Practice Basics

1. Practice Basics Chapter 13: Processing Medication Orders and Prescriptions

2. Inpatient Pharmacies • Receiving Medication Orders • hand-delivered • mechanical method • fax transmission or pneumatic tube • Computer physician order entry, or CPOE • orders verified by pharmacisst • Telephone orders • by prescriber or an intermediary • legal restrictions

3. Upon Receipt • 2 steps • review order for clarity & completeness • prioritize the order

4. Ideal Medication Order • Patient name • Hospital identification # • Room/bed location • Generic drug name • Brand drug name* • Route of administration • Dosage form • Dose/strength • Frequency & duration • Rate & time • Indication • Other instructions • Prescriber’s signature • Printed name if needed • Credentials • Pager number • Date & time of order

5. Prioritization • PATIENT DISCOMFORT • initial treatment of pain, fever, or nausea & vomiting are generally high priority • Urgent orders are filled first • Evaluate by analyzing: • route • time of administration • type of drug • intended use of drug • patient-specific circumstances

6. Order Start Times • STAT – immediately- an urgent need • “Now” or “ASAP” • “start today” or “start this morning” • Has 1st dose of medication been given? (ER) • Standard amount of time to process & deliver order • typical turnaround times in hospital • 15 minutes for STAT order • 1 hour for a routine order • Technicians use critical thinking skills to prioritize orders

7. Processing Medication Orders • Identify patient • Compare order with patient’s existing medication • Order entry steps • choose correct medication from database • identifying administration schedule • enter any special instructions • Medication must be selected, prepared or compounded, checked, dispensed for use

8. Patient Profile • Patient name • Identification numbers • Date of birth/age • Sex • Height and weight • Lab values • Admitting/2nd diagnoses • Room & bed number • Names of admitting & consulting physicians • Allergies • Medication history • Special considerations • Clinical comments-therapeutic monitoring, counseling notes

9. Selecting Drug Product • Drug may be ordered by generic or brand name • Abbreviations often used • Lists of abbreviations that cannot be used • Look-alike & sound-alike drug strategies • store in separate locations • additional labeling • tall man letters (example: buPROPion – busPIRone)

10. Drug Selection • Mnemonic is code, associated with medication • Ampicillin 250 mg • mnemonic, or drug code, “amp250,” • choices: • amp250c ampicillin 250 mg capsule • amp250s ampicillin 250 mg/5 mL oral suspension • amp250i ampicillin 250 mg injection

11. Order Processing • Labels generated upon order entry • IV label format different from unit dose tablet • Form of medication • pediatric • meds through tubes (nasogastric tubes or gastric tubes) • Formulary considerations

12. Order Processing • Pharmacist input • consult pharmacist if any warnings appear • Computer warnings: • interactions • duplications • allergies • dosage range • diluent choices • may be standardized as defaults in computer system • Final step-pharmacist verification of all orders

13. Medication Administration Times • Administration time impacts: • drug efficacy • diagnostic laboratory testing • Pharmacokinetic studies using administration time in relation to lab test time to determine drug dose recommendation • Full stomach or empty stomach • Standard medication administration times

14. Standard Administration Times • daily = 0900 (9 a.m.), • bid = 0900 and 1700 (5 p.m.) • q8h=every 8 hours = 0600 (6 a.m.), 1400 (2 p.m.), and 2200 (10 p.m.) • Warfarin – 1700 to allow time to review lab results • Standardized schedules of drug administration • based on therapeutic issues, nursing, pharmacy

15. MAR • Medication administration record • Part of patient’s medical record • Nurse documents when medication administered • Standardized times appear as default entries on MAR • Default times may differ on some specialized units • “daily” may default to 0900 • physical rehabilitation unit • might require daily administration to occur at 0800

16. Scheduling Considerations • Must be aware of exceptions • Pharmacists must consider other medications • ciprofloxacin & calcium carbonate must be spaced • day or days of the week • important to coordinate with patient’s home schedule • every-other-day orders • avoid advising caregiver to give medication on odd days or even days, because depending on number of days in month, “every other day” will change with respect to odd/even

17. Information System • Physicians’ orders are input into patient profile in pharmacy information system • Information used to generate: • MARs • medication profiles • fill lists (for pharmacy use) • labels for medications to be issued to patient care areas • MARs may be either paper or electronic (eMAR)

18. Special Instructions • Pharmacy instructions • notes between pharmacist/technician • clinical notes • Nursing instructions • storage information • administration instructions • physician-specified parameters • displayed on MAR & medication label

19. Sample Inpatient Order Entry • Enter patient’s name/account number-verify pt • Compare order to patient profile in detail • Enter drug • Verify dose • Enter administration schedule • Enter any comments in clinical comments field • Verify prescriber name • Fill & label medication

20. Filling, Labeling, Checking • Send enough doses to last to next scheduled delivery • 24-hour cart fill system common • Review label carefully • against order • against product • Medication order is filled • Pharmacist checks-legally required in most cases • Technology-order images archived

21. Special Considerations • “Charge-Only” & “No-Charge” Entries • Pharmacist protocols • Diagnostic preparation orders • Computer physician order entry • Automated dispensing technology • Centralized dispensing automation • Decentralized automation

22. Outpatient Pharmacies • Receiving Prescriptions • presented in person • telephoned in from prescriber’s office • facsimile • electronic transmission • Refill requests • internet • phone • manual-uses person • automated system

23. Payer Information • Establish: • primary payer for prescription • patient’s portion of reimbursement (copayment) • drug formulary • Electronic claims adjudication • Prescription may be held until information gathered

24. Clarity & Completeness • Patient name • Patient home address • Date written • Drug info • name • strength • dose • Directions • route • Frequency & duration • Quantity to be dispensed • Number of refills • Substitution (DAW) • Signature/credentials • DEA # if required • Prescriber’s info • name, address, phone • indication (not required, but recommended)

25. Dispense as Written (DAW) • DAW= brand name drug written must be dispensed • Some states require phrase “Do Not Substitute” (DNS) • Must consider state law & pharmacy policy • Preprinted areas-prescriber signs to designate “DAW” or “generic substitution acceptable” ok in some states

26. DAW codes 0 = No product selection indicated 1 = Substitution not allowed by provider 2 = Substitution allowed- patient requested product 3 = Substitution allowed- pharmacist selected product 4 = Substitution allowed- generic drug not in stock 5 = Substitution allowed- brand drug dispensed as generic 6 = Override 7 = Substitution not allowed- brand drug mandated by law 8 = Substitution allowed- generic drug not available in marketplace 9 = Other

27. Forgeries • Screen prescriptions for controlled substances • May be fairly easy to identify • erasure or overwriting of strength or dispensing quantity of drug (changing 3 to 8) • More subtle • theft of preprinted prescription pads • legitimate-looking prescriptions • telephoned in to pharmacy

28. Other Considerations • Legibility problems & interpreting abbreviations • Patient notification if • contacting prescriber • medication is not in stock • Prioritization • order in which presented to pharmacy • common-sense judgment

29. Patient Profile • Patient’s name/identification number • Date of birth/age • Home address/telephone numbers • Allergies • Principal diagnoses • Primary healthcare providers • Third-party payer(s)/other billing information • Over-the-counter medication/herbal supplements • Prescription & refill history • Patient preferences

30. Prescription Entry • Appropriate drug product selection • mnemonic • alphabetical listing • National Drug Code (NDC) number • Directions for use • Fill quantity • Initials of pharmacist checking prescription • Number of refills authorized

31. Primary Prescription Label (information may vary by state) • Patient’s name • Date the prescription is being filled (or refilled) • Prescriber’s name • Sequential prescription number • Name/strength/manufacture • Quantity dispensed • Directions for use • Number of refills remaining/associated refill period • Expiration date • Physical description of med if required by state law

32. Instructions for Use • Administration directions (“Take,” “Insert,” “Apply”) • Number of units constituting one dose/dosage form • Route of administration • Frequency • Duration if applicable (“for 10 days,” “until finished”) • Indication if applicable (ex: “for pain” or “for blood pressure”)

33. Outpatient Prescription Process • Enter patient’s medical record number or name • Enter or verify existing third-party billing information. • Compare order to patient profile in detail • Enter drug • Enter label direction mnemonic • Enter comments • Enter prescriber’s name • Enter amount to dispense/refill information • Fill & label the prescription