, and expiration dates; and other medications that do not belong there.
Drug samples for prescription or legend drugs are secure. Drug samples should be kept in an
area where unauthorized access is not allowed or which is under constant supervision or surveillance
(e.g. behind the receptionist, in a rocked room, in the physician’s private office etc.). If in areas not
under constant surveillance by staff, and where visitors and patients are allowed (e.g. patient
examination rooms) the drug samples must be locked in a drawer or cabinet.
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FIGURE 8
Drug samples for prescription drugs are labeled and dispensed according to the same
standardized method that the organization uses for non-sample prescription medications.
The organization’s policies and procedures for dispensing medications to ambulatory patients should
be followed. If the same system is not used, the same objectives and outcomes should be achieved.
Handwritten and fill-in preprinted prescription labels are acceptable. If the organization normally
provides written patient information with dispensed medications, the same should occur for samples.
Documentation requirements for sample drugs should be the same as other non-sample
medications ordered and dispensed by the clinic or organization. At a minimum, all
documentation requirements for prescription drugs in the medical record (e.g. inclusion on the
summary list, progress notes, etc.) should be followed. There is no requirement to conduct a
perpetual documented inventory of non-controlled substance sample medications, unless such a
process is desired or required by organization policy and procedure.
There must be an effective recall mechanism for drug samples. There is no requirement to have
a log of all dispensed sample medications and lot numbers, unless such a process is desired or
required by organization policy and procedure (including pharmacy procedures for outpatient
prescriptions). As long as all recalled medications can be quickly retrieved from patients and
removed from stock, the process is acceptable. Thus, reviewing each patient’s chart to determine
who received the drug under recall, and calling all patients to remove the drug (irrespective of lot
number) or verifying with the patient the lot number on the package at the time of calling the patient,
is an acceptable method. Many organizations, however, do not want to alarm patients who did not
receive the affected lot of drugs, and thus maintain a log of dispensed medications by lot number or
document that lot number in the medical record. That way, only patients who received the affected
lot of the recalled drug are contacted. However, this is not a JCAHO requirement.
IV.
DEFINITIONS n/a
V.
COMPLIANCE
Failure to comply with this policy or the procedures may result in disciplinary action, up to and
including termination.
VI.
ATTACHMENTS n/a
VII.
OTHER RESOURCES
Internal HealthPartners Safety Toolkit at Healthpartners.com/quality
Other
VIII.
JCAHO Standard, TX.3.17
APPROVAL(S)
Nancy McClure
Senior VP, HPMG and Clinics
IX.
ENDORSEMENT
@[email protected]
Brian Rank, MD
Medical Director, HMPG and Clinics
n/a
3 of 3
FIGURE 9
Improving Quality of Care: Annual Monitoring
for Persistent Medications
The Opportunity:
•
•
•
Patient safety is highly important, especially for patients at increased risk of adverse drug
events from long-term medication use.
Appropriate monitoring of drug therapy remains a significant issue to guide therapeutic
decision making and provides largely unmet opportunities for improvement in care for
patients on persistent medications.
Persistent use of these drugs warrants monitoring and follow-up by the prescribing
physician to assess for side-effects and adjust drug dosage/therapeutic decisions
accordingly. The drugs included in this measure also have more deleterious effects in the
elderly.
o Angiotensin Converting Enzyme (ACE) inhibitors
o Angiotensin Receptor Blockers (ARBs)
o Digoxin
o Diuretics
o Anticonvulsants (phenobarbital, carbamazepine, phenytoin, divalproex sodium and
valproic acid)
The Measure:
•
•
Annual monitoring for select therapeutic agents has been established as a quality
measure of the Healthcare Effectiveness and Information Set (HEDIS).
This measure assesses whether persistent users of medications receive timely
monitoring to prevent potential harms associated with persistent use of these drugs:
o At least one serum potassium (K+) and either a serum creatinine (SCr) or a blood
urea nitrogen (BUN) for prescribed ACE inhibitors, ARBs, digoxin and diuretics.
o At least one drug concentration level monitoring test for prescribed
anticonvulstants (phenobarbital, carbamazepine, phenytoin, divalproex sodium
and valproic acid).
The Approach:
•
•
•
Provide comparative performance information on therapeutic monitoring for ACE/ARBs
and Diuretics for primary care and specialty providers.
Publish annual comparative performance information in Clinical Indicators Report.
Identify patients on CAD, Diabetes, Heart Failure and Hypertension registries that have
been prescribed ACE/ARBs or Diuretics and have not received annual monitoring.
Resources:
•
HealthPartners Ambulatory Patient Toolkit can be found at:
www.healthpartners.com/quality
Who to Contact:
For Clinical Questions: Terry Crowson, MD at 952-883-7109
For Measurement Questions: Rene’ Fisher at 952-883-5113
July 2008RULJLQDO
-DQXDU\UHYLVHG
Annual Monitoring for Patients on Persistent Medications - Angiotensin Converting Enzyme (ACE) and
Angiotensin Receptor Blockers (ARB)
FIGURE
Primary Care 2010
9
Description
The percentage of members 18 years and older who received at least a 180-day supply of
ambulatory medication therapy for ACE and/or ARB during the measurement year and had
at least one therapeutic monitoring event for the therapeutic agent in the measurement
year.
Performance
Measurement
Period
January 1, 2009 through December 31, 2009
Methodology
Administrative
Ages Included
18 and older
Products
All products
Continuous Enrollment
The measurement year
Sample Size
Full population
Attribution
The medical group of the prescribing provider’s primary location of the most recent script
that qualified the member for the denominator. Includes only scripts written by providers
with the reported specialty.
Sample Method
NA
Frequency
Annually
Reported
Provider eligibility is based on a minimum of 30 unique members for the measurement
year. All provider groups are included in the overall rate calculation.
Measures
Annual Monitoring Rate
Denominator
Members 18 and older as of December 31st of the measurement year on persistent
medications – defined as members who received at least a 180 days’ supply of ambulatory
medication in the measurement year (NCQA's web site at www.ncqa.org provides a list of
NDC codes for ACE/ARBS).
To determine continuity of treatment during the 365 day period, sum the number of
treatment days (days supply from all the scripts filled during the year) for a total of 180
days.
NOTE: Members may switch therapy between ACE and ARB during the measurement year
and have the days supply for those medications count toward the total 180 days supply
(i.e. a member who received 90 days of ACE inhibitors and 90 days of ARB’s meets the
denominator definition.)
Numerator
Number of members with at least one serum potassium (cpt 80047, 80048, 80050, 80051,
80053, 80069, 84132) and either a serum creatinine (cpt 80047, 80048, 80050, 80053,
80069, 82565, 82575) or a blood urea nitrogen therapeutic monitoring test (cpt 80047,
80048, 80050, 80053, 80069, 84520, 84525) in the measurement year.
NOTE: The tests do not need to occur on the same service date, only within the
measurement year.
Rate Calculations
Number of members with the required therapeutic monitoring test / Total number of
members on persistent medications within each medical group.
HealthPartners Internal Technical Specification
Primary Care
FIGURE 9
Annual Monitoring for Patients on Persistent Medications - Diuretics
Primary Care 2010
Description
The percentage of members 18 years and older who received at least a 180-day supply of
ambulatory medication therapy for diuretics during the measurement year and had at least
one therapeutic monitoring event for the therapeutic agent in the measurement year.
Performance
Measurement
Period
January 1, 2009 through December 31, 2009
Methodology
Administrative
Ages Included
18 and older
Products
All Products
Continuous Enrollment
The measurement year
Sample Size
Full population
Attribution
The medical group of the prescribing provider’s primary location of the most recent script
that qualified the member for the denominator. Includes only scripts written by providers
with the reported specialty.
Sample Method
NA
Frequency
Annually
Reported
Provider eligibility is based on a minimum of 30 unique members for the measurement
year. All provider groups are included in the overall rate calculation.
Measures
Annual Monitoring Rate
Denominator
Members 18 and older as of December 31st of the measurement year on persistent
medications – defined as members who received at least a 180 days supply of ambulatory
medication in the measurement year (NCQA's web site at www.ncqa.org provides a list of
NDC codes for Diuretics).
To determine continuity of treatment during the 365 day period, sum the number of
treatment days (days’ supply from all the scripts filled during the year) for a total of 180
days.
Numerator
Number of members with at least one serum potassium (cpt 80047, 80048, 80050, 80051,
80053, 80069, 84132) and either a serum creatinine (cpt 80047, 80048, 80050, 80053,
80069, 82565, 82575) or a blood urea nitrogen therapeutic monitoring test (cpt 80047,
80048, 80050, 80053, 80069, 84520, 84525) in the measurement year.
NOTE: The tests do not need to occur on the same service date, only within the
measurement year.
Rate Calculations
Number of members with the required therapeutic monitoring test / Total number of
members on persistent medications within each medical group.
HealthPartners Internal Technical Specification
Primary Care
FIGURE 10
HealthPartners/GHI
Subject
Amiodarone (low-dose) Monitoring Policy
Key words Amiodarone, toxicity
Attachments
 Yes  No
Number
GHI - PC - HP
Nursing xx
Category
Provision of Care (PC)
Manual HP Nursing
Issued By HPMG Nursing Administration
Applicable Ambulatory clinic RN, LPN, CMA and RMA staff
Review Responsibility HPMG&C MTM Pharmacists, Nursing Practice Committee, HPMG
Cardiology
Effective Date
10/10
Last Review Date
10/10
Next Review Date
10/13
Origination Date
3/02
Retired Date
Contact Clinical
Pharmacy Program
Manager
I.
PURPOSE
To provide a uniform and consistent policy for monitoring patients on low-dose amiodarone.
Amiodarone is a medication typically used for the treatment of heart arrhythmias.
II.
POLICY
All HPMG patients on amiodarone should be monitored per this amiodarone policy (these are
minimum expectations). RNs can use the Medication Refill Standing Order to order monitoring lab
tests and procedures. If laboratory or other monitoring tests are abnormal, the RN will consult the
prescribing physician. The physician assumes responsibility for monitoring until the values are within
established parameters.
This policy focuses on monitoring low-dose amiodarone (< 400mg/ day) - additional monitoring may
be recommended during initiation and for higher doses of amiodarone.
Unless otherwise agreed upon, the prescribing physician is responsible for this monitoring. If other
arrangements are made for follow-up, this plan should be documented in the medical record.
III.
PROCEDURE(S)
Amiodarone toxicities that need monitoring are:
1. Pulmonary toxicity
 Pulmonary function tests should be completed at baseline, including diffusion capacity.
 Chest x-rays should be done at baseline and yearly.
 Patients should be referred to prescribing physician for additional testing if symptoms of
pulmonary toxicity occur (unexplained cough, dyspnea).
2. Liver toxicity
 AST (SGOT) or ALT (SGPT) should be monitored at baseline and every 6 months.
3. Thyroid abnormalities
 Thyroid function, using TSH and free T4, should be assessed at baseline, 3 months and every
6 months.
 Refer to the prescribing physician for more frequent monitoring if thyroid abnormalities are
amiodarone monitoring 10-10.doc
Page 1 of 3
FIGURE 10
suspected.
4. Ophthalmic side effects
 An ophthalmologic exam, including funduscopy and slit-lamp examination should be
completed at baseline.
 Refer to an ophthalmologist if the patient has with visual changes.
5. Cardiac effects
 EKGs should be done at baseline and yearly.
 Refer to the cardiologist if the patient has new-onset arrhythmias or bradycardia.
6. Renal function
 Serum creatinine, Bun and electrolytes (K, Mg, Na) should be done at baseline.
7. Interacting medications
 In the event of amiodarone dose changes, monitoring protocols should be followed for
interacting medications like warfarin (Coumadin) and digoxin. Referrals may be made to
anticoagulation nurse, cardiologist, or prescribing physician.
 Caution should also be used with simvastatin (increased risk of myopathy), sildenafil
(increased levels), cyclosporine (increased levels), antiarrhythmic medications (additive
effects), quinolones (increased risk of arrhythmias), antidepressants (increased risk of
arrhythmias), and grapefruit (inhibits conversion of amiodarone to the active metabolite).
IV.
DEFINITIONS
V.
COMPLIANCE
Failure to comply with this policy or the procedures may result in disciplinary action, up to and
including termination.
VI.
ATTACHMENTS Amiodarone Monitoring worksheet
VII.
OTHER RESOURCES
Internal – Medication Refill Standing Order
Other
VIII.
APPROVAL(S) Robert H. VanWhy, Sr. Vice President, Primary Care and Practice Development
IX.
ENDORSEMENT Nursing Practice Committee, HPMG Cardiology
amiodarone monitoring 10-10.doc
Page 2 of 3
Updated October 2010
Amiodarone Monitoring
FIGURE 10
Patient Name _____________________________
Primary MD ______________________________
Amiodarone start date ______________________
ID#: ____________________________________
Primary Clinic ____________________________
Coumadin Y/N ____________________________
DOB ____________________________________
Cardiologist ______________________________
Digoxin Y/N ______________________________
Patient Phone ____________________________
Cardiology Clinic Location ___________________
________________________________________
________________________________________
Open boxes are required monitoring, shaded boxes indicate routine monitoring is not required but can be completed if clinically indicated.
Initial
3 months
6 months
12 months
18 months
24 months
2 ½ years
3 years
Date
Followed by *
Symptoms **
TSH and T4(free)
AST (SGOT)
ALT (SGPT)
Chest x-rays
EKG
Eye exam ***
PFTS ****
Creatinine*****
BUN*****
K *****
Na *****
Mg *****
* Monitoring values are not needed if amiodarone monitoring is done by consultants outside of HPMG. This can be noted with a check mark or the name of the group assuming responsibility for monitoring.
** Patients should be asked about symptoms, both for efficacy and for side effects. Specific questions should address respiratory symptoms, vision problems, thyroid abnormalities, cardiac symptoms, and GI pain.
*** Patients should be evaluated for visual impairment/symptoms and considered for annual eye exams. No monitoring values are needed on this sheet.
**** Pulmonary function testing is recommended at baseline and for otherwise unexplained dyspnea, particularly in patient with underlying lung disease, and for abnormalities on chest x- rays.
***** Serum creatinine and electrolytes are recommended at baseline and as necessary.
Providers also need to be aware of multiple drug interactions, which include warfarin (Coumadin), and digoxin.
This policy focuses on monitoring low-dose amiodarone (<= 400mg/ day) - additional monitoring may be recommended during initiation and for higher doses of amiodarone.
amiodarone monitoring 10-10.doc
Page 3 of 3
FIGURE 11
Reproduced with permission of the Gunderson Lutheran Medical Center, LaCross, WI 2006
FIGURE 12
Clinic Pharmacy Prescriptions
Rx #s_____________________________ Dates of Rx’s__________________________
# of Rx’s written by prescriber ________________
Recommendations
(Number of compliance failures)
Totals
Use ball point pen-no felt tip
Medication name
Dose
Route of administration
Frequency of use
Purpose of medication
Signature and printed name of prescriber
Printed name is almost never present
DEA number on Controlled Substance Rx’s
Write out “unit” – no abbreviations
Write mg, mcg, ml, %, etc.
No drug name abbreviations
Avoid Latin abbreviations (QD, QID, PRN,
BID, TID, etc.)
Use metric measurements
Faxed Rx’s corrected before transmittal
Reproduced with permission of the Gunderson Lutheran Medical Center, LaCross, WI 2006
Institute for Safe Medication Practices
FIGURE 13
ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations
T
he abbreviations, symbols, and dose designations found in this table
have been reported to ISMP through the ISMP Medication
Error Reporting Program (MERP) as being frequently misinterpreted
and involved in harmful medication errors. They should NEVER be used
when communicating medical information. This includes internal
communications, telephone/verbal prescriptions, computer-generated
labels, labels for drug storage bins, medication administration records,
as well as pharmacy and prescriber computer order entry screens.
Abbreviations
µg
AD, AS, AU
OD, OS, OU
BT
cc
D/C
IJ
IN
HS
hs
IU**
o.d. or OD
OJ
Per os
q.d. or QD**
Injection
Intranasal
Half-strength
At bedtime, hours of sleep
International unit
Once daily
Orange juice
By mouth, orally
Every day
qhs
qn
q.o.d. or QOD**
Nightly at bedtime
Nightly or at bedtime
Every other day
q1d
q6PM, etc.
SC, SQ, sub q
Daily
Every evening at 6 PM
Subcutaneous
ss
SSRI
SSI
i/d
TIW or tiw
(also BIW or biw)
U or u**
UD
© ISMP 2010
Intended Meaning
Microgram
Right ear, left ear, each ear
Right eye, left eye, each eye
Bedtime
Cubic centimeters
Discharge or discontinue
Sliding scale (insulin) or ½
(apothecary)
Sliding scale regular insulin
The Joint Commission has established a National Patient Safety Goal
that specifies that certain abbreviations must appear on an accredited
organization's “do-not-use” list; we have highlighted these items with a
double asterisk (**). However, we hope that you will consider others
beyond the minimum Joint Commission requirements. By using and
promoting safe practices and by educating one another about hazards,
we can better protect our patients.
Misinterpretation
Mistaken as “mg”
Mistaken as OD, OS, OU (right eye, left eye, each eye)
Mistaken as AD, AS, AU (right ear, left ear, each ear)
Mistaken as “BID” (twice daily)
Mistaken as “u” (units)
Premature discontinuation of medications if D/C (intended to mean
“discharge”) has been misinterpreted as “discontinued” when followed
by a list of discharge medications
Mistaken as “IV” or “intrajugular”
Mistaken as “IM” or “IV”
Mistaken as bedtime
Mistaken as half-strength
Mistaken as IV (intravenous) or 10 (ten)
Mistaken as “right eye” (OD-oculus dexter), leading to oral liquid
medications administered in the eye
Mistaken as OD or OS (right or left eye); drugs meant to be diluted in
orange juice may be given in the eye
The “os” can be mistaken as “left eye” (OS-oculus sinister)
Mistaken as q.i.d., especially if the period after the “q” or the tail of
the “q” is misunderstood as an “i”
Mistaken as “qhr” or every hour
Mistaken as “qh” (every hour)
Mistaken as “q.d.” (daily) or “q.i.d. (four times daily) if the “o” is
poorly written
Mistaken as q.i.d. (four times daily)
Mistaken as every 6 hours
SC mistaken as SL (sublingual); SQ mistaken as “5 every;” the “q” in
“sub q” has been mistaken as “every” (e.g., a heparin dose ordered “sub
q 2 hours before surgery” misunderstood as every 2 hours before surgery)
Mistaken as “55”
Correction
Use “mcg”
Use “right ear,” “left ear,” or “each ear”
Use “right eye,” “left eye,” or “each eye”
Use “bedtime”
Use “mL”
Use “discharge” and “discontinue”
Use “injection”
Use “intranasal” or “NAS”
Use “half-strength” or “bedtime”
Use “units”
Use “daily”
Use "orange juice"
Use “PO,” “by mouth,” or “orally”
Use “daily”
Use “nightly”
Use “nightly” or “at bedtime”
Use “every other day”
Use “daily”
Use “daily at 6 PM” or “6 PM daily”
Use “subcut” or “subcutaneously”
Mistaken as selective-serotonin reuptake inhibitor
Spell out “sliding scale;” use “one-half” or
“½”
Spell out “sliding scale (insulin)”
Sliding scale insulin
One daily
TIW: 3 times a week
BIW: 2 times a week
Mistaken as Strong Solution of Iodine (Lugol's)
Mistaken as “tid”
TIW mistaken as “3 times a day” or “twice in a week”
BIW mistaken ad “2 times a day”
Use “1 daily”
Use “3 times weekly”
Use “2 times weekly”
Unit
Mistaken as the number 0 or 4, causing a 10-fold overdose or greater
(e.g., 4U seen as “40” or 4u seen as “44”); mistaken as “cc” so dose
given in volume instead of units (e.g., 4u seen as 4cc)
Use “unit”
As directed (“ut dictum”)
Mistaken as unit dose (e.g., diltiazem 125 mg IV infusion “UD” misinterpreted as meaning to give the entire infusion as a unit [bolus] dose)
Use “as directed”
Dose Designations
Intended Meaning
and Other Information
Trailing zero after
1 mg
decimal point
(e.g., 1.0 mg)**
No leading zero before 0.5 mg
a decimal point
(e.g., .5 mg)**
Misinterpretation
Correction
Mistaken as 10 mg if the decimal point is not seen
Do not use trailing zeros for doses
expressed in whole numbers
Mistaken as 5 mg if the decimal point is not seen
Use zero before a decimal point when the
dose is less than a whole unit
Institute for Safe Medication Practices
FIGURE 13
ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations
Dose Designations
and Other Information
Drug name and dose run
together (especially
problematic for drug
names that end in “l”
such as Inderal40 mg;
Tegretol300 mg)
Numerical dose and unit
of measure run together
(e.g., 10mg, 100mL)
Tegretol 300 mg
Mistaken as Tegretol 1300 mg
10 mg
The “m” is sometimes mistaken as a zero or two zeros, risking a
10- to 100-fold overdose
Place adequate space between the dose and
unit of measure
The period is unnecessary and could be mistaken as the number
1 if written poorly
Use mg, mL, etc. without a terminal period
100000 has been mistaken as 10,000 or 1,000,000; 1000000 has
been mistaken as 100,000
Use commas for dosing units at or above
1,000, or use words such as 100 "thousand"
or 1 "million" to improve readability
Intended Meaning
vidarabine
zidovudine (Retrovir)
Compazine (prochlorperazine)
Demerol-Phenergan-Thorazine
Diluted tincture of opium, or
deodorized tincture of opium
(Paregoric)
hydrochloric acid or
hydrochloride
hydrocortisone
hydrochlorothiazide
magnesium sulfate
morphine sulfate
methotrexate
procainamide
propylthiouracil
Tylenol with codeine No. 3
triamcinolone
TNKase
zinc sulfate
Intended Meaning
nitroglycerin infusion
norfloxacin
intravenous vancomycin
Intended Meaning
Dram
Misinterpretation
Mistaken as cytarabine (ARA C)
Mistaken as azathioprine or aztreonam
Mistaken as chlorpromazine
Mistaken as diphtheria-pertussis-tetanus (vaccine)
Mistaken as tincture of opium
Correction
Use complete drug name
Use complete drug name
Use complete drug name
Use complete drug name
Use complete drug name
Mistaken as potassium chloride
(The “H” is misinterpreted as “K”)
Mistaken as hydrochlorothiazide
Mistaken as hydrocortisone (seen as HCT250 mg)
Mistaken as morphine sulfate
Mistaken as magnesium sulfate
Mistaken as mitoxantrone
Mistaken as patient controlled analgesia
Mistaken as mercaptopurine
Mistaken as liothyronine
Mistaken as tetracaine, Adrenalin, cocaine
Mistaken as “TPA”
Mistaken as morphine sulfate
Misinterpretation
Mistaken as sodium nitroprusside infusion
Mistaken as Norflex
Mistaken as Invanz
Misinterpretation
Symbol for dram mistaken as “3”
Use complete drug name unless expressed
as a salt of a drug
Use complete drug name
Use complete drug name
Use complete drug name
Use complete drug name
Use complete drug name
Use complete drug name
Use complete drug name
Use complete drug name
Use complete drug name
Use complete drug name
Use complete drug name
Correction
Use complete drug name
Use complete drug name
Use complete drug name
Correction
Use the metric system
Minim
For three days
Greater than and less than
Symbol for minim mistaken as “mL”
Mistaken as “3 doses”
Mistaken as opposite of intended; mistakenly use incorrect
symbol; “< 10” mistaken as “40”
Mistaken as the number 1 (e.g., “25 units/10 units” misread as
“25 units and 110” units)
Mistaken as “2”
Mistaken as “2”
Mistaken as “4”
Mistaken as a zero (e.g., q2° seen as q 20)
Mistaken as the numerals 4, 6, or 9
100,000 units
/ (slash mark)
@
&
+
°
Place adequate space between the drug
name, dose, and unit of measure
100 mL
Large doses without
properly placed commas
(e.g., 100000 units;
1000000 units)
Drug Name Abbreviations
ARA A
AZT
CPZ
DPT
DTO
x3d
> and <
Correction
Mistaken as Inderal 140 mg
mg
HCT
HCTZ
MgSO4**
MS, MSO4**
MTX
PCA
PTU
T3
TAC
TNK
ZnSO4
Stemmed Drug Names
“Nitro” drip
“Norflox”
“IV Vanc”
Symbols
Misinterpretation
Inderal 40 mg
Abbreviations such as mg.
or mL. with a period
following the abbreviation
HCl
© ISMP 2010
Intended Meaning
(continued)
mL
1,000,000 units
Separates two doses or
indicates “per”
At
And
Plus or and
Hour
zero, null sign
**These abbreviations are included on The Joint Commission’s “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on an
organization’s “Do Not Use” list, effective January 1, 2004. Visit www.jcaho.org for more information about this Joint Commission requirement.
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written
permission. Unless noted, reports were received through the ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the
MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E).
Use “for three days”
Use “greater than” or “less than”
Use “per” rather than a slash mark to
separate doses
Use “at”
Use “and”
Use “and”
Use “hr,” “h,” or “hour”
Use the number “0” or the word “zero”
Institute for Safe
Medication Practices
www.ismp.org
FIGURE 14
Reproduced with permission of the Gunderson Lutheran Medical Center, LaCross, WI 2006
My Medicine List
Fold this form and keep it with you
Name:
Date of Birth:
Allergic To: (Describe reaction)
Emergency Contact/Phone numbers:
Doctor(s):
Pharmacies, other sources:
Immunization Record (Record the date/year of last dose taken)
Pneumonia vaccine:
Tetanus:
Flu vaccine(s):
Hepatitis vaccine:
Other:
List all medicines you are currently taking. Include prescriptions (examples: pills, inhalers, creams, shots), over-the-counter medications
(examples: aspirin, antacids) and herbals (examples: ginseng, gingko). Include medications taken as needed (example: nitroglycerin, inhalers).
START
DATE
NAME OF
MEDICATION
DOSE
DIRECTIONS
(How do you take it? When? How often?)
DATE
STOPPED
NOTES
(Reason for taking?)
FIGURE 15
www.mnpatientsafety.org
Page ______ of ______
Directions for My Medicine List
How does this form help you?
1. ALWAYS KEEP THIS FORM WITH YOU. You may want
to fold it and keep it in your wallet along with your driver’s
license. Then it will be available in case of an emergency.
•
This form helps you and your family members remember all of
the medicines you are taking.
•
It provides your doctors and other providers with a current list of
ALL of your medicines. They need to know the herbals,
vitamins, and over-the-counter medicines you take!
•
With this information, doctors and other providers can prevent
potential health problems, triggered by how different medicines
interact.
2. Write down all of the medicines you are taking and list all of
your allergies. Add information on medicines taken in
clinics, hospitals and other health care settings — as well as
at home.
3. Take this form with you on all visits to your doctor, clinic,
pharmacy and hospital.
4. WRITE DOWN ALL CHANGES MADE TO YOUR
MEDICINES on this form. When you stop taking a certain
medicine, write the date it was stopped. If help is needed, ask
your doctor, nurse, pharmacist, or family member to help you
keep it up-to-date.
For copies of the My Medicine List and
a brochure with more tips, visit the Minnesota
Alliance for Patient Safety’s Web site at
www.mnpatientsafety.org or call (651) 641-1121.
5. In the “Notes” column, write down why you are taking the
medicine (Examples: high blood pressure, high blood sugar,
high cholesterol).
6. When you are discharged from the hospital, someone will
talk with you about which medicines to take and which
medicines to stop taking. Since many changes are often made
after a hospital stay, a new list may be filled out. When you
return to your doctor, take your list with you. This will keep
everyone up-to-date on your medicines.
FIGURE 15
(1/06)
FIGURE 16
SAMPLE POLICY
.
Policy for Pill Box Distribution
Purpose: Increase compliance with prescribed therapeutic regime and reduce the potential for
medication errors by distribution of medication boxes to those patients determine to be high risk.
Definition: A person considered being high risk if two or more of the following conditions are
identified or present:
•
Greater than 5 prescriptions.
•
Greater than 12 doses of medications per day.
•
Four or more medication changes in the past 12 months.
•
More than 3 concurrent disease states.
•
On a medication that requires therapeutic monitoring (narrow therapeutic index).
•
History of non-compliance.
Policy:
After evaluation by a physician, pharmacist, or nurse, those patients meeting the above criteria of
high risk will be offered a medication box to aid in the correct administration of their medications.
Education of the proper use of the medication box will be provided for the patient/surrogate/or
designated person by the physician, pharmacy, or nurse.
The person providing the medication box should note this either in the discharge note or on the
patient profile at the pharmacy.
The patient or the patients surrogate will need to designate the person responsible for filling and
monitoring the medication boxes.
It is the patient or the patients’ surrogate responsibility to monitor the status of medication refills
and notify the patient’s attending physician when refills are needed
Reproduced with permission of the Gunderson Lutheran Medical Center, LaCross, WI 2006
FIGURE 17
Medication Reconciliation
Medication reconciliation is the process of comparing a patient's medication
orders to all of the medications that the patient has been taking. This
reconciliation is done to avoid medication errors such as omissions, duplications,
dosing errors, or drug interactions. It should be done at every transition of care in
which new medications are ordered or existing orders are rewritten.
Hospital discharge is a critical transition point for all patients. High-risk patients
with multiple medical issues and elderly patients are especially vulnerable to the
consequences of ineffective discharge handoffs that leave the individual without
clear understanding of discharge instructions that likely includes changes or
additions to their pre-hospital medication list.
HEDIS Measure:
HEDIS instituted a new measure in 2009 (2008 data year) regarding “Medication
Reconciliation Post-Discharge”. This measure continues as one of a select
number of measures addressing the special needs of Medicare members
enrolled in Special Needs Plans (SNPs). The specification from CMS requires
that medication reconciliation occur within 30 days post-discharge from an
inpatient facility. Even though this measure has a restricted population, the
standard of care should apply to any member with complex medical care needs
on multiple medications.
HealthPartners Quality Improvement:
HealthPartners, Inc., as part of their 2009 and 2010 Medical Record
Documentation review, assessed the occurrence of medication reconciliation
using the HEDIS specifications for a sample of Medicare members at multiple
clinics that serve our members. Results showed that an average of 85 – 90% of
the charts reviewed indicated post-discharge medication reconciliation was
completed within 30 days post discharge.
In 2011, HealthPartners entered a collaborative arrangement with other major
health plans on a Performance Improvement Project (PIP) for our seniors. Each
health plan will partner with a hospital and provider group to increase the number
of members who are discharged from hospital to home that have a follow-up visit
with their Primary Care Provider (PCP) within 15 days after discharge. The
purpose of this visit is to promote a safe recovery and prevent rehospitalization. .
An extremely important component of that is the inclusion of a thorough
medication review and reconciliation.
Sheila Dalen, Quality Consultant
Quality Measurement & Improvement
02/02/11
FIGURE 18
SUBJECT:
WARFARIN THERAPY DOSE PROTOCOL FOR MAINTENANCE
EFFECTIVE DATE:
APPROVED BY:
3/10
Beth Averbeck, MD Associate Medical Director, Primary Care
Randy Hurley, MD Department Head, Hematology/Oncology
Colleen Morton, MD Hematology/Oncology
William Nelson, MD Department Head, Cardiology
Doug Olson, MD Assistant Medical Director Pathology and Lab
Rae Ann Williams, MD Department Head, Internal Medicine
Art Wineman, MD Department Head, Family Medicine
CONTACT:
SUPERSEDES:
Beth Averbeck, MD Associate Medical Director, Primary Care
John Butler, MD Internal Medicine
Jo McLaughlin, RN Director, Nursing and Nutrition Services
Colleen Morton, MD Hematology/Oncology
3/09
REVIEW DATE:
3/11
PURPOSE
To provide a population based standing order for Registered Nurses to manage anti-coagulation maintenance
therapy for established and stable patients who are on an anti-coagulation medication (Coumadin).
POLICY
To provide in a safe, efficient manner, guidelines for the RN to manage patients’ dose therapy for their anticoagulation medication. The patient must be established and stable, meaning he/she must have been on anticoagulation therapy for at least one month and have at least three (3) INR readings within their ordered
range. All patients should read and sign the Anticoagulant Medications health information sheet (H Ed
master 120037). The nurse will review this information with patients with emphasis on patient
responsibility, i.e. obtaining INRs as directed and contacting clinic or CareLine if a nurse doesn’t call with
results within 36-48 hours.
The standing order may be used for clinic visits or telephone encounters. The RN may adjust the patient’s
anti-coagulation medication based on a complete and clear standing order originated by a HPMG provider
annually and per the following procedure. The RN will use the Epic anticoagulation careplan and
SmartForm for documentation.
@BCL@741789C8
Page 1 of 16
FIGURE 18
Approval for use as a Population Based Standing Order:
Beth Averbeck, MD
Date
Randy Hurley, MD
Date
Colleen Morton, MD
Date
William Nelson, MD
Date
Doug Olson, MD
Date
Rae Ann Williams, MD
Date
Art Wineman, MD
Date
@BCL@741789C8
Page 2 of 16
FIGURE 18
Anti-Coagulation Dose Protocol for Maintenance Therapy
High Range
2.5-3.5
INR Result
Low Range
2.0-3.0
INR Result
Other Range
First Action
Weekly Dose Change
Follow-up After Dose Change
<1.6 Alert ♦
<1.3 Alert ♦
Range minus 0.9
Notify physician; consider risk
factors in determining action. 
Per Physician
Repeat INR in 3-5 days depending
upon patient risk.
1.6-2.0 ♦
1.3-1.5 ♦
Range minus
0.8-0.5
Consider Risk factors and Patient
INR stability in determining
action. 
Increase dose after first low reading or
recheck in 3-7 days
and then increase if still low.
Repeat INR in 3-7 days depending
upon patient risk.
INR Result
Change dose according to large
increase column or by 7-14%.
2.1-2.4
1.6-1.9
Range minus
0.4-0.1
2.5-3.5
2.0-3.0
Ordered range
3.6-4.5
3.1-4.0
Range plus
0.1-1.1
4.6-5.0
4.1-5.0
Range plus
1.1-2.0
>5.0
Critical ●
>5.0
Critical ●
Range plus 2.1
Or > 5.0
If previous INR in range, repeat
INR in 5-14 days depending on
pt. risk factors & INR stability
before changing dose
Target Range
If 2 consecutive low results, change
dose according to small increase
column or by 3 ½ -7 %.
If previous INR in range, repeat
INR in 5-14 days depending on
pt. risk factors & INR stability
before changing dose
Hold scheduled dose for one day.
If 2 consecutive high results, change
dose according to small decrease
column or by 3 ½ -7%.
Notify Physician. Hold
scheduled dose for 2 days.
Consider risk factors in
determining action. ●
Per physician
No Change
Change dose according to large
decrease column or by 7-14%.
Repeat INR in 5-9 days or up to 14
days for established pts. at low risk
who have had stable INRs in the past
(see low risk definition)
Repeat INR in 4-6 weeks
Repeat INR in 5-9 days or up to 14
days for established pts. at low risk
who have had stable INRs in the past
(see low risk definition)
Repeat INR in 5-9 days
Repeat INR in
1-5 days
♦
Patients with mechanical prosthetic heart valves who require an INR range of 2.5-3.5 should be placed on enoxaparin (Lovenox) if their INR is <2.

High Risk patients may require heparin or enoxaparin therapy while INR is subtherapeutic or warfarin is held for surgery.
●
Risk factors for major hemorrhage include: history of GI bleed or any other major bleed, hypertension, stroke, renal disease, age>75, ASA, or NSAIDS.

Low risk is defined as those patients with no recent venous thromboembolism (>3 months from the event), atrial fibrillation without history of stroke or other risk factors and bileaflet mechanical
cardiac valve in aortic position (ACCP guidelines: Chest vol. 126, number 3 supplement, September, 2004)
Depending upon risk, low dose Vitamin K may be indicated in non-urgent situations (RN consults with provider, provider orders Vitamin K therapy):
INR 5-9
0, 1mg, or 2.5mg by mouth, depending on risk of bleeding. Since the tablet is only available as 5mg, these lower doses are most easily given using the injectable form
diluted in a glass of water. Nursing will stock vitamin K vials (Lawson # 801861).
INR >9
5-10 mg by mouth, consider fresh frozen plasma
Serious bleeding at any elevation of INR
10 mg slow IV infusion and fresh frozen plasma, consider adding recombinant Factor VII for life-threatening bleed
RNs may adjust a patient dose up to 7% per week (one daily dose per week) based upon patient history and nursing assessment and then recheck INR within 5-9 days.
@BCL@741789C8
Page 3 of 16
FIGURE 18
The following guidelines may be useful in Anti-Coagulation dosing
flexibility:
 Expect a 15% dose adjustment to result in an approximately 1.0 INR
change.
 A 10% dose adjustment will result in an approximate 0.7-0.8 INR change.
 Steady state INR values will not be realized for up to 3 weeks following a
dose adjustment.
 Patients with INR values by +/- 0.5% INR out of range should be
considered for more frequent monitoring and should have a repeat INR
within 7 days.
 The dose response relationship is best interpreted when at least 16 hours
elapse between dose and lab draw.
 Any drug has the potential to interact with warfarin; in such circumstances
close INR monitoring is required during initiation and discontinuation of
the interacting agents. Refer to drug/food interactions tables for selected
interactions.
@BCL@741789C8
Page 4 of 16
FIGURE 18
Procedure for Reporting Low INR Results
PURPOSE
To provide a process for reporting low INR results when the clinic is closed
 1.6 or below OR
 2.0 or below for patients with a mechanical mitral valve as described in the policy.
POLICY
INR values of less than 1.6 OR less than 2.0 for patients with mechanical mitral valves are considered on Alert
status and should be reviewed for possible adjustments in dosing decisions.
 All patients with mechanical heart valves who need an INR range of 2.5-3.5 are high risk patients and need
low molecular weight heparin (Lovenox) if their INR is less than 2. This includes mitral valve and any aortic
valve patients with additional risk factors. They should be seen emergently at Urgent Care or the ER and
covered with low molecular weight heparin until their INR is raised to at least 2.5 or greater. These patients
require an expeditious evaluation as to the origin of the declining INR and the INR needs to be rapidly
corrected with close follow-up and monitoring.
 Patients with mechanical heart valves who need an IRN range of 2-3 are those with aortic valves, without
additional risks; do not need low molecular weight heparin (Lovenox) with a low INR. An aggressive plan to
raise their INR to an accepted normal range needs to be expeditiously pursued.
PROCEDURE
(For clinics that are evaluating INRs at the Point of Care, low INRs will be evaluated and adjusted at
that time.)
Action:
1. Ask patients, whenever possible, to have their INRs drawn before 1 p.m., Monday through Thursday. If an
INR needs to be drawn on Friday, request that the patient comes in on Friday morning to facilitate the
process of getting the INR result back to the clinic before the 5:00 closing time.
Rationale: Receiving INR results back during the regular clinic hours facilitates communication between
the nurse and physician regarding clinical decision making on anticoagulation dosing.
2. Monday-Thursday, INR results of less than 2.0 for patients with a mechanical heart valve that are not
reported to the clinic before closing, will be called to the CareLine by Central Lab for follow-up. No
action needs to be taken by Central Lab on INR results less than 2.0 for non-mechanical heart valve
patients.
Rationale: Mechanical aortic valve patients need emergent follow-up if their INR is less than 2.0. Dosing
decisions for other patients with INRs less than 2.0 can wait overnight.
3. On Fridays, or the day before a holiday, INR results of less than1.6 OR less than 2.0 for patients with
mechanical mitral valves, that are not reported to the clinic before closing, will be called to the CareLine
by Central Lab.
Rationale: Patients with mechanical heart valves, especially those with decreased LV systolic function
and/or atrial fibrillation are a higher risk when exposed to a subtherapeutic INR. Patients with a St. Jude,
bileaflet, aortic valve have a low risk for valve related thromboembolism. Notification of CareLine
facilitates follow-up for patient management.
4. If a clinic nurse is concerned about dosing for a patient with an unreported INR result at the end of the day,
the nurse will notify the CareLine that an INR result, for an at risk patient, has not come back and will
provide the CareLine nurse with careplan directions.
Rationale: Ensure continuity of care.
5. Document actions taken.
6. CareLine forwards a telephone encounter to the PCP’s clinic RN pool with the report of actions taken.
Rationale: Ensure appropriate clinic follow-up.
@BCL@741789C8
Page 5 of 16
FIGURE 18
Select Warfarin - Drug Interactions (not a complete list)
Drug
Interaction
Effect
Management
Comments
Acetaminophen (Tylenol)
Elevations in INR
have occurred within
1-2 weeks of
initiating
acetaminophen at
moderate to high
doses (2- 4 g/day
Consider early and frequent
monitoring of INR for several
weeks when acetaminophen is
added or discontinued.
Effect is likely related to dose and
length of treatment.
Amiodarone (Pacerone,
Cordarone)
INR increases by 22108%
Bleeding episodes 2
days to one month
after initiation
Monitor INR at least weekly1st month of combined
therapy. Drop warfarin dose
by 25% on start of
amiodarone. Daily warfarin
needs usually drop by 2550%.
Potentiation occurs from 4 days to 2
weeks. May persist up to 4 months
after amiodarone discontinued.
Carbamazepine (Tegretol,
Carbatrol)
Cimetidine (Tagamet)
Decrease in INR
Monitor INR more closely
Induces warfarin metabolism
Can increase INR
Dose dependents with at least 300800 mg/day
Ciprofloxacin (Cipro)
Levofloxacin (Levaquin)
Moxifloxacin (Avalex)
Clarithromycin (Biaxin)
Erythromycin (Erytab,
Erythrocin)
Increase INR in 2-16
days
Use alternative medication
[e.g. ranitidine (Zantac),
famotidine (Pepcid)]
Monitor INR more carefully
Increased INR seen
within 7 days
Monitor INR closely when
add or stop clarithromycin or
erythromycin
Clopidogrel (Plavix)
Increased risk of
bleeding
Inhibits platelet aggregation
Corticosteroids (prednisone,
methylprednisone, others)
May increase INR
Monitor INR more closely
during initiation or
discontinuation
Monitor INR more closely
during initiation or
discontinuation
Dronedarone (Multaq)
May increase INR
Limited data suggests up to 20%
increase in S-warfarin concentration.
Is structurally similar to amiodarone.
Duloxetine (Cymbalta)
Increase in INR
Fluconazole (Diflucan)
Itraconazole (Sporanox)
Ketoconazole (Nizoral)
Fluvoxamine (Luvox)
Slight to 2 fold
increase in INR
Monitor INR closely when
adding or stopping
dronedarone.
Monitor INR more closely
during initiation or
discontinuation of duloxetine
Monitor every 2 days when
add or stop fluconazole,
itraconazole, or ketoconazole
Levothyroxine (Levoxyl,
Synthroid)
Lovastatin (Mevacor)
Simvastatin (Zocor)
Metronidazole (Flagyl)
Increased risk of
bleeding
NSAIDs (Aspirin, Ibuprofen,
Naproxen, Diclofenac, Celebrex)
Increased risk of
bleeding
@BCL@741789C8
Can increased INR
May increase INR
Increase in INR
Monitor INR more closely
for1-2 weeks after
fluvoxamine is started.
Monitor closely when
add/change levothyroxine
dose
Monitor closely when add or
stop lovastatin or simvastatin
Monitor INR more carefully
when starting and stopping
metronidazole
Monitor INR closely when
add or stop NSAIDs
Unpredictable but can be clinically
significant, especially in the elderly
Onset of INR effect is variable and
may be anticipated 3-10 days after
initiating steroid
Increases metabolism of Vitamin Kdependent clotting factors
Lovastatin commonly associated
with hypoprothrombinemia
Inhibits platelet aggregation &gastric
erosion
Page 6 of 16
FIGURE 18
Drug
Interaction
Effect
Management
Comments
Nicotine
Decrease INR
Nicotine induces warfarin
metabolism
Omeprazole (Prilosec)
Paroxetine (Paxil)
Increase of INR after
a few days
Can increased INR
Monitor INR more closely
when stopping/starting
nicotine replacement therapy
or smoking more or less/day
Monitor INR closely when
add/change omeprazole dose
Monitor INR frequently when
paroxetine is added
Penicillin (Veetids)
Increased INR
Phenobarbital (Luminal)
Phenytoin (Dilantin)
Decrease in INR
Monitor INR more closely
when add or stop penicillin
Monitor INR more closely
Penicillin reduces GI synthesis of
vitamin K
Induces warfarin metabolism
Prasugrel (Effient)
Increased risk of
bleeding
Induces warfarin metabolism,
enhances metabolism of clotting
factors
Inhibits platelet aggregation
Rifampin (Rifadin)
Decrease INR within
2-4 days
Increase in INR
Monitor INR frequently for 1
month or more after
phenytoin added
Monitor INR more closely
during initiation or
discontinuation
Monitor INR closely for 1-2
weeks after rifampin is added.
Monitor INR more closely
when starting and stopping
Sulfamethoxazole
Monitor INR more closely
during initiation or
discontinuation
Sulfamethoxazole
Tamoxifen (Nolvadex)
@BCL@741789C8
Decrease in INR
Increase in INR. A
35-60% reduction of
warfarin dose may
be required.
Dose related
Induces warfarin metabolism
Use of sulfamethoxazole is not
recommended if acceptable
alternative exists.
Use is contraindicated with warfarin
therapy in high-risk women.
Page 7 of 16
FIGURE 18
Select Warfarin - Food/Dietary Supplement Interactions (not a complete list)
Drug
Alcohol
Interaction Effect
Management
Comments
Can increase or decrease INR
Caution pts to drink in moderation
and to avoid binge drinking; start at
lower doses in pt has liver damage
Dong quai
Can increase INR
Ginseng
Can increase INR
Co-Q10
Decrease INR
Cranberry Juice (100%)
Can increase INR
Garlic
Can increase INR
Glucosamine/chondroitin
Feverfew
Chondroitin may have
anticoagulant activity increasing
bleeding time and INR
Potential to increase INR due to
platelet aggregation inhibition
Potential to decrease in INR due to
Vitamin K content
Can increase INR
Monitor INR more closely when
add or stop. Advise pt to use
consistent dose if must use
Monitor INR more closely when
add or stop. Advise pt to use
consistent dose if must use
Monitor INR more closely when
adding or stopping. Advise patient
to use consistent dose if must use.
Monitor INR more closely, advise pt
to use consistent amount if drink
cranberry juice
Monitor INR more closely, advise pt
to use consistent dose if must use.
Monitor INR more closely when
adding or stopping. Advise patient
to use consistent dose if must use.
Monitor INR more closely, advise pt
to use consistent dose if must use
Acute use may inhibit
warfarin metabolism;
chronic use induces warfarin
metabolism; Cirrhosis is
associated with reduced
warfarin metabolism
Inhibits platelet activation
and aggregation.
Fish oil
Can increase INR
Flaxseed oil
Can increase INR
Gingko Biloba
Can increase INR
Omega 3
Can increase INR
Salvia Root (Danshen)
Can increase INR
St. John’s Wort
Can decrease INR
Vitamin K containing
foods in large amounts
(Leafy greens)
Decrease INR
Green Tea
@BCL@741789C8
Monitor INR more closely, advise pt
to use consistent dose if must use
Monitor INR more closely when
adding or stopping. Advise patient
to use consistent dose if must use.
Monitor INR more closely when
adding or stopping. Advise patient
to use consistent dose if must use.
Monitor INR more closely, advise pt
to use consistent dose
Monitor INR more closely when
adding or stopping. Advise patient
to use consistent dose if must use.
Monitor INR more closely, advise pt
to use consistent dose if must use
Monitor INR more closely, advise pt
to use consistent dose if must use.
Advise pt to keep diet steady.
Inform clinic of major dietary
changes.
Pts don’t always consider
dietary supplements
medications.
Inhibits platelet aggregation
Inhibits platelet aggregation
Contains small amount of
Vitamin K
Inhibits platelet aggregation
May decrease platelet
aggregation
May decrease platelet
aggregation
Inhibits platelet aggregation
May decrease platelet
aggregation
Inhibits platelet aggregation.
May contain coumarin
derivatives.
Induces metabolism of
warfarin
Consistency and moderation
is key.
Page 8 of 16
FIGURE 18
Anticoagulant Medications
What do anticoagulants do?
Anticoagulants are medications that help keep blood from clotting. Warfarin, Coumadin,
Jantoven and Lovenox are common anticoagulants. These medications were sometimes called
“blood thinners” in the past. However, they do not make blood “thinner.” They make the blood
less able to clot.
What are the possible side effects of anticoagulants?
 Bleeding
 Easy bruising
 Diarrhea and decreased appetite are
uncommon side effects of
Coumadin/warfarin
 Patients on Lovenox must watch for leg
or arm swelling that is new or gets
worse, chest pain, difficulty breathing or
skin breakdown at the site of injections.
If you have any of these, contact your
doctor immediately. These may be signs
of a serious reaction to Lovenox.
Why do I need to have my blood tested so much?
Your doctor will monitor your blood with a test called an INR. This test is done more often at
first. If possible, have the INR test done before1 p.m., Monday-Thursday (unless your doctor
gives you other instructions). This is so that you get the results in a timely manner. This test
helps your doctor decide how much anticoagulant you should take.
Your doctor may change your dose several times to find what is best for you. A nurse will call
you within a day of your test to let you know if you need to change your dose or not. If the nurse
does not call you within 36-48 hours of a test, call your clinic or the CareLine (612-339-3663) to
check on the results.
Once the dose you need is stable, most of the time you’ll be able to have the test done monthly. It
is very important that you take your anticoagulant medication the way your doctor tells you to.
It’s also important to get the recommended blood tests.
I agree to follow my doctor’s recommendation about when to have my blood test (INR) done.
_____________________________________
Patient signature
Continued
FIGURE 18
How do I take this drug?
Take the medication at the same time every day. It’s best to take it with your evening meal or at
bedtime. Take each dose with a full glass of water. Do not stop taking this medication unless
you are told to by your doctor.
What if I miss a dose?
Take it as soon as you remember. You can take your anticoagulant medication up to six hours
after the usual time of your dose. After that time, count it as a missed dose. Do not take two
doses at the same time. Write down the date of the missed dose and tell your doctor at your next
visit. Missing a dose may change your blood test result. If you miss doses on two or more days,
call your doctor right away.
When should I call my doctor?
Complications with medications are rare when you are closely monitored. Call your doctor right
away if you have any of the following:











Bleeding, including nosebleeds or
bleeding gums
Bleeding that does not stop after an
injury
Frequent bruises or bruises that keep
getting larger
Dark brown or red urine
Vomiting or spitting up blood or
brown material that looks like coffee
grounds
Bloody or black, sticky stool
Severe headache, stomach ache, back
or kidney pain
Swelling, redness, warmth, pain,
firmness or heaviness in an area
Pain in any part of your leg
Small red spots on your skin
Sudden anxiety or restlessness













Any changes in diet, activity level, how
much alcohol you use, medications
Cough or difficulty breathing
Fast heartbeat
Shortness of breath
Heavy sweating when at rest
Chest pain
Faintness, dizziness or increased
weakness
A serious fall or injury to the head
Fever or sickness that gets worse
Women: heavier-than-usual periods
Pregnancy or you plan to get pregnant
Something unusual happens that you
question
If you plan to travel
What you avoid when taking an anticoagulant
Anticoagulants interact with many other medications, vitamins, herbs and certain foods. If any
new drugs are prescribed for you, make sure your doctor, nurse and pharmacist know that you
take an anticoagulant.
Anticoagulants should not be taken during pregnancy. They may harm an unborn baby. Please
discuss plans for pregnancy with your doctor. Then, safer medications may be prescribed.
Continued
FIGURE 18
Aspirin and NSAIDs
Do not take aspirin or any nonsteroidal anti-inflammatory drugs (NSAIDs) until you have talked
to your doctor. (See list below.) These drugs can increase your risk of bleeding. If you need
something for pain, use acetaminophen (Tylenol® ). Do not take more than four extra-strength
Tylenol® in a day (2000 mg). If you are unsure of what to do for your pain, ask your pharmacist,
nurse or doctor.
Do not take the following drugs while you are on anticoagulant medications.
Generic Name
Acetylsalicylic Acid
Diclofenac
Etodolac
Flurbiprofen
Fenoprofen
Ibuprofen
Indomethacin
Ketoprofen
Ketorolac
Meclofenamate
Mefenamic acid
Naproxen
Oxaprozin
Piroxicam
Sulindac
Tolmetin
Brand Names
*Aspirin, Excedrin, Aspergum, Ecotrin, Bufferin, Ascriptin,
Empirin, Midol
Cataflam, Voltaren
Lodine
Ansaid
Nalfon
Motrin, Motrin IB, Haltran, Midol IB, Nuprin, Advil, Arthritis
Foundation
Indocin, Indocin SR, Indochron E-R
Orudis KT, Actron, Orudis, Oruvail
Toradol
Meclomen
Ponstel
Aleve, Anaprox, Naprosyn, Naprelan
Daypro
Feldene
Clinoril
Tolectin 200, Tolectin 600, Tolectin DS
*Many medications combine aspirin with another drug. Examples are: Percodan, Empirin with
codeine, Fiorinal, Robaxisal, Soma Compound and Ascriptin with codeine. Please ask your
pharmacist, doctor, or nurse if you have questions.
Other substances to avoid
Do not take any nonprescription drugs, herbal teas or vitamin supplements without talking to
your doctor.
Some herbs affect how anticoagulants work. Check with your doctor before using any of these
herbs: garlic, ginger, fenugreek, feverfew, ginkgo biloba, ginseng, horse chestnut, red clover, and
tonka beans.
Do not eat large amounts of food with Vitamin K. This can reduce the effect of the
anticoagulant. See the handout called “Guidelines for vitamin K intake for patients taking
anticoagulants.”
Avoid eating or drinking cranberry products.
Continued
FIGURE 18
What can I do to reduce the risk of bleeding when taking an anticoagulant?













Take your medications exactly the way your health care provider tells you, and at the same
time each day.
Keep follow-up appointments for blood tests to monitor clotting times.
Use a soft-bristle toothbrush and floss gently.
Use an electric razor instead of a blade.
Check regularly for bruises.
Avoid contact sports and heavy physical activity that could cause injury.
Tell other care providers about your blood thinner medication.
Check with your doctor before scheduling surgery or dental work.
Get a medical alert bracelet and carry a drug identification card if you will be on an
anticoagulant for a long time.
Check with your doctor before taking any other medications.
Avoid alcohol, food fads, crash diets, or changes in your eating habits.
Talk with your health care provider if you become pregnant or plan to become pregnant.
Anticoagulants cause birth defects. You must take precautions against pregnancy while
taking an anticoagulant.
© 2003-9 HealthPartners
3-09/7.1/#120037
FIGURE 18
WARFARIN 2 MG DAILY DOSE
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Total mg./wk
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
4
4
4
4
4
4
4
1
2
2
2
1
1
2
2
3
3
3
2
2
3
3
4
4
4
3
3
4
4
5
5
5
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
4
4
4
4
4
4
4
1
1
1
2
1
2
2
2
2
2
3
2
3
3
3
3
3
4
3
4
4
4
4
4
5
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
4
4
4
4
4
4
4
1
1
2
2
1
1
1
2
2
3
3
2
2
2
3
3
4
4
3
3
3
4
4
5
5
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
4
4
4
4
4
4
4
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
January 2000
@BCL@741789C8
Page 13 of 16
FIGURE 18
2 MG
DECREASE
LARGE
SMALL
DECREASE
DECREASE
TOTAL/MG/WK TOTAL MG/WK
7
8
9
10
11
12
12
13
14
15
16
17
18
18
19
20
21
22
23
23
24
25
26
7
8
9
10
11
12
13
14
15
15
16
17
18
19
20
21
22
23
24
25
25
26
27
28
WEEKLY DOSE
TOTAL
MG/WK
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
INCREASE
SMALL
LARGE
INCREASE
INCREASE
TOTAL/MG/WK TOTAL/MG/WK
8
9
10
11
12
13
14
15
17
18
19
20
21
22
23
24
25
26
27
29
30
31
9
10
11
12
13
14
16
17
18
19
20
22
23
24
25
26
28
29
30
31
January 2000
@BCL@741789C8
Page 14 of 16
FIGURE 18
WARFARIN 5 MG DAILY DOSE
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Total mg./wk
2.5
2.5
2.5
2.5
5
5
5
5
5
5
5
7.5
7.5
7.5
7.5
7.5
7.5
7.5
10
10
10
10
10
10
10
2.5
5
5
5
2.5
2.5
5
5
7.5
7.5
7.5
5
5
7.5
7.5
10
10
10
7.5
7.5
10
10
12.5
12.5
12.5
2.5
2.5
2.5
2.5
5
5
5
5
5
5
5
7.5
7.5
7.5
7.5
7.5
7.5
7.5
10
10
10
10
10
10
10
2.5
2.5
2.5
5
2.5
5
5
5
5
5
7.5
5
7.5
7.5
7.5
7.5
7.5
10
7.5
10
10
10
10
10
12.5
2.5
2.5
2.5
2.5
5
5
5
5
5
5
5
7.5
7.5
7.5
7.5
7.5
7.5
7.5
10
10
10
10
10
10
10
2.5
2.5
5
5
2.5
2.5
2.5
5
5
7.5
7.5
5
5
5
7.5
7.5
10
10
7.5
7.5
7.5
10
10
12.5
12.5
2.5
2.5
2.5
2.5
5
5
5
5
5
5
5
7.5
7.5
7.5
7.5
7.5
7.5
7.5
10
10
10
10
10
10
10
17.5
20
22.5
25
27.5
30
32.5
35
37.5
40
42.5
45
47.5
50
52.5
55
57.5
60
62.5
65
67.5
70
72.5
75
77.5
April 26, 2000
@BCL@741789C8
Page 15 of 16
FIGURE 18
5 MG
DECREASE
LARGE
SMALL
DECREASE
DECREASE
TOTAL/MG/WK TOTAL MG/WK
17.5
20
22.5
25
27.5
30
30
32.5
35
37.5
40
42.5
45
45
47.5
50
52.5
55
57.5
57.5
60
62.5
65
17.5
20
22.5
25
27.5
30
32.5
35
35
37.5
40
42.5
45
47.5
50
52.5
55
57.5
60
65
65
65
67.5
70
WEEKLY DOSE
TOTAL
MG/WK
17.5
20
22.5
25
27.5
30
32.5
35
37.5
40
42.5
45
47.5
50
52.5
55
57.5
60
62.5
65
67.5
70
72.5
75
77.5
INCREASE
SMALL
LARGE
INCREASE
INCREASE
TOTAL/MG/WK TOTAL/MG/WK
20
22.5
25
27.5
30
32.5
35
37.5
40
45
47.5
50
52.5
55
57.5
60
62.5
65
67.5
70
75
77.5
22.5
25
27.5
30
32.5
35
40
42.5
45
47.5
50
52.5
57.5
60
62.5
65
70
72.5
75
77.5
January 2000
@BCL@741789C8
Page 16 of 16
FIGURE 19
Date
Dr.«FirstName» «LastName»
«Addr1»
«Addr2»
«City», «State» «ZipCode»
Dear Dr.«Provider»:
In the last month, your patient has been identified through pharmacy claims as obtaining six
or more controlled substances, by at least three different prescribers and filled by at least
three different pharmacies.
In an effort to ensure your patient is getting appropriate, safe and high quality care, a subset
of the patient’s prescription profile representing only the prescriptions you have prescribed
has been attached. State privacy laws prevent us from disclosing the full prescription
history.
What can you do?
• Review the complete patient profile for this patient’s controlled medications by using the
Minnesota Prescription Monitoring Program. Minnesota law requires all pharmacies to
report the dispensing of all controlled substances to the Minnesota Prescription
Monitoring Program. To access this data please visit http://pmp.pharmacy.state.mn.us/.
Registration is required.
o Many states have similar programs.
• If you believe that this patient would benefit from case management services, you can
contact HealthPartners Connect (HealthPartners' case management program) to make a
referral at 952-883-5469.
If you have questions or suggestions regarding this communication, please contact Pete
Marshall, PharmD, directly at (952) 967-5807.
Thank you for your attention and partnership in providing appropriate care for this member.
Sincerely,
Terry W. Crowson, MD
Medical Director
Medical Management & Government Programs
HealthPartners Health Plan
(Optional) Physician Feedback -Fax back to HealthPartners (952) 967-6667
 Yes -- I found this information helpful
 No -- I did not find this information helpful
Comments:
FIGURE 20
To ensure members are getting appropriate, safe and high quality care, HealthPartners developed
the Exceptional Use Intervention Program for controlled substances. It targets members who
received six or more controlled substance medications prescribed by three or more physicians or
obtained from three or more pharmacies.
The member is identified through pharmacy claims; we send a letter to the most recent prescriber
describing the Exceptional Use Intervention Program and identifying the controlled substance
prescriptions written by that provider. Physicians can re-evaluate the treatment plan and if they
need a complete patient profile they can call HealthPartners Pharmacy Benefits Manager, or refer
the member to our Case Management Program at the phone number listed below. Minnesota
prescribers can log on to the Minnesota Prescription Monitoring Program. Minnesota law
requires all pharmacies to report the dispensing of all controlled substances to the Minnesota
Prescription Monitoring Program. Some states have similar programs.
Alabama, Arizona, California, Colorado, Connecticut, Hawaii, Idaho, Illinois, Indiana, Iowa,
Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Nevada, New
Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode
Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia, and
Wyoming.
Seven states (Alaska, Florida, Kansas, New Jersey, Oregon, South Dakota and Wisconsin) and
one U.S. territory (Guam) have enacted legislation to establish a PDMP, but are not fully
operational. <http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm> accessed 1.28.2011.
Reports are compiled monthly and are reviewed for trends. Any member that recurs three times
in a rolling 12-month period is automatically forwarded to our Case Management Program for
investigation.
If misuse is identified, HealthPartners can request system limitations that restrict the patient to a
particular pharmacy or provider. Or, in the case of provider or pharmacy misuse, HealthPartners
can restrict that provider or pharmacy or remove that provider or pharmacy from our network.
FIGURE 21
Acute Bronchitis
Summary Recommendation
Antibiotics are NOT indicated in acute bronchitis unless in specific circumstances where pertussis is suspected or in patients with significant medical co‐morbidities.
Introduction Acute bronchitis is one of the most common conditions encountered in clinical practice and is also one of the commonest causes of antibiotic misuse. Both the Centers for disease control and the American College of Physicians have stated unequivocally that the only indication for antibacterial agents in uncomplicated acute bronchitis is pertussis. Although the usage of antibiotics had decreased in recent years the prescriptions are now slanted towards broader spectrum antibiotics increasing risk for emergence of resistant strains. Microbiology
Viruses are overwhelmingly the main causative agents for acute bronchitis. Influenza A and B, parainfluenza, coronavirus, rhinovirus, and respiratory syncytial virus are the predominant viruses implicated. Apart from pertussis bacterial etiologies are rare unless there are airway violations such as tracheostomy or endotracheal intubation or those patients with structural lung disease or immune suppression.
Natural History
In the first few days the symptoms are similar to any upper airway infection but with acute bronchitis the cough typically persists for 10‐20 days and occasionally for more than 4 weeks. 50% of patient swill report purulent looking sputum. Fever is relatively uncommon and when present may suggest either pneumonia or influenza. Reactive airways and wheezing is not uncommon. In the vast majority of patients symptoms resolve without antibiotic therapy.
Bronchitis is often “under coded” when a diagnosis code is selected. If cough is the predominant feature of an upper respiratory infection, it usually should be coded “Bronchitis” rather than simply “URI or Upper Respiratory Infection.” This is more accurate, and it will make it easier to compare HealthPartners experience to national data.
Diagnostic testing
Pearl of Knowledge: Acute Bronchitis 2.10.10
FIGURE 21
In the presence of typical symptoms and the absence of abnormal pulmonary findings further
testing is usually not indicated. Wheezing alone does not require tests. Specifically sputum
gram stain and culture rarely leads to specific diagnosis. Spirometry and chest x rays are also not
indicated for initial workup.
Rapid tests can be used to diagnose influenza. PCR testing for pertussis is diagnostic if the
typical symptoms are present especially in the presence of a known epidemic.
Treatment
Antibiotics are generally not recommended for acute bronchitis . Exceptions include extremes of age, patients with COPD, immune deficiencies, cystic fibrosis, pneumoconiosis or other structural lung disease. A Cochrane review of nine randomized controlled trials showed a significant but minor reduction in duration of cough (0.6 days) and decrease in duration of symptoms by one day. There was a non significant reduction in the number of days feeling ill and a non significant increase in adverse effects attributed to antibiotics. As mentioned both the CDC and the ACP guidelines state that antibiotics are not indicated except in cases of pertussis.
The guidelines from the national institute for health and clinical excellence in the UK advise not treating acute bronchitis with antibiotics with the following exceptions: Preexisting comorbidity (heart, lung, renal, liver or neuromuscular disease or immunosuppression), 2. Patients over the age of 65 with acute cough and two or more of the following or patients over 80 with one or more of the following: admission to the hospital within the prior year, Diabetes, CHF or current use of steroids.
1.
Antimicrobial therapy is indicated to limit transmission of pertussis. A Macrolide would be the first line treatment. Antibiotic therapy should be initiated within the first week where possible but there is no evidence that cough will be less severe or the course less protracted with treatment. Treatment with oseltamivir or zanamivir decreases duration of symptoms for acute bronchitis due to influenza by only one day and results in a slightly earlier return to work (0.5 days.)
Symptomatic treatment with beta agonists for the cough may be beneficial in patients with airflow limitation. A recent Cochrane review however did not support this recommendation. In practice a short course of inhaled or oral steroids may be tried for troublesome cough. There are no compelling data from clinical trials supporting the use of antitussives or mucolytics in acute bronchitis. There are small studies to show benefit treating cough associated with allergic rhinitis with antihistaminics. A decongestant or antihistaminic could be used for cough associated with post nasal drip in the setting of acute bronchitis. Non specific antitussives like codeine are also prescribed for significant cough in acute bronchitis with very little evidence to support this. Pearl of Knowledge: Acute Bronchitis 2.10.10
FIGURE 21
References:
1.
Gonzales R, Barltlet JG, Besser RE et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med 2001;134:521‐529
2. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence‐based clinical practice guidelines. Chest 2006;129:Suppl:95s‐103s
3. Bent S, Saint S, Vittinghoff E, Grady D. Antibiotics in acute bronchitis: a meta‐analysis. Am J Med 1999;107:62‐67
4. Wenzel P, Fowler AA. Acute Bronchitis. NEJM 2006;355:2125‐2130
Questions: Please reply to this e-mail, and your questions(s) will be directed to the author of this Pearl
Pearl Archive: http://www.imehealthpartners.com
All Pearl recommendations are consistent with professional society guidelines,
and reviewed by HealthPartners Physician Leadership.
Pearl of Knowledge: Acute Bronchitis 2.10.10
FIGURE 22
SUBJECT:
MEDICATION REFILL (Behavioral Health) STANDING ORDER
EFFECTIVE DATE:
APPROVED BY:
July 2010
Carol Novak, MD Department Head, Behavioral Health
CONTACT:
Jo McLaughlin, RN Director, Nursing and Clinical Dietitians
Ryan Michels, PharmD BCPS, Clinical Pharmacist
SUPERSEDES:
July 2009
REVIEW DATE:
July 2011
PURPOSE:
To provide a process for RNs working in Behavioral Health to review and approve maintenance
prescription refill requests for designated medications.
POLICY:
To provide in a safe, efficient manner, approval for a supply of medication for patients. The RN is the
agent of the prescriber delegated to refill medications as per the following procedure. The prescription
must clearly originate with HPMG physicians or other HPMG authorized prescribers.
PROCEDURE:
1. Obtain information from the requesting pharmacy: patient’s name, medical number or date of birth,
pharmacy, pharmacy phone number, medication requested, amount requested and the last date the
medication was filled. Document the information in an EpicCare Refill Encounter or phone message.
A 24 to 48 hour turn-around time on a medication request may be necessary.
2. Review the patient’s medical record for the following areas:
a. Review the record for visit compliance. In order to refill mediations, a patient needs to be
“current” or as indicated in the plan of the last visit. If the patient is overdue for a visit, contact
the patient by phone to schedule a follow-up appointment. If unable to contact the patient to
schedule an appointment, the pharmacy is notified that the patient needs to contact his/her
provider’s clinic to schedule an appointment so that a refill can be authorized. All
communications and outcomes are documented in the patient’s medical record.
b. Verify the medication and dosage. The patient must be contacted if any discrepancies are noted,
for example, a medication is being refilled too frequently for the way it is prescribed. Also, the
patient is contacted for any p.r.n. medications that are being used with increased frequency, for
example, benzodiazepines, sleeping pills or stimulants. Identified problems are clearly
documented in the medical record.
c. Verify that no lab testing/monitoring is required before ordering refills. (See Refill Guidelines
attached.) If patient is due for testing/monitoring, a month refill may be provided to allow the
patient the opportunity to see his/her provider/complete tests or monitoring.
3. The following medications are excluded from this policy. Refill requests must be routed to a licensed
prescriber:
a. Scheduled II Controlled Substances (medications such as oxycodone and morphine)
b. Medications excluded per careplan
c. Indications of non-compliance, including overuse or underuse
d. Indications that the patient may be experiencing a side effect or drug interaction
e. Specific medications as noted by the ordering prescriber
f. Requests to change from a brand name medication to a generic when a physician specified the
brand name to be used
4. Determine appropriate refill quantity
@BCL@C0040D71
Page 1 of 4
FIGURE 22
If the patient has been keeping his/her appointments and is not overdue for a visit, refills may be
given to last until the patient is due for his next visit, not to exceed one year from the last visit.
b. If the patient has been keeping his/her appointments and is not overdue for a visit, RNs may
increase the quantity from 30 to 90 days supply per patient request or to meet the mail order
benefit.
c. If the patient is overdue for a visit and the patient has scheduled a visit after being contacted, a
refill can be called in by the nursing staff for one month or until the next scheduled appointment
if it is beyond one month.
d. If a patient’s appointment is canceled and rescheduled, a refill can be called in by the nursing
staff for one month or until the next scheduled appointment if it is beyond one month.
e. If a client cancels and reschedules a second consecutive time, nursing will only order enough
days of non-scheduled medication to last to the scheduled appointment regardless of co-pay
status. Further refills of scheduled medications require authorization by the provider. The client
will be told at that time that there will be no further refills until he/she is seen.
f. If a client cancels and reschedules a third time, there will be no refills until the client is seen by
the provider.
g. If a client is a no-show, there will be no refills until he/she has rescheduled another appointment,
and then a refill of non-scheduled medications can be approved by the nursing staff for one
month or until the next scheduled appointment if it is beyond one month. Scheduled medications
refills will only be given for exactly the amount needed until the next scheduled appointment
unless authorized by the provider.
Refills are returned to or called into the pharmacy of the patient’s choice.
Document that the medication was refilled per standing order (PSO).
The RN may question any medication refill and refer to an ordering provider for review.
If the medication refill is denied, the medical record should be routed to the physician for review and
to determine if it is acceptable to deny.
a.
5.
6.
7.
8.
Monitoring Parameters for Selected Medications
NOTE: This is not an all-inclusive list. The RN may refill any maintenance medication, including those
not included in the following categories, unless it is identified in the exclusions. Although a specific
drug may not be listed below, the monitoring parameters apply to all medications in the drug class.
Antipsychotics
Older Antipsychotics
AIMS or DISCUS every 6 months
Labs every 2 years: Fasting lipid profiles (total cholesterol, LDL, HDL,
triglycerides)
Atypical Antipsychotics
AIMS or DISCUS annually
Weight, calculated BMI every visit
Labs at start, 4 months after start, then annually:
 Fasting plasma glucose level
 Fasting lipid profiles (total cholesterol, LDL, HDL, triglycerides); if
LDL level > 130 mg/dl increase to every 6 months
Haldol (haloperidol)
Mellaril (thioridazine)
Navane (thiothixine)
Prolixin (fluphenazine)
Thorazine
(chlorpromazine)
Trilafon (perphenazine)
Abilify (aripiprazole)
Fanapt, Fanapta
(ioperidine)
Geodon (ziprasidone)
Invega (paliperidone)
Risperdal (risperidone)
Saphris, (asenapine)
Seroquel (quetiapine)
Zyprexa (olanzapine)
@BCL@C0040D71
Page 2 of 4
FIGURE 22
Antipsychotics
Clozaril, FazaClo
(clozapine)
WBC every week for 6 months, then every two weeks. If <3,000 increase
frequency of monitoring.
Antidepressants
Effexor (venlafaxine)
Prestiq (desvenlafaxine)
Cymbalta (duloxetine)
Remeron (mirtazepine)
Blood pressure at all visits where the medication was started or raised at the last
visit
Blood pressure at all visits where the medication was started or raised at the last
visit
Weigh at each visit for one year then annually
Tricyclics
Weigh at each visit for one year then annually
Note last blood level
MAO Inhibitors
Blood pressure every visit
SSRI’s
n/a
Wellbutrin (bupropion)
n/a
Serzone (nefazodone)
Inquire if patient has signs/symptoms of liver disease such as jaundice, malaise,
nausea or anorexia.
amitriptyline
clomipramine
desipramine
doxepin
imipramine
nortriptyline
isocarboxazid
phenelzine
tranylcypromine
Celexa (citalopram)
Lexapro (escitalopram)
Luvox (fluvoxamine)
Paxil, Pexeva (paroxetine)
Prozac, Sarafem
(fluoxetine)
Zoloft (sertraline)
ADHD Medications
Stimulants
Adderall
(dextroamphetamine,
amphetamine)
Concerta, Metadate,
Ritalin (methylphenidate)
Daytrana
(methylphenidate patch)
Dexedrine
(dextroamphetamine)
Focalin
(dexmethylphenidate)
Provigil (modafinil)
Vyvanse
(lisdexamphetamine)
Strattera (atomoxetine)
@BCL@C0040D71
Blood pressure at all visits where the medication was started or raised at the last
visit and every 6 months
Weigh every visit under age 16
Height every 6 month under age 16
Weigh every visit under age 16
Page 3 of 4
FIGURE 22
Mood Stabilizers
Depakote (valproic acid)
Tegretol (carbamazepine)
Lithium
Topamax (topiramate)
Weigh at each visit for one year then annually
Labs at one month after start, 6 months after start then annual:
 CBC with platelets
 SGOT
 Valproate level
Weigh at each visit for one year then annually
Labs at one month after start, 6 months after start then annual:
 CBC with platelets
 Na (Sodium)
 SGOT
 Tegretol level
Weigh at each visit for one year then annually
Labs every 6 months:
 Lithium level
 BUN and Creatinine
Annual Labs:
 TSH
Labs at 3 months and 6 months after start then annually
 Basic Metabolic Panel (CHEM8)
 UA
Annual eye exam for glaucoma screening
Approval for use as a Population Based Standing Order:
Carol Novak, MD
@BCL@C0040D71
Date
Page 4 of 4
FIGURE 23
SUBJECT:
EFFECTIVE DATE:
MEDICATION REFILL STANDING ORDER
July 2010
Avandia removed 7/21/10
Celebrex & Azmacort removed 8/3/10
APPROVED BY:
Debra Johnson, MD Department Head, Pediatrics & Adolescent Medicine
Art Wineman, MD Department Head, Family Medicine
Rae Ann Williams, MD Department Head, Internal Medicine
Beth Averbeck, MD Associate Medical Director, Primary Care
CONTACT:
Jo McLaughlin, RN Director, Nursing and Clinical Dietitians
Ryan Michels, PharmD, Clinical Pharmacist
SUPERSEDES:
July 2009
REVIEW DATE:
July 2011
PURPOSE:
To provide a process for RNs and Pharmacists to review and approve maintenance prescription refill
requests.
POLICY:
To provide in a safe, efficient manner, approval for a supply of medication for patients (this would also
include supplies for maintenance medications, for example, insulin syringes). The RN or Pharmacist is
the agent of the prescriber delegated to refill medications as per the following procedure. Prescriptions
must clearly originate with HPMG physicians or other HPMG authorized prescribers.
PROCEDURE:
1. Obtain information from the requesting pharmacy: patient’s name, medical number or date of birth,
pharmacy, pharmacy phone number, medication requested, amount requested and the last date the
medication was filled. Document the information in a phone message or an EpicCare Refill
Encounter. A 24 to 48 hour turn-around time on a medication request is necessary.
2. Review the patient’s medical record for the following areas:
a. Review the record for compliance. In order to refill medications, a patient needs to be “current”
that is, seen annually (primary care visit for any reason within the last 12 months) or as indicated
in the plan of the last visit. If the patient is overdue for a visit, one refill is approved to allow the
patient the opportunity to be seen by his/her provider. Contact the patient by phone or mail to
explain the need for a follow-up appointment. The pharmacy is also notified that the patient
needs to see his/her physician and should note this on the prescription. All communications and
outcomes are documented in the patient’s medical record.
b. Verify the medication and dosage. The patient must be contacted if any discrepancies are noted,
for example, a medication is being refilled too frequently for the way it is prescribed. Also, the
patient is contacted for any p.r.n. medications that are being used with increased frequency, for
example, sublingual nitroglycerin, respiratory inhalers, migrane medications or narcotics.
Identified problems are clearly documented in the medical record.
c. Verify that lab testing/monitoring is not required before ordering refills. (See Refill Guidelines
attached.) If patient is due for testing/monitoring, a month refill may be provided to allow the
patient the opportunity to see the provider/complete tests or monitoring. The RN or Pharmacist
will order the appropriate lab tests in Epic and will ensure communication of needed tests to
patient.
Medication Refill SO Policy_2010.doc
Page 1 of 10
FIGURE 23
3.
4.
5.
6.
7.
8.
d. If a medication alert appears when the refill order is placed, verify that the patient has had a
previous order for this medication and history of tolerating the medication, and then proceed to
refill. If there are any questions or concerns, forward to the ordering provider.
The following medications are excluded from this policy. Refill requests including but not limited to
the following list must be routed to a licensed prescriber. RN or Pharmacist use “.no standing order”
or “.narcotics” for narcotic medications, to document that the request is being routed to a licensed
prescriber.
a. Controlled Substances
b. Oral Steroids
c. Cox II inhibitors
d. Chemotherapeutic agents
e. Antibiotics
f. Indications of non-compliance, including overuse or underuse
g. Indications that the patient may be experiencing a side effect or drug interaction
h. Specific medications as noted by the ordering prescriber
i. Requests to change from a brand name medication to a generic when a physician specified the
brand name to be used
Refills may be given to last until the patient is due for his next visit, not to exceed one year from the
last visit.
a. RNs or Pharmacists may increase the quantity from 30 to 90 days supply per patient request or to
meet the mail order benefit.
b. This exludes scheduled medications (II – V) and psychotherapeutic drugs and any medication
excluded from this standing order (per section 3).
The DISPENSING PHARMACIST may change the quantity and days supply dispensed on
maintenance medications, up to a 3-month supply, to meet patient requests or a mail order benefit.
This policy excludes all scheduled medications (II – V), psychotherapeutic drugs and any medication
ordered by a behavioral health provider.
Refills are returned to or called into the pharmacy of the patient’s choice.
Document that the medication was refilled per standing order (PSO).
The RN or Pharmacist may question any medication refill and refer to an ordering provider for
review. If the medication cannot be filled per the standing order, the request should be routed to the
physician for review.
Monitoring Parameters for Selected Medications
NOTE: This is not an all-inclusive list. The RN or Pharmacist may review any maintenance medication
that falls into the categories below unless it is identified in the exclusions. Although a specific drug
may not be listed below, the monitoring parameters apply to all medications in the drug class. For
combination products, the RN or Pharmacist will review the parameters for each component. RNs and
Pharmacists may also consult the PDR, Facts and Comparisons, or clinical Pharmacy Specialist for drug
specific monitoring.
Nonprescription/Over-the-counter (OTC) Medications (not listed elsewhere)
Medications
ALL
Medication Refill SO Policy_2010.doc
Monitoring
Review for the following using a reputable drug
information source, such as Micromedex or Up-To-Date:
• No contraindications for use exist
• Lack of significant drug, disease or dietary
interactions.
• Dosage/usage appropriate
• Therapeutic benefit (effectiveness) demonstrated
• Lack of significant adverse effects
Page 2 of 10
FIGURE 23
Allergy
Medications
ANTIHISTAMINES (oral)
• desloratidine (Clarinex®)
• fexofenadine (Allegra®, Allegra-D®)
• levocetirizine (Xyzal®)
ANTIHISTAMINES (nasal)
• azelastine (Astelin®)
• olopatadine (Patanase®)
NASAL STEROIDS
• budesonide (Rhinocort®)
• fluticasone (Flonase®)
• mometasone (Nasonex®)
• triamcinalone (Nasacort®)
• ciclesonide (Omnaris®)
• fluticasone furoate (Veramyst®)
Monitoring
Antidepressants
Medications
SSRI ANTIDEPRESSANTS
• citalopram (Celexa®)
• escitalopram (Lexapro®)
• fluoxetine (Prozac®)
• fluvoxamine (Luvox®)
• paroxetine (Paxil®)
• sertraline (Zoloft®)
SNRI ANTIDEPRESSANTS
• duloxetine (Cymbalta®)
• desvenlafaxine (Prestiq®)
• venlafaxine (Effexor®)
• milnacipran (Savella®)
TRICYCLIC ANTIDEPRESSANTS
• amitriptyline (Elavil®, Endep®)
• amoxapine (Asendin®)
• clomipramine (Anafranil®)
• desipramine (Norpramin®)
• doxepin (Sinequan®)
• imipramine (Tofranil®)
• maprotiline (Ludiomil®)
• nortriptyline (Aventyl HCL®, Pamelor®)
• protriptyline (Vivactil®)
• trimipramine (Surmontil®)
• mirtazepine (Remeron®)
•
Monitoring
Annually
• BP
• Heart rate
Savella – FDA approved only for fibromyalgia
Annually
• BP
• Heart rate
• Weight
Annually
• Weight
bupropion (Wellbutrin®)
Anti-her petics
Medications
ORAL AGENTS
• acyclovir
• famciclovir (Famvir®)
• valacyclovir (Valtrex®)
TOPICAL AGENTS
• acyclovir (Zovirax®)
• penciclovir (Denavir®)
Medication Refill SO Policy_2010.doc
Monitor ing
Annually in patient’s with known renal insufficiency
• BUN
• serum creatinine
Page 3 of 10
FIGURE 23
Benign Prostatic Hyperplasia (BPH)
•
•
•
Medications
alfuzosin HCl (Uroxatral®)
silodosin (Rapaflo®)
tamsulosin (Flomax®)
Monitoring
Annually/dosage change
• BP
Cardiovascular (not HTN)
Medications
All cardiovascular (not HTN) medications
• amiodarone (Cordarone®)
•
•
Monitoring
BP annually
Baseline, 3 months, and every 6 months: TSH
Baseline and every 6 months: ALT
Baseline and annually (or as needed per symptoms):
chest radiograph and EKG
Baseline and as necessary: Cr, BUN, K, Mg, Na,
PFT, and eye exam
refill only 6 months
Baseline and annually (or as needed per symptoms):
EKG
Baseline and as necessary: K, Mg
refill only 6 months
•
•
•
INR regularly
Refer to Warfarin standing orders and SmartForm
K+, Mg, BP, serum creatinine annually
•
•
•
•
•
•
•
•
dronedarone (Multaq®)
•
isosorbide (Isordil®, Imdur®)
nitroglycerin/ NTG (Nitrostat®, Nitrol®, Nitrek®,
Minitran®)
warfarin (Coumadin®)
•
•
•
digoxin (Lanoxin®)
clopidroget (Plavix®)
prasugrel (Effient®)
•
•
Cholesterol
Medications
FIBRATES
• gemfibrozil (Lopid®)
• fenofibrate (Tricor®, Lofibra®, Antara™ ,
Triglide®, others)
• fenofibric acid (Trilipix®)
STATINS
• atorvostatin (Lipitor®)
• pravatatin (Pravachol®)
• simvastatin (Zocor®)
• fluvastatin (Lescol/ Lescol XL®)
• lovastatin (Mevacor®, Altocor®, generics)
• rosuvastatin (Crestor®)
• simvastatin/ezetimibe (Vytorin®)
• lovastatin/niacin ER (Advicor®)
• Ezetimibe (Zetia®)
NIACIN
• Niacin ER (Niaspan®)
Medication Refill SO Policy_2010.doc
Monitoring
Annually/dosage change
• ALT
• lipid panel
Annually/dosage change
• ALT
Annually/dosage change
• lipid panel
New start or changing dose
• ALT every 3-6 months for first year
Annually/dosage change
• Lipid panel
Every 6 months
• ALT
Annually/dosage change
• Lipid panel
New start
• ALT every 6-12 weeks for first year.
Page 4 of 10
FIGURE 23
OMEGA-3 FATTY ACIDS
• Omega-3-acid ethyl esters (Lovaza®)
Annually/dosage change
• ALT
• lipid panel
Diabetes
Medications
BIGUANIDES
• metformin (Glucophage®, Glucophage XR®)
INSULIN
• insulin (Apidra®, Humalog®, Lantus®, Levemir®,
Novolog®, NPH, Regular)
• supplies
GLUCAGON-LIKE PEPTIDE 1 AGONIST
 Exenatide injection (Byetta®)
 Pramlintide injection (Symlin®)
DIPEPTIDYL PEPTIDASE IV INHIBITOR
 Saxagliptin (Onglyza®)
 Sitagliptin (Januvia®)
SULFONYLUREAS
• glimeperide (Amaryl®)
• glipizide (Glucotrol®, Glucotrol XL®)
• glyburide (Micronase®, Diabeta®)
THIAZOLIDINEDIONES
• pioglitazone (Actos®)
Medication Refill SO Policy_2010.doc
Monitoring
Annually
• serum creatinine
• ALT
• BP
• Lipid panel
• microalbumin
Every three months
• HgbA1c
Annually
• serum creatinine
• BP
• Lipid panel
• microalbumin
Every three months
• HgbA1c
Annually
• serum creatinine
• BP
• Lipid panel
• microalbumin
Every three months
• HgbA1c
Annually
• serum creatinine
• BP
• Lipid panel
• microalbumin
Every three months
• HgbA1c
Annually
• serum creatinine
• BP
• Lipid panel
• microalbumin
Every three months
• HgbA1c
Annually
• serum creatinine
• ALT
• BP
• Lipid panel
• microalbumin
Every three months
• HgbA1c
• ALT
Page 5 of 10
FIGURE 23
MEGLITINIDES
• nateglinide (Starlix®)
• repaglinide (Prandin®)
COMBINATIONS
• metformin/pioglitazone (Actoplusmet®)
• metformin/rosiglitazone (Avandamet®)
• metformin/glipizide (Metaglip®)
• metformin/glyburide (Glucovance®)
• glimepiride/pioglitazone (Duetact®)
• metformin/sitagliptin (Janumet®)
• metformin/repaglinide (Prandimet®)
BLOOD GLUCOSE TESTING SUPPLIES
Annually
• serum creatinine
• ALT
• BP
• Lipid panel
• microalbumin
Every three months
• HgbA1c
• ALT
• Follow the monitoring guidelines of the medication
components.
Hormone Replacement
•
•
•
•
•
•
•
Medications
conjugated estrogens (Premarin®)
conjugated estrogens/ medroxyprogesterone
(Combipatch®, Premphase®, Prempro®)
esterified estrogen/ methyltestosterone (Estratest®,
Estratest HS®)
estrodiol (Estrace®, Estraderm®, Vivelle®)
ethinyl estradiol/ norethindrone (FemHRT®)
medroxyprogesterone (Provera®)
progesterone (Prometrium®)
Monitoring
Annually
• mammography
• breast exam
• Pap (3 normals then every 2-3 years)
Oral Contraceptives
Medications
•
various products
Monitoring
Annually
• BP
• Pap (3 normals then every 2-3 years)
Hypertension
Ace Inhibitors
•
•
•
•
•
•
Medications
captopril (Capoten®)
benazepril/amlodipine (Lotrel®)
enalapril (Vasotec®)
enalapril/HCTZ (Vasoretic®)
lisinopril (Prinivil®, Zestril®)
lisinopril/HCTZ (Prinzide®, Zestoretic®)
Monitoring
Annually/dosage change
• K+
• serum creatinine
• sodium (only applies to medications that include a
diuretic)
• BP
Alpha Blockers
•
•
•
Medications
doxazosin (Cardura®)
prazosin (Minipress®)
terazosin (Hytrin®)
Monitoring
Annually/dosage change
• BP
Alpha/Beta Blockers
•
•
Medications
carvedilol (Coreg®, Coreg CR®)
labetalol (Trandate®, Normodyne®)
Medication Refill SO Policy_2010.doc
Monitoring
Annually/dosage change
• BP
Page 6 of 10
FIGURE 23
Angiotensin II Receptor Blockers
•
•
•
•
•
•
Medications
irbesartan (Avapro®)
irbesartan/HCTZ (Avalide®)
losartan (Cozaar®)
losartan/HCTZ (Hyzaar®)
telmisartan (Micardis®)
telmisartan/HCTZ (Micardis HCT)
Monitoring
Annually/dosage change
• K+
• serum creatinine
• sodium (only applies to medications that include a
diuretic)
• BP
Beta Blockers
•
•
•
•
Medications
atenolol (Tenormin®)
atenolol/chlorthalidone (Tenoretic®)
metoprolol (Lopressor®, Toprol XL)
propranolol (Inderal®)
Monitoring
Annually/dosage change
• BP
• Heart rate
Calcium Channel Blockers
•
•
•
•
Medications
amlodipine (Norvasc®)
diltiazem (Cardizem®, Cardizem CD/SR®,
Dilacor®)
nifedipine (Procardia XL®) long acting
verapamil (Calan®, Calan SR®, Isoptin®,
Verelan®)
Monitoring
Annually/dosage change
• BP
• Heart rate (diltiazem, verapamil)
Central Acting Antiadrenergics
•
•
Medications
clonidine (Catapres®, Catapres TTS®)
methyldopa (Aldomet®)
Monitoring
Annually/dosage change
• serum creatinine
• BP
Direct Renin Inhibitors
•
Medications
aliskiren (Tekturna®)
Monitoring
Annually/dosage change
• K+
• serum creatinine
• BP
Diuretics
•
•
•
•
•
•
•
•
Medications
furosemide (Lasix®)
hydrochlorothiazide/ HCTZ (Hydrodiuril®)
chlorthalidone (Thalitone®)
indapamide (Lozol®)
spironolactone (Aldactone®)
eplerenone (Inspra®)
triamterene/HCTZ (Dyazide®, Maxzide®)
metolazone (Zaroxolyn®)
Monitoring
Annually/dosage change
• K+
• serum creatinine
• sodium
• BP
Hypothyroidism
•
Medications
Levothyroxine (Synthroid®, Levothroid®)
Medication Refill SO Policy_2010.doc
Monitoring
Annually/ dosage change (6wks)
• TSH sensitive
Page 7 of 10
FIGURE 23
Migraine
•
•
•
•
•
•
Medications
almotriptan (Axert®)
eletriptan (Relpax®)
rizatriptan (Maxalt®)
sumatriptan (Imitrex®)
frovatriptan (Frova®)
naratriptan (Amerge®)
Monitoring
Non-Steroidal Anti-Inflammatory Drugs
•
•
•
•
•
•
•
•
•
Medications
flurbiprofen (Ansaid®)
ibuprofen (Motrin®)
indomethacin (Indocin®)
meloxicam (Mobic®)
naproxen (Naprosyn®)
piroxicam (Feldene®)
salsalate (Disalcid®)
sulindac (Clinoril®)
tolmetin (Tolectin®)
Monitoring
Annually
• serum creatinine
• Hgb
• ALT (if on sulindac [Clinoril®])
Osteoporosis
Medications
BISPHOSPHONATES
• alendronate (Fosamax®)
• alendronate/ cholecalciferol (Fosamax +D®)
• risedronate (Actonel®)
• ibraondranoate (Boniva®)
Monitoring
PUD (peptic ulcer)/ GERD (reflux)
Medications
H2 BLOCKERS
• cimetidine (Tagamet®)
• famotidine (Pepcid®)
• ranitidine (Zantac®)
PROTON PUMP INHIBITORS
• dexlansoprazole (Dexilant®)
• lansoprazole (Prevacid®)
• omeprazole (Prilosec®)
• pantoprazole (Protonix®)
• rabeprazole (Aciphex®)
• esomeprazole (Nexium®)
Medication Refill SO Policy_2010.doc
Monitoring
Page 8 of 10
FIGURE 23
Respiratory
Medications
BRONCHODILATOR INHALERS
• albuterol (Proair®, Ventolin HFA®)
• albuterol/ipratropium (Combivent®)
• ipratropium (Atrovent®)
• pirbuterol (Maxair®)
• salmeterol (Serevent®)
• tiotropium (Spiriva®)
BRONCHODILATOR for NEBULIZER
• albuterol (Proventil®, Ventolin®)
• albuterol/ipratropium (Duoneb®)
• ipratropium (Atrovent®)
LEUKOTRIENE MODIFIERS
• montelukast (Singulair®)
STEROID INHALERS
• beclomethasone (QVar®)
• mometasone furoate (Asmanex®)
• budesonide (Pulmicort®)
• fluticasone (Flovent®)
• fluticasone/salmeterol (Advair®)
• budesonide/formoterol (Symbicort®)
STEROID for NEBULIZER
• budesonide (Respules®)
THEOPHYLLINE
• various products
Monitoring
Each refill
• Check for refill requests. If requests more
frequently than provider ordered, route for provider
review (may require adding or increasing dose of
steroid inhaler).
Albuterol
• 4th refill request for an albuterol inhaler within 1 yr
of the original prescription - RN assesses for
increasing asthma severity level and/or need for
controller medication. Review with provider.
See Bronchodilator Inhaler monitoring
Annually
• theophylline level
Seizures
•
•
•
•
•
•
•
•
•
•
Medications
carbamazepine (Tegretol®)
phenobarbital (Luminal®)
phenytoin (Dilantin®)
valproic acid/divalproex (Depakote®, Depakote ER
®)
gabapentin (Neurontin®)
lamotrigine (Lamictal®)
levitiracetam (Keppra®)
oxcarbamazepine (Trileptal®)
topiramate (Topomax®)
zonisamide (Zonegran®)
Monitoring
Annually
• drug level (carbamazepine, phenobarbital, phenytoin
and valproic acid/divalproex)
• Weight
• CBC (carbemazepine only)
• ALT (carbemazepine and valproic acid)
• Sodium (carbamazepine, oxcarbamazepine)
• BMP (topiramate)
Supplements
Medications
•
•
•
calcium
Vitamin D
potassium
Monitoring
Annual/change in dose
• K+ level
MULTIVITAMINS
• multiple products
Medication Refill SO Policy_2010.doc
Page 9 of 10
FIGURE 23
Topical Agents
Medications
ACNE, ROSACEA, ECZEMA, PSORIASIS
• adapalene (Differin®)
• azelaic acid (Azelex®; Finacea®)
• benzoyl peroxide (Benzac®, Brevoxyl®, others)
• clindamycin (Cleocin T®)
• metronidazole (MetroCream®, MetroGe®l,
MetroLotion®)
• tazarotene (Tazorac®)
• tretinoin (Retin-A®, Retin-A Micro®)
Monitoring
Tazarotene should not be used during pregnancy.
Urinary Incontinence
•
•
•
•
•
•
Medications
oxybutynin (Ditropan ®, Ditropan XL®, Oxytrol®)
tolterodine (Detrol®, Detrol LA®)
darifenacin (Enablex®)
fesoterodine (Toviaz®)
solifenacin (Vesicare®)
trospium (Sanctura®)
Monitoring
Miscellaneous
•
Medications
acetaminophen (Tylenol®)
•
allopurinol (Zyloprim®)
•
Nicotine patches (Nicoderm CQ®, Nicotrol®)
Monitoring
Annually (with frequent usage)
• ALT
• serum creatinine
Annually
• serum creatinine
• ALT
• CBC
Annually
• Heart rate
• BP
Drug Information: http://micromedex.HealthPartners.com
Approval for use as a Population Based Standing Order:
Debra Johnson, MD
Date
Art Wineman, MD
Date
Rae Ann Williams, MD
Date
Beth Averbeck, MD
Date
Medication Refill SO Policy_2010.doc
Page 10 of 10