Read 2008 Medication management text version

2008-09 MEDICATION MANAGEMENT STANDARDS

Questions & Answers

1

PHARMACY DEPARTMENT 1. Question How are non-formulary drug requests handled? Answer Physician is contacted for consideration of formulary alternatives. If alternatives are not acceptable, Pharmacy will obtain medication within 24 hours unless weekend or holiday. MD is required to fill Non-Formulary form, signed by chair/attending dept. head. The physician may want the patient to use his/her own medication if it is not immediately available by the hospital pharmacy. The physician will write the order and have the medication brought to the pharmacy. It will be identified, affixed with pharmacy label and dispensed. 2. Question Do pharmacists review all medication prescriptions or orders? Answer Yes. All orders are reviewed and profiled by pharmacy. A patient may receive a medication without a pharmacist's review if 1) the physician controls the ordering, dispensing and administration of the drug 2) in some emergencies when time does not permit: ex. pyxis overrides. 3. Question What important patient information is considered when medications are dispensed? Answer Patient name, age, sex, clinical diagnosis, relevant lab values, past medical history, pregnancy and lactation, height, weight and allergies are considered. Current medication therapy (including prescription, non prescription, and herbal medications) are considered as well as drug-to-drug interactions. Drug contraindications based on patient condition (including impaired renal/liver function) etc. are also considered.

2

PHARMACY DEPARTMENT 4. Question If a physician orders a medication not available in the Pharmacy, is it documented as a medication administration (timing) error? Answer No. Physician is notified that medication is unavailable and an alternative is requested. A telephone/verbal order is generated based on the change and the nurse must be notified. 5. Question What is the policy and procedure for medication recalls? Answer Pharmacy checks department inventory, determines if any patients are currently on the recalled medication and checks patient care areas where medications may be located. Actions are documented and inventory removed is recorded on back of recall notice. Any recalled medication that is found is returned to the company who initiated the recall. All medication recalls are reviewed by Pharmacy and Therapeutics Committee (P&T). 6. Question How do Pharmacists deal with patient allergies? Verify with patient/nurse/physician as appropriate. If physician orders a drug the patient is known to be allergic to, the medication is not dispensed and the physician is notified immediately to change the order. The nurse will be informed that there will be a delay in delivery of medication due to allergy. Allergies are also noted on patients MAR. Nurse double checks patient allergies prior to administering any medication.

3

PHARMACY DEPARTMENT 7. Question How are prescribing habits monitored? Answer On-going drug utilization evaluations with reports to Pharmacy & Therapeutics Committee (P&T) and performance improvement. Data collection is also done to monitor prescribing habits and use of dangerous drug abbreviations. 8. Question How do you assure the security of drugs outside of the Pharmacy? Answer Medications are only stored in secured areas; i.e. medication room, locked medication cart, pyxis, and crash cart. 9. Question How secure is the Pharmacy? Who is allowed in? Under what circumstances? Answer Pharmacy is always locked. Pharmacy staff, hospital staff only when necessary; non hospital staff as appropriate, eg deliveries, pharmaceutical reps, maintenance service contractors, etc. While non-Pharmacy workers are in the pharmacy, they are always supervised by a pharmacist/technician. 10. Question How do you identify a pediatric admission? Answer Patient demographic information on patient profile. DOB, location of patient in a pediatric ward.

4

PHARMACY DEPARTMENT 11. Question How are you notified of a drug-drug interaction? What do you do now? Answer Computer flags interaction on patient's profile when pharmacists process the order. Determine significance of interaction and notify physician/nurse as appropriate. Any interventions are documented. 12. Question How do you know who can prescribe medication? Where is your signature verification log and "DEA" numbers located? How and when is this list updated? Answer MD Signature and license book is located at the command station in the Pharmacy. This list is updated as soon as new MD's are given privileges. 13. Question Competency: How is it maintained? How is it measured? Answer CE, new drug in-services, newsletter, online mandatory quizzes. Magazine stand located in pharmacy with journals for everyone to use. New staff orientation package is available to orient staff. We keep records of in-services. Some technicians are certified. Measurement is by observation, written testing annually, and review of errors/events/QI as related to individuals. Aseptic technique is also tested annually, competencies are maintained in the employee file. 14. Question How many FTE's do we have? Answer 69

5

PHARMACY DEPARTMENT 15. Question How do you predict staffing needs? Answer The acuity/census. Slower in summer and around holidays. Schedule bulk of vacations around those times. 16. Question What are the Pharmacy hours of operation? Answer 24 hrs/day, 7 days/week 17. Question How are drugs delivered to your unit? Answer Pharmacy provides hourly rounding of medications for inpatient units. 18. Question Do you have a unit dose system? Answer Yes. 19. Question What do you do with a patient's own medications? Answer Families are requested to take medications home. If not possible meds are collected by nurse and kept in pharmacy. Patient may use own medication if not a formulary item and prescribed by MD, as long as they are labeled by our pharmacy. Patient's own medications not picked up upon discharge are discarded after 10 days, as per UH policy. When patient medications are brought to the pharmacy a receipt is issued after RPh verifies medications.

6

PHARMACY DEPARTMENT 20. Question If a patient is using a medication which is not on formulary and not available from pharmacy, can a patient use their own medication? Answer Yes. If the physician writes an order allowing a patient to use their own medication. The medication must then be sent to pharmacy so that it can be identified, properly labeled, and dispensed to the patient. It will then be stored in the Pharmacy and dispensed daily in cassette bin until discharge. 21. Question Can a patient self-administer medication? Answer Yes. The following applies: 1. A physician must write an order indicating such. 2. RN will instruct the patient on administering the medication. 3. Medication must be sent to pharmacy for identification, labeling with patient's name, room number and instructions for use. 4. Medications will be stored in the patient's cassette 5. Nurse assesses competency of patient. 6. The name of the medication, dosage, route and time of administration will be documented in the MAR. The nurse taking care of that patient will be responsible to note the number and frequency of doses taken by the patient. 22. Question How do medication orders get to the Pharmacy? Answer Orders are faxed or picked up by technician on hourly rounds. Stats are sometimes brought down by unit clerk to pharmacy.

7

PHARMACY DEPARTMENT 23. Question How do nurses chart the medication they administer? Answer Every medication administered by a nurse in a patient care area is documented on the Electronic Medication Administration Record (e-MAR) Epic Rx. 24. Question What steps have been taken to prevent drug herbal interactions? Answer: If the physician writes an order allowing a patient to use their herbal medicines, the herbal medicines must be sent to pharmacy so that it can be identified, properly labeled, and dispensed to the patient. The physician writes an order by using Home Medication Order Sheet on admission. · Herbal medicines are not permitted to be on the hospital formulary and shall be handled by special request only by the treating physician for those patients who require such medicines. · Below are guidelines of the University Hospital Pharmacy and Therapeutic Committee that should be considered by the treating physician when he/she orders a herbal medicine. a) The possibility of drug-herb interactions or that the interference that herbal products may have on diagnostic tests remains unknown and poses a potential safety issue for University Hospital patients. b) FDA approved, product purity and potency comparisons are usually unavailable because herbal product formulations are generally not standardized. c) Effective dosing comparisons to assess clinically effective treatment outcomes are also difficult to obtain.

8

PHARMACY DEPARTMENT d) The department of pharmacy cannot guarantee outcome, strength, dose or freedom from misbranding, mislabeling or tampering. These are not FDA approved agents and cannot be compared against with therapeutic medication. Herbal products are considered non-formulary agents.

e) f)

25. Question How do we educate patients regarding the use of herbals? Answer A Pharmacist will educate any patient on herbal medications when requested by the nurse to do so. Micromedex system is also available. 26. Question How do you educate patients and families about their medications? What do you do if a patient/family cannot read a drug handout? Answer The educational needs of the patient concerning medication therapy are assessed on admission and on an on-going basis by the nurse. Knowledge deficits are identified and incorporated into a plan of care. Upon request, the pharmacist is available to educate any patient on medications. Verbal discussion with feedback from the patient/family is an alternative method. Patient education materials are accessible at every nursing station. This material is obtained through the system wide hospital intranet. Micromedex patient information can be printed at the nursing stations in either English or Spanish. Upon discharge, each patient receives written instructions regarding medications.

9

PHARMACY DEPARTMENT 27. Question Who teaches the patients and families? Answer Responsibility is multidisciplinary between nursing, pharmacy, medical staff, nutrition, respiratory, and physical therapy. 28. Question Who checks your drug stock? How often? Where is it documented? Answer Pharmacy does monthly inspections of each patient care area as well as in the pharmacy and documents inspection in the inspection log maintained in the Pharmacy. RN does daily check as medications are administered. 29. Question How are problems with drug stock (dates, quantities, etc.) resolved? Answer Each clinical area has an established par level that is reassessed based on volume or needs. All additions and deletions of floor stock are brought to the Pharmacy and Therapeutics Committee for review. 30. Question What is the refrigerator temperature range for safe medication storage? What do you do if the temperature is outside the range? Answer 36-46 degrees Fahrenheit. If the refrigerator temperature is out of range, the staff member assigned to the daily refrigerator check will notify plant operations. Notify the pharmacy to determine whether medications are still efficacious. If need be, medications are moved to another refrigerator. All information is noted on temperature charts. Refrigerator checks are done daily by Nursing.

10

PHARMACY DEPARTMENT 31. Question Do you have a formulary? Is it available on your unit and where? Answer Yes. Every year the department of pharmacy provides each patient care area with a revised hospital formulary. Any additions or deletions to the formulary are published in our monthly newsletter which is sent to all MD's and nursing units. 32. Is there a committee that oversees all aspects of medication use within your institution? Answer Yes. The Pharmacy and Therapeutics Committee meets monthly and is an interdisciplinary group comprised of medical staff, pharmacy, clinical nutrition, nursing, finance and administration. The functions of the committee include the following: · Review of policies and practices related to control drugs; · Review of all drug utilization policies and practices to assure optimal clinical results; · Review of all safety precautions; · Review all significant untoward drug reactions and all medication errors and make recommendations for improvement in the use of drugs and other therapeutic agents; · Develop and periodically review the formulary; · Formulate broad professional policies regarding the evaluation, appraisal, selection, procurement, storage, distribution, use, safety procedures, and other matters relating to drugs; and · Evaluate clinical data concerning new drugs

11

PHARMACY DEPARTMENT 33. Question Are you a poison control center? If yes, how do you handle questions about poisoning? If no, where is the nearest poison center? Where is the phone number? Answer No. The poison control phone number is on every phone in the Pharmacy and every phone in each of the patient care areas. There is also Micromedex, which is accessible to the Pharmacy, Nursing and Physicians for the management of poisonings. The N.J. Poison Control Center is located on the UMDNJ-UH campus. 34. Question Who inspects medications stored outside of the Pharmacy? How often is this done? Answer Pharmacy staff, monthly, documented in inspection log maintained in pharmacy. 35. Question Can a patient refuse treatment? Answer Yes! 36. Question What should you do if a patient complains? Answer Inform the supervisor/nurse taking care of the patient. You may also refer them to the patient advocacy department. 37. Question How do we ensure a uniform level of care throughout the organization? Answer Multidisciplinary actions of committees, standards, PI initiatives, policy & procedures, guidelines, job orientation form when hired, orientation day upon hire, ongoing competency employee evaluations.

12

PHARMACY DEPARTMENT 38. Question How do we communicate plans (anything throughout the hospital, to you)? Answer Information is disseminated via minutes, newsletters, memos and bulletin boards. 39. Question Are you evaluated on age-based competency? Answer Yes. This is documented in the annual competency assessment. 40. Question Why do we do Performance Improvement? Answer To improve outcomes and to continuously improve the quality of all services for our patient and all other customers. 41. Question Are you managing your PI data in a statistical manner? Answer Yes, we report to our QA/PI Committee quarterly and P&T monthly. 42. Question Who checks for outdates? Answer Pharmacy checks for outdates on a monthly basis. The nurse checks package for outdates prior to administering the drug. Medications are checked as they are used, during the Pyxis restocking process, and on a monthly basis.

13

PHARMACY DEPARTMENT 43. Question Who keeps the temperature logs? Answer The temperature of each refrigerator/freezer is recorded daily by nursing on a monthly log sheet. The log sheet is located on the front of each refrigerator/freezer. At the end of the month, the department manager collects these logs and audits them for accuracy and compliance, and then files them for future reference. Twelve months of logs must be kept on hand. 44. Question Concerning Medication Errors, what is considered a near miss? Answer A near miss is considered an error that occurred but did not reach the patient. (i.e. Pharmacy may have caught an order entry error prior to the drug leaving the pharmacy. Nurses may have grabbed the wrong drug for the patient but realized this before the patient received the drug). All errors (including near misses) are written up and reported to P&T. 45. Question Does pharmacy purchase in large bulk instead of unit dose? Answer Pharmacy purchases in unit dose whenever possible. Some items are only available, as bulk. Bulk items are unit dosed in the pharmacy. 46. Question What is our policy concerning expiration dating of multi-dose vials and single dose vials? Answer Multi-dose vials are given a 28 day expiration date from initial use. All staff opening vials must record date opened on label. All single dose vials must NOT be dated because they are discarded after ONE TIME USE.

14

PHARMACY DEPARTMENT 47. Question Who mixes your chemotherapy drugs? Answer Pharmacists mix chemotherapy drugs. All pharmacists who mix chemotherapy have been trained to do so and have passed annual competency test (Chemoteq). 48. Question Does Pharmacy have a role in overseeing the contrast or radiology? Answer Yes. Pharmacy has a list of current contrast dyes and radiologicals. Each month expiration dates for these items are checked. We profile oral contrasts before use for inpatients. 49. Question What do you do about computer security and patient confidentiality? Answer Each pharmacy staff member has a unique security code that allows him or her access to the pharmacy system. Pharmacists also have a code to grant them access to the hospital system. The Pharmacy doors are always locked. When a pharmacist leaves a computer terminal, whether it is in the pharmacy or on the nursing unit, the pharmacist is to logout of the computer system so as to maintain strict confidentiality. If a patient's case must be discussed it will be discussed in a private area to maintain strict confidentiality. Different levels of personnel have different security access. Terminated employees are removed from the system immediately. 50. Question What is FMEA? Answer Failure Mode Effects Analysis. The goal is to identity potential failures before they happen. Systematic method to identify and prevent product or process problems before they occur. It does not require complicated statistics, but takes time, people and resources.

15

PHARMACY DEPARTMENT 51. Question What are you doing for PI? Answer · We trend medication incidents/errors and develop action plans to prevent any more occurrences. · We also track unit dose bin filling accuracy. · Conduct turn around time studies. · Track ADR's and look for trends and ways to prevent them. · TPN monitoring double check by pharmacists. · Antibiotic Drug Utilization Evaluation (DUE). · In services to staff. · Track cassette filling time. 52. Question What have you done to improve Pharmacy Services? Answer 1. Look alike/sound alike medications: The Look Alike/Sound Alike medication pairs are physically separated from one another in pharmacy & pyxis pockets. "Look Alike/Sound Alike" stickers to be attached to the medication shelves carrying these drugs in pharmacy and to individual drugs when dispensed from pharmacy. Pyxis pockets on nursing units to be marked with "Look Alike/Sound Alike" Stickers if these medications are carried in the pyxis. Inservices given to RNs, residents, pharmacists, respiratory therapists, physicians, physician assistants on identifying these medications and taking appropriate preventive measures to avoid potential mix-ups. A list of look alike/sound alike medications is available on UHNET and posted in patient charts, formulary & nursing units. Pop-up alerts are shown on Pharmacy computer system (Epic Rx) and pyxis Screen in nursing units indicating look alike/sound alike medication status when these medications are profiled in Epic Rx or taken out of Pyxis. Standardized drug concentrations are available to reduce potential errors and the standardized drug list is posted on UHNET, patient charts, formulary and nursing

16

PHARMACY DEPARTMENT units. Annual training of employees is done to identify and handle these medications. Different insulin vials in refrigerators in nursing unit are categorized and separated from one another to prevent potential mix up. Monthly floor inspections are done by pharmacy staff to verify that these medications are stored on nursing units as per UH Policy. 2. High risk/High alert medications: Bright "High Alert" stickers are attached to all high risk/high alert medications stored in pharmacy and when dispensed from pharmacy, Pyxis pockets are marked with bright "high alert" Stickers if these medications are carried in the pyxis. 3. Concentrated electrolytes removed from patient care areas: Concentrated electrolytes, KCL, Phos, NaCl are removed from patient care areas. 4. Standardized Drug concentrations: 16 drugs are available as standardized drip concentrations throughout UH. A list of look alike/sound alike medications is posted in patient charts, nursing units and formulary booklet. Similar Action plan as look alike/sound alike medications. 5. Dangerous abbreviation list: 14 dangerous abbreviations identifed from JCAHO list is posted on UHNET, the patient charts and formulary by nursing department. Inserviced Residents, Nurses, etc. 6. IV Program: Full fledged IV admixture program started throughout UH as of March 07, 2005. 7. Remodeling of pharmacy: Remodeling of pharmacy department to meet Joint Commission standards, addressing distractions and better work/medication flow.

17

PHARMACY DEPARTMENT 8. Chemotherapy: Chemotherapy protocols are being developed by pharmacy in conjunction with nursing on a number of agents that are used in the facility. Protocols will be available on all nursing stations as part of the formulary manual as well as in the Pharmacy Policy and Procedure manual. All chemotherapeutic orders will be written on newly revised preprinted order forms (starting April 2005) approved by the Oncology Subcommittee, P&T, and MEC. Failure Mode Effects Analysis (FMEA) - Pharmacists in collaboration with nurses and physicians developed guidelines and protocols for proper chemotherapy ordering, mixing, dispensing, administration and monitoring. Oncology subcommittee consisting of RPHs, RNs and MDs meet on a monthly meeting basis and monitors patient safety goals periodically. All chemotherapeutic agents are stored separately from other medications and NOT in alphabetical order. All chemotherapeutic orders are checked by two registered pharmacists. All chemotherapeutic products are labeled and sent separately in clearly identifiable oncology bags to patient care areas. As part of the overall Patient Safety initiatives, NO VERBAL ORDERS FOR CHEMOTHERAPY AGENTS WILL BE ACCEPTED. All antineoplastic agents dispensed with following sticker, CAUTION: CHEMOTHERAPY, HANDLE WITH GLOVES, DISPOSE PROPERLY. 9. Competency assessment: Periodic competency assessment of all pharmacy technicians and RPHS.

10. Code carts: Code carts throughout the hospital monitored and assessed for compliance with newly updated policy.

18

PHARMACY DEPARTMENT 11. New samples policy is implemented, all locations in the hospital carrying the samples are identified, a log book of samples specific to outpatient clinic is maintained, and any new sample addition to an outpatient clinic is now required to pass through the regulatory approval process of P&T. 12. Pharmacy in collaboration with nursing to bring standards to the IV Push / Drip List is a guide to medication administration throughout the hospital. Some of the medications have specific guidelines in terms of the rate of administration, type of fluid, and the maximum dosage allowed. The guidelines and policy will be a dynamic P&P, any new additions of IV medication or deletions will result in revision as the medication final approval by MEC 13. E Level Satellite Pharmacy Pharmacy department added a satellite pharmacy which services the Surgical ICU (E Green), E Blue, E Yellow, EPAR, MSP, & D Yellow 14. Review and updated Pyxis inventories based on usage. 53. Question Are all medications available for dispensing/administration reviewed at least annually based on emerging safety and efficacy information? Answer Review of medication or medications class are reviewed periodically and submitted to antibiotic subcommittee, oncology subcommittee, psychiatry subcommittee and Pharmacy and Therapeutics.

19

PHARMACY DEPARTMENT 54. Question What level of detail does the Joint Commission expect with regard to the annual review of drugs on the formulary? Answer There is no expectation as to the level of detail. The review is comprehensive enough to determine if any of the organization's written criteria for additions or deletions to the formulary still apply. Basically, we want enough detail to make a decision about the continued inclusion of drugs on the formulary. UH has 4 committees to review the medications on the formulary. · Antibiotic sub-committee · Psychiatry sub-committee · Oncology sub-committee · P&T 55. Question Standard MM.2.10 implies that the strength of the formulary drug must be included in the formulary. If the hospital and medical staff have agreed to keep "drug x, 125mg/5mL," on formulary and we get an order for drug x, 250mg/5mL", would this be considered formulary use? Answer Yes. A dosage change requires physician notification to clarify a change in concentration of formulary items that are not available. Once drug is approved for formulary inclusion, all available strengths are approved too. 56. Question Please comment on the definition of "secure" specifically on the JCAHO definitions vs. the Medicare (CMS) definition (MM.2.20). Answer The Joint Commission's definition of secure is "reasonable measures are taken to prevent theft by unauthorized individuals." The CMS interpretation of secure for hospitals is "locked, in a locked room, or under constant surveillance by a health care professional." When surveying Medicare- certified hospitals we are bound by the CMS interpretation - not our definition.

20

PHARMACY DEPARTMENT 57. Question With the definition of "medications" including OTC items, is there a need to lock or secure clean utility rooms where items such as Vaseline or lubricants are kept? Answer Yes. The Joint Commission requirement (MM.2.20) is that "medications are secured in accordance with the organization's policy" and with law and regulation so that unauthorized persons cannot obtain access to them. The standard has a note stating: "The Centers for Medicare and Medicaid Services' (CMS') definition of `secured' states that all medications including non prescription medications are locked in containers, in a locked room, or are under constant surveillance." Thus, it should be noted that, based on our discussion with CMS, it is their expectation or interpretation of the Medicare Condition of Participation for hospitals that all nonprescription drugs be locked or secure. 58. Question Do the standards include normal saline vials used by nursing for flushing or diluting meds? That is, do these have to be locked at all times? Answer The FDA classifies some of these products (sodium chloride and heparin flushes) as "medical supplies" rather than drugs. The only way to tell is by the product labeling. If the product is a "medical supply" it is not considered a medication by our definition and the MM standards do not apply. However, if it is classified as a drug, then our MM standards apply and the products must be either locked, kept in a locked room or under constant surveillance by a health care professional.

21

PHARMACY DEPARTMENT 59. Question Can IV solutions be stored and distributed (replaced) by materials management? Answer Yes. Just because the products are considered medications (and thus the MM standards apply), does not mean that the pharmacy must control or distribute these products. 60. Question Concerning unit inspections is there a defined frequency for the inspections or can the organization develop a policy defining this (MM.2.20)? Answer Unit inspections are done monthly according to our policy. 61. Question If an order stating, "Resume home medication" is clarified with the patient's list of medications and signed by the physician, is this acceptable (MM.3.20)? Answer No, the order is not acceptable. All the medications plus all elements required by the organization in its policy for a medication order to be complete (eg, name, strength, frequency, route, etc.) are listed and then signed by the physician. 62. Question How is JCAHO going to survey how hospitals are trying to minimize the use of verbal orders? Answer Most likely, surveyors will ask clinical leadership from nursing, pharmacy and the medical staff as to "What have you done to minimize the use of verbal orders?" Any reasonable response will be accepted, provided that the surveyor can validate implementation of what was done through interview with other staff. Verbal orders are discouraged except in emergency cases.

22

PHARMACY DEPARTMENT 63. Question Specifically, what are the criteria for "as appropriate in the patient - weight and height"? Answer The criteria would be as follows: 1) If the patient is receiving a drug that is dosed based on weight, then weight must be included; 2) If the patient is receiving a drug that is dosed based on height, then height must be included; 3) If the drug is dosed based on body surface area, then height and weight are required. 64. Question Standard MM.2.10 If a physician orders a non formulary medication and the patient brings in their own supply from home, is that acceptable? If one purchases the nonformulary medication but the patient does not use the entire supply and there is some left over, can it then be used for the next patient for whom it is ordered? Answer It is perfectly acceptable to use the nonformulary medication that the patient brought with them from home (see standard MM.2.40). However, the patient should not be required to obtain the medication from the outside if it is unavailable in the organization and has been approved for use in the patient. If you acquire the nonformulary medication, using an abbreviated approval process required by MM.2.10 and the patient does not use the entire supply; you can store the leftover nonformulary medication for the next patient who needs it.

23

PHARMACY DEPARTMENT 65. Question How do you segregate look-alike/sound alike drugs? Answer With regard to segregation of look-alike, sound-alike drugs when we discover look-alike products, we try to obtain one of the products from a different source so that the products look different. For drugs with sound alike names, we label the bins in the pharmacy using "tallman" lettering. If we were to segregate all drugs with look or sound-alike names, it would be difficult for our staff to locate drugs in a timely manner. In the automated storage and distribution device, sound-alike and look-alike drugs are stored in different drawers, as much as possible. We have identified 13 medication pairs at UH which have look alike/sound alike potential. Please see the detailed preventive measures taken by pharmacy to avoid mix up with these drugs. 66. Question Can volunteers be used to deliver medications from the hospital pharmacy to the nursing units provided that (a) all medication packages are sealed and labeled; (b) there are no controlled substances; (c) there is documentation of orientation and annual in-service on the topic of "medication control and security", and (d) they are delivering to designated "secure" areas or handed to specifically authorized people (ie, charge nurse)? Answer No. It is our hospital policy not to allow volunteers to deliver medications. Our staff provides hourly drug delivery.

24

PHARMACY DEPARTMENT 67. Question Most hospitals have vials of insulin in floor stock for use by multiple patients. Is this practice something that JCAHO will look at under the "non emergency" medications that are in floor stock, especially since there are a lot of medication errors associated with insulin and JCAHO considers insulin a high-alert medication? Answer Unfortunately, there is no standard that would prevent stocking of insulin on patient care units (ie, insulin as floor stock). We do require that quantities are limited, drug concentrations (strengths) are limited, and vials are clearly marked and segregated to differentiate the different forms of insulin and to differentiate insulin from other products. In addition, as with any drugs, it is required that a pharmacist reviews the order before the nurse administers the insulin as floor stock, it might still be a good subject for proactive risk assessment (failure modes and effects analysis). 68. Question Regarding the new standard "pharmacy compounds all sterile medication and IV admixture (MM.4.20) - Does this now eliminate medication compounded in the intensive care unit (Nipride), obstetric department (epidurals), or surgery setting by the nurse? Answer Yes, unless it is an emergency, and the patient would be harmed by the delay, or for drugs with limited stability. 69. Question Can an abbreviation be on the list of dangerous abbreviations for one meaning and be an approved abbreviation for another meaning?

25

PHARMACY DEPARTMENT Answer No, one cannot have an abbreviation approved for one meaning and on the list of abbreviations that is not to be used for another meaning. The reason is simple: As long as people use an abbreviation for two meanings, you will never be able to decipher which meaning was intended in 100% of the cases. The hospital has a list of approved abbreviations as well as a DO NOT USE. These "do not use" abbreviations are available on the Dangerous Abbreviations list. 70. Question MM.3.10 state, "There is a documented diagnosis, condition, or indication-for-use for each medication ordered." MM.3.2 states that written policy must address "whether or when indication for use is required on a medication order." Does this imply that a policy can state which groups of drugs require a documented indication? Answer No, it does not. Standard MM.3.10 requires a documented diagnosis, condition, or indication for use for each medication ordered; however, the documentation can be anywhere in the patient's medical record (chart). MM.3.20 states that you must have policy that states when the indication for use is required as part of the medication order. Our organization decided as long as it is noted in the chart this will be sufficient. 71. Questions Do orders need to be rewritten when a patient undergoes a procedure under local anesthesia care? Answer The standard does not require that orders be rewritten; nor does any other Joint Commission standard. MM.3.20 only requires that if the orders are required to be rewritten, an order that says "resume all previous medications" is unacceptable.

26

PHARMACY DEPARTMENT 72. Questions Many times a physician writes, "Continue home medications." Is this acceptable or must a physician sign the list? Does the same thing apply when the patient is transferred from one area to another? Answer Reviewing the list by itself is unacceptable. The physician must rewrite the list of drugs or sign a prewritten list indicating which of the drugs on the list are to be renewed. And, yes, this also applies anytime your organization requires that orders be rewritten when the patient is transferred from one level of care to another. 73. Question Please explain how standard MM.4.10 applies to radiographic contrast agents and radioactive isotopes? Pharmacists often do see orders for these medications, because they are part of a radiology protocol. Is it sufficient for the pharmacy to just review the protocol? How would this be accomplished when the patient is an outpatient with no medication profile available? Answer In the preamble to the chapter, it clearly states that these medications (specifically contrast agents, diagnostic agents, and radioactive agents) are subject to all medication management standards. Thus, all standards in the MM chapter apply to these agents, including standard MM.4.10, which requires a pharmacist review of the order prior to administration of these agents unless a physician controls the dispensing and administration of the agent or there is an urgent situation in which the patient would be clinically harmed by the delay involved in reviewing the order. In other words, standard MM.4.10 applies to these agents. In most cases, the radiology department is under control of the radiologist in charge. They are legally responsible for all medications prepared and administered by radiology technicians in the area who are under their direct supervision and which are considered part of the procedure. In such cases, drugs administered in this area do not need a pharmacist review.

27

PHARMACY DEPARTMENT 74. Question How does the requirement for pharmacist review of orders pertain to floor stock? Answer It applies to floor stock to the same degree as medications in a unit-dose bin or automated storage and distribution device. Nurses can not remove drugs from floor stock and administer them without a prior review of the order by a pharmacist, with the exceptions noted in the standard. Note: This has been a standards requirement since 1993; it is not new.

Pyxis Related Questions

75. Question May nursing remove a "first dose" from Pyxis (or anywhere else) prior to Pharmacy reviewing the order? Answer No! There are 2 exceptions: 1. When a physician controls the order, dispensing and administration of the drug, such as in the OR, ED, Endoscopy suite or Cardiac Cath Lab. 2. In an emergency situation when time does not permit pharmacy review of the order, or when the clinical status of patient would be significantly compromised by a delay resulting from a pharmacist's review of the order. Only when drug is available as an override. 76. Question As a temporary solution, can access codes be shared with other nurses assigned to the floor. Answer No. Access codes are private and are not to be shared among users. You are responsible for any discrepancies or error logged under your access code. If a nurse does not have a permanent access code yet, another nurse should remove medications from pyxis for him/her to administer to patients. However, most users are using Bio-ID rather than passwords.

28

PHARMACY DEPARTMENT 77. Question Do Narcotic inventories of the Pyxis machine contents have to be done at the change of each shift? Answer Yes. The Pyxis machines utilitize a perpetual inventory. Inventory is taken with the removal of each medication and any discrepancies will be noted immediately. In addition, a complete inventory is done on all units. It is done at change of each shift by nurse and log maintained. 78. Question If only half a tablet of a controlled substance is required for a patient, what do you do with the other half? Answer It must be wasted and documented in Pyxis with a second licensed professional. It must be wasted in a secure manner (e.g. a sharps container). 79. Question How should a Fentanyl patch, which has been removed or replaced on a patient, be disposed of? Answer As with any controlled substance (a used Fentanyl patch still contains considerable drug in its reservoir), it must be wasted in a secure manner (e.g. a sharps container). The patch should be cut in half before wasting. 80. Question How are new hires granted access to Pyxis? Answer New hires should first perform the Pyxis tutorial training session on a designated station. After obtaining proof of completion, the nurse will sign a password security form and bring both documents to the pharmacy. The pharmacy will then assign the code.

29

PHARMACY DEPARTMENT

Pyxis Access Request Form

81. Question How are terminations/resignations handled? Answer When necessary, the Nurse Manager will inform pharmacy of any termination or resignation and effective date. Human Resources will also supply pharmacy on a monthly basis a list of any terminations or resignations. The person will then be taken out of the Pyxis system from the console in the Pharmacy department. 82. Question Can a nurse access a Pyxis machine located in a different nursing station? Answer Yes. Float RNs, RN managers, and ANMs are able to access a Pyxis machine located in a different nursing station. (maximum of 6 areas). There are certain floors linked together. 83. Question What Pyxis machines can MDs access? Answer Anesthesiologist and radiology MDs are the only MD with access to Pyxis. Their access is limited to the OR, recovery room and Radiology dept respectively.

30

PHARMACY DEPARTMENT 84. Question How are returns of narcotics handled in Pyxis. Answer Narcotics are returned through the return medication function on the Pyxis. The nurse will need to enter the patients name and will choose the medication to return from a list of medications that have been removed for this patient. A witness co-signature (via pyxis sign in) is required when returning any controlled substances. The RN will place medication along with receipt in a plastic bag and place in return bin. 85. Question How is wastage of a controlled substance done through the Pyxis machine? Answer Wastage can be done one of two ways. If the nurse knows the dosage to be given, he/she can use the "integrated waste" function. This is done at the same time as the removal of the medication (Pyxis will always ask if a full dose is to be given. If no, how much). Wastage can also be done using the "waste medication" function. Both transactions require a witness sign-in to verify the amount to be wasted. 86. Question How are discrepancies handled within the Pyxis system in Anesthesia? Answer It is the responsibility of the Anesthesiologist/nurse/pharmacist who use the Pyxis. Nurse manager and Narcotic Pharmacist attempt to resolve the discrepancy in conjunction with the "prior access" staff members. If unable to resolve, the discrepancy details should be given to the Chief Anesthesiologist/Nurse Manager for further review and a Medication Event form must be completed. Once an explanation of the discrepancy is evident, the resolution should be entered through the Pyxis station. In all cases, discrepancies should be resolved within 24 hours of discovery.

31

PHARMACY DEPARTMENT 87. Question What drugs do we monitor for food-drug interactions and what is our procedure? Answer 1) The Registered Dietitian (RD)/Dietetic Technician (DT) Staff in the Food and Nutrition Services Department will print out lists of all patients being treated with any of the medications listed below. Cross reference: Interdisciplinary Nutrition Care Plan (University Hospital Policy & Procedure # 800-200-001 Drug Nutrient Interaction.) 2) All patients will receive instructions in potential Drug Nutrient Interaction(s) (DNI) by the Registered Dietitian / Dietetic Technician staff. Inpatient menu choices will be appropriately modified during hospital stay. 3) The registered Dietitian / Dietetic Technician staff of Food Nutrition Services will document identification of potential Drug Nutrient Interaction(s), intervention and diet instruction provided, as well as education materials provided (DNI Guideline Cards) in progress report section of the medical record, as part of their nutritional assessments or follow-up interventions. The Registered Dietitian / Dietetic Technician staff may also use the DNI sticker to document drug nutrient interaction in the medical record. DRUG LIST

Generic (Brand) Atovaquone (Mepron) Chlorpromazine (Thorazine) Fluphenazine (Prolixin) Furosemide (Lasix) Haloperidol (Haldol) Hydrochlorothiazide (HydroDiuril) Isoniazid (INH) Levothyroxine (Synthroid) Lithium (Lithobid) MAO-Inhibitors Isocarboxazid (Marplan) Phenelzine (Nardil) Tranylcypromine (Parnate) Phenytoin (Dilantin) Propofol (Diprivan) Theophylline (Theo-Dur) Tetracycline (Achromycin) Warfarin (Coumadin)

32

PHARMACY DEPARTMENT 88. Question What is an ADR? Answer An Adverse Drug (medication) Reaction (ADR) is a response to a drug that is noxious and unintended and that occurs when using the drug appropriately. An ADR can be defined as "any unintended, undesirable and/or unexpected effect of a medication that: 1) Requires discontinuing the medication or modifying a dose. 2) Requires treatment with other medication; 3) Requires a hospitalization or longer length of hospital stay. 4) Results in cognitive deterioration or impairment; 5) Results in congenital anomalies 6) Results in disability; 7) Is life threatening 8) Results in death 89. Question What is the reporting process for ADR's? Answer 1) All Adverse Drug Reactions must be reported to the Pharmacy on ADR/ME Form or Hotline x - 2 - 5009. 2) Each Adverse Drug Reaction requires a completed Adverse Drug Reaction Reporting Form to be completed by a Pharmacist or other Clinicians/Nurses. 3) All Adverse Drug Reactions will be reviewed and classified for reporting purposes. 4) Pharmacy will complete necessary documentation for submission to appropriate institutional committees (e.g. Pharmacy and Therapeutics Committee: Medical Executive Committee) and FDA, when necessary. 5) The Pharmacy and Therapeutics Committee will review monthly and quarterly adverse drug reaction summary reports. The focus will be on identifying risk factors, trends in reporting and education needs of the organization. Upon implementation of Patient Safety Net, staff will utilize the online, electronic reporting tool.

33

PHARMACY DEPARTMENT 90. Question What is a Medication Error? Answer A Medication Error (ME), as used in UHC's Patient Safety Net (PSN), refers to an error or near miss in the sub-processes of medication administration (prescribing, transcribing, preparing/dispensing and administering). 91. Question Who reports medication errors? Answer Any health care professionals involved in the medication use are required to participate in the detection and reporting of medication incidents, the identification of the process based causes of incidents, and the facilitation of process improvements to reduce the probability of incidents. 92. Question How is a medication error reported? Answer All health care professionals complete an ADR/ME reporting form or call Ext 2-5009. The identity of the reporting individual is optional and non-punitive. 93. Question What do we do with our medication error data/Adverse Drug Reactions (ADR/ME) data? Answer We look at internally generated reports of ADR/ME data to identify problem prone areas in the medication use system. We report/evaluate the data to P&T Committee monthly and quarterly. The data is analyzed, tracked and trended and resulting needs are acted upon.

34

PHARMACY DEPARTMENT 94. Question Do you perform intense analysis of medication errors? Answer Yes, through the Pharmacy & Therapeutics Committee and QA/PI. 95. Question What is an investigational drug? Answer Investigational Drugs: Drugs which have not been approved by the FDA but under study through an Investigational New Drug (IND) application. Also, includes those that have FDA approval for at least one indication but are being studied for new indications, new routes of administration, or new dosage forms. 96. Question Do we allow Investigational Drugs in our hospital? Answer Yes. All protocols involving investigational drugs must be approved by the Institutional Review Board (IRB) before they may be initiated. All investigational drugs shall be stored and dispensed from the Pharmacy department. The principal Investigator must provide a copy of the protocol being followed and information about the drug to the Pharmacy Department. The Pharmacy Department shall provide information to the nursing staff regarding their handling and administration of the drug. 97. Question What if a patient has "Continued Administration of Investigational Drugs Initiated prior to Admission? Answer 1) The administration of investigational drug brought in by a patient may be continued provided the administration, to the best knowledge of the physician or facility, was properly initiated (informed consent, etc) prior to admission to this

35

PHARMACY DEPARTMENT facility and the continued administration of the drug is deemed in the best interest of the patient. 2) Approval from the IRB, (Institutional Review Board), or the Chairman of the Pharmacy and Therapeutics Committee or Chairman of appropriate Service or Chief of Medical Staff shall be obtained by the prescribing physician. 98. Question How are Investigational Drugs dispensed? Answer 1) Investigational drugs must be properly packaged in accordance with all applicable standards and regulations (e.g. FDA, USPNF, Poison Prevention Packaging Act). 2) For all studies coordinated by the Investigational Drug Service (IDS), a study binder will be constructed. The study binder consists of specific dispensing instructions, randomization log, drug accountability form, drug invoice, drug return form and labels, IDRF forms, the protocol, investigator's brochure, a copy of the blank consent form, amendments (if applicable), and IRB current approval notice. 3) All investigational drugs must be signed out on Investigational Drug Accountability Forms by the pharmacist dispensing the drug. These records are maintained for a minimum of two years after the drug has been FDA approved or for at least two years after the study is discontinued and FDA is notified. For studies involving international sites, records shall be maintained for 15 years after study closure. 4) All used and unused investigational drugs (i.e. bottles, vials) must be saved unless otherwise specified by the sponsor or the IDS.

36

PHARMACY DEPARTMENT 5) All patients admitted who are currently enrolled in an outpatient drug trial must have the drug dispensed by inpatient pharmacy. It is the principal investigator's responsibility to notify the IDS of such a patient. Under no circumstances will the patient be allowed to keep the drug at his/her bedside unless specifically mandated by study protocol. 6) If a patient is to receive the study drug at another institution, suitable arrangements for its transfer must be made. 7) Investigational drugs should be handled by the IDS. If investigational drugs need to be handled outside of the service, methods used by the investigator responsible for such drugs are subject to audit inspection by the pharmacy to ensure that the storage, dispensing, accountability and security of the investigational drugs are in compliance with the federal and state regulations and standards used by the IDS. 99. Question Standard MM.2.10 requires that a list of drugs that includes dosage form and strength be maintained. I was told that this means the strengths available and route (IV, PO, IM, etc). Answer Route and strengths available are listed in our formulary. 100. Question Please comment on how you see the definition of "medication," which includes herbal products and nutraceuticals, being operationalized to meet JCAHO standards. Most nutraceutical/herbals are not in First Data Bank; thus pharmacists cannot use the database to check against other drugs for drug-drug interactions, etc, during the medication ordering process (MM.4.10).

37

PHARMACY DEPARTMENT Answer The definition only states that these products are subject to the medication management standards. There are no requirements for the organization to stock these products or have them on formulary. Also, not being in the First Database is not an exclusion criteria for when a medication order needs to be reviewed for drug interactions, etc. For these products, you may need a chart of significant interactions and not be able to rely on your computer system for screening.

101. Question What are your hospital High Risk/High Alert Medications and Look Alike/Sound Alike Medications? What preventive measures do you have in place for these medications? Answer High Risk/ High Alert Medications 1. Chemotherapeutic Agents (e.g. Methotrexate, Cisplatin, Carboplatin, Paclitaxel, Docetaxel, Vinblastine, Vincristine etc.) 2. Heparin 3. Fosphenytoin/ Phenytoin IV 4. Digoxin IV 5. Neuromuscular Blocking Agents (e.g. Mivacron®, Norcuron®, Pavulon®, Quelicin®, Nimbex®, Zemuron® etc.) 6. Colchicine IV 7. Insulin Products (e.g. Novolin R, Novolin N, Novolog, Lantus, Novolog Mix 75/25, ULTRAlente, Lente)

38

PHARMACY DEPARTMENT The concentrated electrolyte solutions that have been removed from the patient care areas at University Hospital are: 1. Concentrated Potassium Chloride Injection (Vials) 2. Potassium Phosphate Injection (Vials) 3. Sodium Phosphate Injection (Vials) 4. Magnesium Sulfate Injection (Greater than 2 ml) 5. Sodium Chloride (Greater than 0.9%) Look Alike/ Sound Alike Medications 1. Chemotherapeutic Products (e.g. Cisplatin and Carboplatin, Taxol and Taxotere, Vinblastine and Vincristine) 2. Lipid-based Amphotericin products vs. Conventional Forms of Amphotericin 3. Avandia and Coumadin 4. Celebrex, Celexa and Cerebyx 5. Clonidine and Clonazepam 6. Dopamine and Dobutamine 7. Diflucan and Diprivan 8. Heparin and Hespan 9. Retrovir and Ritonavir 10. Pitocin and Pitressin 11. Insulin Products (e.g. Lantus and Lente, Humalog and Humulin, Novolog and Novolin, Humulin and Novolin, Humalog and Novolog, Novolin 70/30 and Novolog Mix 70/30) 12. Folic Acid and Folinic Acid (leucovorin calcium) 13. HydrOXYzine and HydrALAzine · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. When high risk medications are dispensed from pharmacy, it is accompanied by a "high alert" sticker. Pharmacy triggered computer pop-up alerts indicating dosage/ drug/strength checks for pharmacists profiling the drug. In Pyxis pockets carrying high risk medications are labeled with "high alert" sticker.

39

· · ·

PHARMACY DEPARTMENT · · Laminated sheets with high risk medications posted in patient charts, nursing units and UHNet. In-services provided to nursing to identify high alert medications and to verify the drug/dosages/strengths/administration routes against the physician order and MAR on a regular basis. Annual mandatory education training for health care professionals in UH on patient safety goals, high risk and look alike/ sound alike medications. All units have a copy of drug formulary which includes high alert medication list. This information is also available on the UH web at http://formularyproductions.com/umdnj/

·

·

102. Question Do you have a Standardized Drug Concentrations? Answer Yes, we do. Standardized Drug Concentrations

The following standardized drug concentrations have been approved at The University Hospital as part of patient safety. Diluents Generic Name Brand Name Concentration (Special Notes) Abciximab Aminophylline Amiodarone Cisatracurium Cordarone® Nimbex® Reopro® 4.5mL (9 mg)/ 250 mL 500mg/250mL 900mg/500mL 100mg/100mL D5W or NS D5W D5W (Glass Bottle) D5W

40

PHARMACY DEPARTMENT

Generic Name Brand Name Diltiazem Cardizem® Concentration 125mg/100mL 400mg/250mL If Fluids are Restricted: 800mg/250mL 250mg/250mL (pre-mixed) If Fluids are Restricted: 500mg/250mL 1mg/250mL Integrilin® 75mg/100mL 25,000units/250mL 100units/100mL 2grams/500mL 100mg/100mL Natrecor® 1.5mg/250mL 2gram/500mL Diprivan® 1gram/100mL Diluents (Special Notes) D5W (Total Volume 125mL)

Dopamine

D5W (premixed) D5W (premixed) D5W D5W D5W Premixed D5W NS D5W D5W D5W D5W Premixed

Dobutamine

Epinephrine Eptifibatide Heparin Insulin (Regular) Lidocaine Morphine Nesiritide Procainamide Propofol

Rev: Standardized Drug Concentration & High Risk 02/05

41

PHARMACY DEPARTMENT 103. Question What do you do when the patient is given a medication that is new to the patient? Answer When the patient is given a medication that is new to the patient, the first several doses (amount of doses dependent upon the medication) will be monitored by RN/MD. 1. Patients may experience adverse reactions to medications that are new to their systems. Therefore when new medications are administered to the patient, the care provider will physically observe and assess the patient one-half hour (30 minutes) after the patient receives the medication to assure there is no evidence of adverse effect. The patient care provider will again physically observe the patient in another 30 minutes (which will be one (1) hour from initial administration time) to assure the new medication did not produce adverse effects or sensitivities to the patient. 2. For medications or categories of medications known to commonly produce side effects or sensitivities in patients (for example sulfa drugs), the patient will be physically observed for the known side effects and sensitivities for a 24-hour period. 3. Other Clinical Laboratory studies may be ordered as appropriate to monitor the patient's response to medications that are new to his or her system to prevent unnecessary side effects or adverse reactions (i.e., peak and trough levels). 4. The information obtained through patient medication monitoring and assessment will be documented in the patient's medical record.

42

PHARMACY DEPARTMENT 104. Question What is your hospital non-approved abbreviations list?

DANGEROUS ABBREVIATIONS ­ Not accepted in orders or

medication-related documents and recommended against for any other documents or notes

July 2005 forward:

Abbreviation

Intended Meaning Misinterpretation Required Practice

U or u

unit

Read as a zero (0) or a four (4), causing a 10-fold overdose or greater (4U seen as "40" or 4u seen as "44"). Misread as "IV" (intravenous) or 10 (ten) Misinterpreted as "right eye" (OD - oculus dexter, causing administration of oral medications in the eye). Period after Q or "O" can be mistaken for "I"

Write "units"

IU

international unit once daily

Write "International Unit"

qd or QD

Write "daily"

qod or QOD Trailing Zero (X.0mg); Lack of Leading Zero (.Xmg) MS MSO4 MgSO4

every other day

Write "every other day" Remember, "Always lead, never follow"

Decimal point is missed

Always write a leading Zero before a decimal point (0.X mg) and never write a Zero by itself after a decimal point (X mg) Write "Morphine Sulfate" or "Magnesium Sulfate"

morphine sulfate or magnesium sulfate

Confused for one another ­ can mean morphine sulfate or magnesium sulfate

43

PHARMACY DEPARTMENT 105. Question What happens if someone uses a crash cart in the middle of the night? How are contents refilled? What is your Hospital's Code Cart Policy and Procedure? Answer RN notifies Central Supply, Central responds and picks up, used cart (with BLUE lock placed on by RN) and brings to Pharmacy. Pharmacist will empty used trays and replenish new trays once Central Supply Carts are checked. Contents of the code cart medications are approved by Pharmacy and Therapeutics Committee and Critical Care Committee. The procedure for the Code Cart follows: · All Code Carts will receive the FINAL LOCK from the Pharmacy Department. · The new final lock will be a RED serial numbered lock labeled "Pharmacy" · Pharmacy will be the only supplier of the final lock. · Whenever the RED lock is compromised, Central Supply needs to be notified to exchange the cart. · RED locks that are broken accidentally will require the cart to be exchanged- no replacement RED locks will be given out. · After the RED lock is broken, a Pharmacy supplied BLUE lock (labeled "Return to Pharmacy) located in the Code Cart (drawer 1 for the ped/neo cart and drawer 2 for the adult carts) must be used by the Nurse to re-lock the cart for the exchange by Central Supply. · A laminated inventory list of the Pharmacy supplied items (including the locks) are placed on all code carts. 106. Question Do you give out SAMPLES? What is the Policy and Procedure for Samples?

44

PHARMACY DEPARTMENT Answer The distribution of sample medications within UMDNJ-UH will be permitted for the patient population with procedures as follows. · Ambulatory clinics that store medication samples have been identified · All ambulatory clinics shall have an approved sample medication list provided by the pharmacy department in conjunction with the requesting clinic of all active sample medications stored within that area. · Medication samples will be permitted only within ambulatory clinic settings. · Medication samples will be stored within a separate and secure area of the ambulatory clinic. · Only medications listed on the approved sample medication list are to be stored in the respective areas. · Approved Medication samples will be received directly and logged into the UH clinic upon receipt of said samples. · All medication samples will be logged in indicating the following information. · Name and strength of medication · Date received · Manufacturer and lot number · Expiration date of medication · Quantity of medication received · Balance · Signature of receiver Ambulatory clinics storing samples will maintain an inventory log on site for the purposes of tracking sample medications dispensed to individual patients. · Monthly inspections of all medication areas within UH are to be conducted by pharmacy personnel in cooperation with the ambulatory care units staff to: · Verify expiration dating of sample medications · Ensure safe handling and labeling of sample medications

45

PHARMACY DEPARTMENT · Ensure safe storage and accuracy of documentation of sample medications · EACH MEDICATION SHALL BE ASSIGNED ITS OWN LOG OUT SHEET. · On the approval of a sample medication the Pharmacy will provide the clinic with the AUXILIARY LABELS TO BE USED for the drug to be dispensed. The Clinic staff will be responsible for indicating on subsequent log sheets the auxiliary labels to be used. (Auxiliary labels will be supplied by the pharmacy department and kept in the dispensing unit). · The following information shall be documented for each sample medication dispensed (see "Sample Medication Inventory/Dispensing Log" form). · Name of Patient · Date · Medical Record Number · Lot number · Expiration date · Quantity of medication dispensed · Balance · Signature

R

Medication Samples Dispensed · Dispensing labels will be supplied by the pharmacy department. · All / each medication samples dispensed shall be properly labeled with a dispensing label to include but not limited to the following information: · Patient name and date · Instructions for administration E.g. (Take one tablet twice a day) · Name of medication and strength · Prescribing physician · Relevant auxiliary labels (indicated on top of each log sheet) (supplied by the pharmacy department).

46

PHARMACY DEPARTMENT Adding New Sample Medication to Existing Inventory: · To add a new sample medication, the requesting clinic must complete and submit a "Sample Medication Formulary Request" form. · All requests for new sample medications will be forwarded by the pharmacy department to The Pharmacy and Therapeutics Committee for approval. · All new sample medications must be approved by P&T committee PRIOR to the requesting clinic stocking said medication. Patient Education of Medication Usage · An ambulatory unit clinician (Attending / Resident / APN) dispensing medication will conduct patient medication education. · The ambulatory unit clinician (Attending/Resident/APN) will document in the patient chart any patient medication counseling that is completed. Medication Sample Recall · The Department of Pharmacy will forward medication recall and relevant information to all patient care areas including ambulatory care units to ensure immediate tracking. · All recalled medication would be immediately removed and quarantined from all patient care areas. · All recalled medications will be returned to the pharmacy department for final disposition. · The ambulatory care unit physician administrative personnel or their designee will be responsible for identifying and subsequent notification of any ambulatory care unit patient who has received a recalled medication sample.

47

PHARMACY DEPARTMENT Enforcement · Pharmacy Administration will confiscate medication samples throughout the UH that have not been identified by the Pharmacy Department and/or have not been approved by P&T committee. · Pharmacy administration will contact medication sample supplier, pharmaceutical representative and or District Manager to inform of UMDNJ-UH Policy and Procedure on medication samples. · Repeat Policy and Procedure violations will result in prohibition of representation and distribution of medication sample from UMDNJ-UH. 107. Question How are we transitioning the "Rule-of-6" to standardized concentrations by the end of 2008? Answer "Rule-of-6" Phase-out Rules · The Rule-of-6 does not comply with this Goal · Organizations using the Rule-of-6 must transition to standardized concentrations by the end of 2008. · During the transition period, continued use of the Rule-of-6 may be approved as an alternative approach if the following criteria are met: · All Ro6 admixtures are prepared in the pharmacy · All Ro6 calculation are independently validated · All Ro6 preparations are labeled w/ Drug wt./vol. · Special aids are available if 2 systems are used · If Ro6 is used in NICU, must have 24° pharmacy · Must use "smart pumps"

48

PHARMACY DEPARTMENT 108. Question What is the procedure when there is a chemo spill? Answer Immediately following a chemotherapy spill: Nursing Staff 1. Notifies the Environmental Services Supervisor also notifies Public Safety 2-4490 on duty, via pager, or calls the Environmental Services Office at extension 2-5400. On the second and third shifts, the Supervisor may need to be paged overhead. 2. Places a physical barrier next to the spill to keep patients away from the affected area. Environmental Services Worker 3. The assigned Environmental Services Worker will pick up a chemotherapy spill kit from the Environmental Services Office before responding to the area where the spill is located. 4. Clean up the chemotherapy spill and remove the waste in accordance with department procedure. 5. Notifies his/her Supervisor when the spill clean up is completed. Environmental Services Supervisor 6. Completes the Cytotoxic Drug Spill Kit Summary Report with the responsible Nurse Manager or Patient Care Coordinator on duty. 7. Files the completed Cytotoxic Drug Spill Kit Summary Report in the Environmental Services Office. Director of Environmental Services 8. Makes a quarterly report to the Hospital Safety Committee/Environment of Care Committee of all chemotherapy spill clean ups.

49

PHARMACY DEPARTMENT 109. Question What is the expectation for labeling contrast media that are loaded into power injectors? Answer The expectations are the same as for other medications. If the contrast is drawn up and administered immediately, it doesn't have to be labeled. If it is not administered immediately, then it must be labeled. It doesn't matter whether it is administered manually or by power injector. [New 2/06] 110. Question When labeling medications and solutions in the context of NPSG 3D, what information must be on the label? Answer: The labeling expectations for this safety goal are consistent with the requirements of standard MM.4.30, Elements of Performance 3 & 4, which state the label must include: · Drug name, strength, amount (if not apparent from the container) · Expiration date when not used within 24 hours (this would be rare for procedures) · Expiration time if less than 24 hours (applies to only a few drugs) · Date prepared and the diluent for all compounded IV admixtures In most cases of medications and solutions in the procedural setting, only the drug name and strength (concentration) will be needed. [New, 2/06] 111. Question: We have discovered that pre-sterilized, pre-labeled syringes are now commercially available. Is this acceptable? Answer: No; prelabeling medication and solution containers is not acceptable. The label should be prepared and applied at the time the medication or solution is prepared. We have also heard that some people are engraving basins for use only with sterile saline or other routine solutions. This practice carries some risk of pouring

50

PHARMACY DEPARTMENT a solution into a basin that is pre-labeled for a different solution and is not considered acceptable. [New 2/06] 112. Question: When requirement 3D was first announced, the Implementation Expectations said the initials of the person preparing the medication or solution and the date of preparation needed to be on the label. Are those items still required? Answer: No. These additional requirements were reviewed late in 2005 and were deleted based on expert opinion that these items did not add to the safety of the medication use process. [New, 2/06] 113. Question: The Implementation Expectations also require a two-person verification of the label. Is this still required? Answer: Yes; if two or more people participate in the preparation and administration of the medication or solution, a two-person verification of the label's accuracy is required. However, if the same person prepares and administers a medication, or pours and uses a solution, a two-person verification is not required. In these oneperson scenarios, if the medication or solution is not used immediately, it will still need to be labeled, but verification by a second person will not be required. [New, 2/06] 114. Question: Is it acceptable to "label" a syringe by taping the vial (from which the medication was drawn up) to the syringe? Answer: No; this is not acceptable as a label. [New 2/06] 115. Question: Labels don't stick; markers don't mark; we're getting mixed opinions about pre-labeled containers. What do you suggest?

51

PHARMACY DEPARTMENT Answer: JCAHO is aware of these problems and, while there are no perfect solutions, they can offer some advice. First, sterile labels are available and will adhere to most containers, including bulb syringes, if the surface is dry. In the case of bulb syringes, this means the label must be applied before submerging the syringe. Association of periOperative Registered Nurses (AORN) recommends placing the label at the furthest point from contact with the solution and not placing the properly labeled device into the larger container of solution. For example, for an "Asepto" syringe, place the label at the top collar of the unit and do not leave the syringe in the irrigation basin. Other options are to use sterile skin adhesive strips across the top width of the bulb of the syringe. [New 2/06] 116. Question: (Reduce influenza and pneumococcal disease) Who are these vaccines recommended for? Answer: According to CDC, influenza vaccines (recommended for 50 years of age or older) and pneumococcal vaccinations (recommended for persons aged 65 years and older) and for persons of any age who have medical conditions that place them at high risk for complications from influenza. While influenza vaccinations are administered annually, the pneumococcal vaccine is generally a once-in-a-lifetime vaccination that can be given at any time. Both influenza and pneumococcal vaccinations are covered preventive service benefits under Medicare Part B. Although coverage of immunizations for adults is an optional service under Medicaid, virtually all states cover immunizations for high-risk groups such as residents of nursing facilities. (www.cdc.gov) [New, 2/06] 117. Question: What is meant by "completely reconcile?" Answer: To "reconcile" is to compare and reach agreement. In the context of

52

PHARMACY DEPARTMENT this safety goal, reconciliation is the process of comparing the medications that the patient has been taking prior to the time of admission or entry to a new setting with the medications that the organization is about to provide. The purpose of the reconciliation is to avoid errors of transcription, omission, duplication of therapy, drugdrug and drug-disease interactions, etc. It is up to each organization to determine how this process takes place. Whenever and however the comparison takes place, it should take place early enough to improve the safety of the organization's medication management processes, and hence patient safety. Ideally, the information will be available prior to ordering new medications. [Revised 2/06] 118. Question: Do you have a process to evaluate the integrity of medications brought in by a practitioner prior to use in patient care? Yes, we have a written policy #707-600-120 (PCS # 601-1000928) that addresses the safety and use of medications acquired by a practitioner from sources other than the hospital for use in patient care in the hospital. 119. Question: Does your hospital use information from data analysis to identify subsequent changes to improve its medication management system? Yes, University Hospital acts to implement improvements based on · evaluation of its medication management system · review of new technologies-e.g. Pyxis Connect, EPIC · external data · successful practices that have been demonstrated to enhance safety. 120. Question: Do you have a written policy addressing the storage of medication between receipt of a medication by an individual health care provider and medication administration?

53

PHARMACY DEPARTMENT Yes, We have a policy #707-700-110 addressing: · Safe storage · Safe handling · Security and · Disposition of these medications including return to the pharmacy. 121. Question: How does Joint Commission define "secure" in relation to medication stored in the pharmacy, patient units, operating rooms, and crash carts. Stock medications stored in the Pharmacy and in patient care areas must be either locked or under constant surveillance. The same holds true for the operating room including anesthesia carts - when an anesthesia cart is unattended and not under constant surveillance, it must be locked or stored in a locked room. The same requirement applies to floor medication carts and crash carts and any prepackaged surgical or treatment packs that may contain medication. 122. Question How do we play a role in establishing the institution's budget? Answer The pharmacy department submits an annual budget that's part of the institution's overall budget. Budget is discussed with the pharmacy management team based on bench mark information concerning drug prices forecasting and other various issues impacting hospital pharmacy budget. Our bench mark information and budget are shared with staff at our regularly scheduled staff meeting 123. Question How do you educate staff about JCAHO's standards? Answer Our education is ongoing. We publish articles on JCAHO standards in our newsletter and University Hospital UH Net web site. We also discuss JCAHO topics at staff meetings and supply our staff with

54

PHARMACY DEPARTMENT JCAHO questions and answers booklets. We also have a PharmacyNursing Structure Outcomes Committee lead by Pharmacy and Patient Care Services management team. The committee is overseeing (a) identification and resolution of operational issues affecting medication delivery and administration (b) policy revisions and (c) review of medication errors and implementation of relevant practice and policy changes that affect JCAHO standards. 124. Question How do we store expired drugs? Answer: Expired medications are stored in a separate area of the storage room. This area is clearly labeled for "Expired Medications" only. 125. Question How are medications reviewed for inclusion in the formulary? Answer: Through the Pharmacy and Therapeutics Committee (P&T) which meets monthly. After a physician requests a medication to be put on formulary, we will assess the need, safety, cost effectiveness, review the clinical efficacy, pharmacokinetics, adverse effects, pharmacology, comparison with medications from the same class, and check for potential for medication error. 126. Question Explain how your unit dose system works? Answer We deliver a 24 hour supply of medications and try to ensure that medications are delivered in their most ready to administer form when available.

55

PHARMACY DEPARTMENT 127. Question Explain your alternative medication administration system? We have policies on how to handle Herbal Medication Policy (Policy # 707-500-111), Patient Self Administer Medication Policy (policy # 707-700-107), Patient's Personal Medications Policy (Policy # 707-600-120) and Investigational Drug Policy (Policy # 707-600-117) These policies are on http://uhpolicies.umdnj.edu/live/ 128. Question Who can receive and write the Verbal Medication Orders? According to the administration policy # 831-200-271, the following staff members can accept and transcribe verbal orders for patients only under their care and only within their scope of professional practice: 1. Registered Nurse 2. Certified Physician assistant 3. Licensed respiratory care practitioner 4. Registered Pharmacist 5. Advanced Practice Nurse (APN) 6. Certified Registered Nurse Anesthetist (CRNA) · Verbal orders for antineoplastic agents shall not be given or received under any circumstances. · After conferring with the physician, obtaining the order change and the change is read back to the physician for verification, the pharmacist will reduce the order to write on the original white copy of the physician order sheet. · The verbal order must contain the patient's full name, medical record number and room number, the date and time order is taken, the complete order (drug, dose, route, frequency), physician's name, pharmacist's full signature and pharmacists must write "Read Back Verified by Repetition". · The transcriber of the verbal order must perform a read-back of the order to the prescribing clinician and document as stated above.

56

PHARMACY DEPARTMENT · The original white copy will be sent to the nursing unit (during the next Pharmacy round) with the drug or I.V. A yellow copy of the order will be kept in the pharmacy for our records, and a white copy will be faxed to the nursing unit for immediate processing. · The original order will be pulled off by nursing, placed in the patients medical Record and signed by the physician within 48 hours of patient discharge. 129. Question Who reports ADR and what triggers an ADR report? All health care professionals including Radiology, Respiratory Therapist, nurses, pharmacists, physicians, etc.... must report both actual and suspected Adverse Drug Reactions/ Medication Errors. A report can be filled out anonymously. To report, dial the Pharmacy Hotline Number at 2-5009, 24 hours a day, seven days a week. The initial indicator may be indirect: for example, a high potassium level in the blood that prompts lab staff to start an ADR report. Other trigger medications cautions include romazicom, benadryl, discontinued heparin, vitamin K, steroids, etc..... Upon the implementation of Patient Safety Net, staff will utilize the online, electronic reporting tool. 130. Question What are we doing on this unit to improve performance; to improve patient outcome? Answer Clinical pharmacists participate on a clinical pathways committee e.g. VAP protocol, Pneumonia Protocol, Sedation Protocol.

57

PHARMACY DEPARTMENT 131. Question How can we check if our food-drug policies are effective? Answer The Registered Dietitian (R.D.)/Dietetic Technician (D.T.) staff of Food and Nutrition Services will review the Medical Record and provide all Inpatients and Ambulatory Care patients with instruction and diet modification on potential food and drug interactions as identified in the patient's medical record during routine Initial Nutrition Assessment and Follow-up Intervention Care. The CQI data is presented to The Pharmacy and Therapeutics Committee (P&T) monthly. 132. What guidelines do you have on educating patients about food-drug interaction? How do you ensure that nutritionist, pharmacy, and nurses all find out accurately and promptly when a patient is on a medication with a potential interactions? Answer 1. An extensive list of Drug ­Nutrient Interactions is posted on all Medical Surgical Nursing units which includes the Drug ­ Food Interaction and Patient Education Guidelines. 2. "A Guide to Food and Drug Interactions" education materials in English as well as Spanish version is given to all patients. Also for a specific medication drug/nutrient interaction, Registered Dietitians provide written and verbal instructions to the patient. e.g. Warfarin ( Coumadin® ) Dietary Instruction: 1. Avoid excessive amounts of foods high in vitamin K and caffeine. Examples of vitamin K rich foods: liver, cabbage, broccoli, turnip greens, green leafy vegetables 2. Food high in caffeine: Tea, chocolate, coffee, carbonated beverages containing caffeine. 133. Question: Does security have access to the pharmacy? Tell me a little about pharmacy security.

58

PHARMACY DEPARTMENT Answer: No, security does not have access to the pharmacy. Pharmacy entrance door is coded. Only authorized personnel can enter the pharmacy. All other people have to be cleared by RPH/ RPH in charge before entering the pharmacy and once inside the pharmacy, all non pharmacy personnel have to be accompanied by pharmacy staff. 134. Question: How are the National Patient Safety Goals (NPSGs) implemented or monitored? Answer: Patient safety committee at UH quarterly reviews the NPSGs and rolls out the plan to implement a new goal or change in the existing goal. Pharmacy, nursing, QA/PI, and other UH dept. are assigned their responsibilities to comply with the new standard. The patient safety committee also assesses post implementation results. 135. Question: Tell me how you do your Range order and indicator for "prn" order Answer: Please refer to policy #707-500-112 for range order, policy #707500-106 for prn orders 136. Question: How do you know about Look Alike Sound Alike drugs (LASA)?

59

PHARMACY DEPARTMENT Answer: Please refer to the" High risk high alert/ look alike-sound alike" policy # 707-500-110 137. Question: How are you notified in Pyxis® about look alike sound alike drugs? Answer: Pyxis pockets in nursing units are marked with look alike sound alike stickers. Pop up alerts are shown on pyxis screen indicating look alike sound alike medication when these medications are taken out of pyxis. 138. Question: Do you have Pyxis® over ride capability? Answer: Yes, it is needed in case of emergent medication administration, in areas such as OR/ ER, where delay in medication delivery can compromise patient condition 139. Question: Does pharmacy check your crash cart? Answer: Yes, the medication drawers, please refer to policy #831-200139(Code blue- cardiopulmonary resuscitation), 831-200-145 (Resuscitation equipment checks) 140. Question: Discuss medication reconciliation? What happens when patient comes in? Answer: Please refer to policy # 831-200-320 ( Medication reconciliation process)

60

PHARMACY DEPARTMENT 141. Question: ED- What are you required to do to demonstrate the medications are reconciled? Reviewed form and policy. Answer: Please see the excerpt from policy # 831-200-320.( Medication reconciliation process) 1. Every home medication the patient was on will be reconciled and accounted for prior to being treated and released from the Emergency Department. 2. Regardless of who initiated the list of current home medications, a medication is considered reconciled for an Emergency Department patient who is treated and released only when a prescriber completes the discharge reconciliation. a. If the current home medication is discontinued at discharge, this is noted "Stopped" or "Discontinued" on order set. b. If the current home medication is being continued, this is noted as "Continued" on order set. 3. After the prescriber has completed the reconciliation, the discharging nurse verifies the reconciliation and educates the patient about the discharge regimen using the Emergency Department Wellsoft discharge instruction form and notes the complete list of medications on the form. 142. Question: Do you have emergency medications in Radiology department? How do you access them? Answer: Yes, 4 locked ( break away locks) emergency boxes are stored in radiology dept. Please refer to policy# 707-600-167 (Provision of emergency medications for management of contrast media reactions) 143. Question: How is contrast media brought down? Who covers if you have IV contrast at night?

61

PHARMACY DEPARTMENT Answer: RN/ nursing assistant brings the contrast media along with physician order to the pharmacy stat window. RPH reviews the order, labels the contrast media container and dispenses the medication. Please refer to policy# 707-600-167 ( Provision of emergency medications for management of contrast media reactions) Pharmacy is open 24hrs-7days. 144. Question: Does pharmacy review radiology dept. orders? Answer: Yes 145. Question: Who puts the medications in the medication carts? Pharmacy technician? Answer: We have patient cassette system. Pharmacy technician fills the cassette and pharmacist checks the cassette after filling. Then pharmacy technician delivers the cassette to specific units in locked medication rooms. For new orders, after pharmacist checks the medication, pharmacy technician delivers the medication to the individual patient cassette on nursing units. 146. Question: What is your process for reporting critical values? Is there a time frame? Do you get lab results sent to the pharmacy? Answer: 1. In the Epic Rx, a corresponding critical value field is displayed with the associated medication order. For e.g INR for warfarin orders, Serum K level for potassium orders etc. Pharmacist reviews these critical values and then profiles the medication order as appropriate. 2. Daily printing of a list of patients with abnormal laboratory values and RPH follow up. 3. Lab values are reported in Epic Rx system for pharmacists to review.

62

PHARMACY DEPARTMENT 147. Question: Do you have a policy on hand-off communication? Answer: For pharmacy dept., there is a log book to record issues from shift to shift, pharmacy staff must read this log book at the start of their shift. Also, shift supervisors communicate with each other at the change of shifts. There is 8:00am and 4:00pm huddle for different shifts to communicate on outstanding issues. On the weekends, management team is on call. 148. Question: Do you provide a list of medications to the patient when they are discharged from the hospital? Answer: Please refer discharge medication reconciliation policy # 831-200320 149. Question: ED-Where were your stumbling blocks in the ED with the core measure of giving antibiotics within 4 hours? Answer: None, antibiotics are in pyxis available as overrides. 150. Question: ED- What about stopping antibiotics within 24 hours? Answer: Antibiotics are stopped when MD writes an order to stop the antibiotics or as per stop order policy # 707-600-103, 707-700118 (SCIP) (24hrs SCIP, 7 days- empiric/therapeutic)

63

PHARMACY DEPARTMENT 151. Question: What is INR? Answer: International Normalized Ratio-[ PT ( prothrombin time) of patient/PT of control] is to monitor level anticoagulation in patients. When pharmacists profile orders for warfarin, INR values are displayed in the computer database so that pharmacists can review the appropriateness of the orders. 152. Question: Pharmacist:What is the Vitamin K dosage for supratherapeutic INRs in patients on coumadin? Answer: Chest guidelines: Here are the recommendations for management of supratherapeutic INRs for patients on warfarin (J. Ansell, J. Hirsh, J. Dalen et al., Managing oral anticoagulant therapy. CHEST 2001; 119:22S­38S) Management of Nontherapeutic INRs 1. For patients with INRs greater than the therapeutic level but <5.0 who do not have significant bleeding, lower the dose or omit a dose and resume therapy at a lower dose when the INR is at the therapeutic level. If the INR is only minimally greater than the therapeutic range, no dose reduction may be required (grade 2C). 2. For patients with INRs >5.0 but , <9.0 with no significant bleeding, omit the next one or two doses, monitor the INR more frequently, and resume therapy at a lower dose when the INR is at the therapeutic level. Alternatively, omit the dose and administer vitamin K1, 1 to 2.5 mg orally, particularly if the patient is at increased risk of bleeding. If more rapid reversal is required because the patient requires urgent surgery, administer vitamin K1, 2 to 4 mg orally, with the expectation that a reduction of the INR will occur in 24 h. If the INR is still high, administer an additional dose of vitamin K1, 1 to 2 mg orally

64

PHARMACY DEPARTMENT (all grade 2C compared with no treatment). 3. For patients with INRs >9.0 with no significant bleeding, hold off on warfarin therapy and administer a higher dose of vitamin K1, 3 to 5 mg orally, with the expectation that the INR will be reduced substantially in 24 to 48 h. Monitor the INR more frequently and administer additional vitamin K1 if necessary. Resume therapy at a lower dose when the INR reaches the therapeutic level (all grade 2C compared with no treatment). 4. For patients with INRs >20 with serious bleeding, hold off on warfarin therapy and administer vitamin K1, 10 mg by slow IV infusion, supplemented with fresh plasma or prothrombin complex concentrate, depending on the urgency of the situation. Administration of vitamin K1 can be repeated every 12 h (grade 2C). 5. For patients with life-threatening bleeding, hold off on warfarin therapy and administer prothrombin complex concentrate supplemented with vitamin K1, 10 mg by slow IV infusion. Repeat this treatment as necessary, depending on the INR (grade 2C) 153. Question: Do you have PT, PTT, Coumadin protocol. Answer: Heparin and Warfarin protocols in progress and currently in development. 154. Question: How often are you getting labs? Answer: Based on MD orders. 155. Question: Do you find you are getting a lot of people with elevated INR's?

65

PHARMACY DEPARTMENT Answer: We monitor INR before dosing warfarin. Warfarin order is only good for 24hrs, MD is also forced to review and renew warfarin order every day. We are working on developing a warfarin protocol for UH. They can be abnormal due to patient underlying disease state ( e.g. liver disease, sepsis, DIC etc.) 156. Question: What is the policy on Pneumovax and flu vaccine? Answer: We have Standing Orders and Administration of Influenza and Pneumococcal Vaccine policy. Please refer to policy # 831200-173) 157. Question: Do most of the physicians consult pharmacists? Answer: Physicians consult pharmacists/ clinical pharmacists. We have 2 clinical pharmacists making rounds in SICU, and MICU and providing pharmacy consultation. Also MDs will call main pharmacy whenever they have a drug/disease related query. 158. Question: Who determines pharmacy consults? Answer: No formal policy, they are provided on as needed basis by clinical staff. 159. Question: At what time, is the coumadin dose administered? Answer: 6pm, please refer to standard administration time policy # 707600-103

66

PHARMACY DEPARTMENT 160. Question: What criteria are used to determine vendor choices for procurement of supplies as part of our emergency planning procedure? Answer: University Hospital reviews the vendors prior experience planning for and responding to different types of emergencies, specially natural disasters, accidents, and terrorist threats. Our vendor provides us the following: a. Crisis management b. Inventory management c. Product movement security d. Customer procedures 161. Question: With coumadin ­ What warfarin is available at UH Pharmacy? Answer: We only use the brand name Coumadin® manufactured by BMS. 162. Question: Who is involved in patient safety? Answer: Patient safety committee comprising of representation from pharmacy, nursing, physicians, QA/PI, risk & claims is responsible for maintaining the patient safety standard. 163. Question: How do physicians get involved in medication? Answer: Through involvement in committees- P&T, subcommitteesPsychiatry, antibiotic, factor VII, and oncology, hospital wide committees- e.g. cardiology, combined critical care, sepsis, infection control, glycemic etc.---They are involved in formulary decision process through P&T/MEC, developing ordersets/guidelines on medications and assessing DUE/MUE.

67

PHARMACY DEPARTMENT 164. Question: How do nurses get involved in medication selection? Answer: Through involvement in committees P&T, subcommitteesOncology, psychiatry, hospital wide committees- cardiology, combined critical care, sepsis, infection control, glycemic, clinical practice committee--. They are involved in orderset/ medication usage guideline development. 165. Question: How do you get physician engagement outside the P&T committee? Answer: Through participation in hospital committees, pharmacy newsletter and QA/PI. 166. Question: When you administer a medication, do you label it? Answer: 1. Pharmacy dispenses medications after labeling, please refer to labeling policy #707-600-160. 2. Also, please refer to policy ( Labeling medication container and other solutions in perioperative field ) # 831-200-326, 707-600-166 167. Question: How often are you reviewing formulary? Answer: Annually through P&T and subcommittees 168. Question: Do you have a policy to address from the time the drug is distributed to the time the nurse administers to maintain drug integrity?

68

PHARMACY DEPARTMENT Answer: Yes, we do have a Storage, Safe Handling, Security and Disposition of Medications Policy #707-700-110 Medications are dispensed pursuant only to a physician's order received in the Pharmacy. The pharmacy department and Patient Care Services are responsible for assuring medications are properly stored and accounted for throughout the hospital. The proper storage and accountability are intended to assure the availability of medications for patients that are within the manufacturer's intended potency and safety standards. All medication storage areas shall be either locked or otherwise secured in such a way to prevent access to medication by unauthorized persons, diversion of medications to unintended persons and to assure that they will be available to patients when needed. 169. Question: How do you address the issue of prospective medication review in the ED? Answer: When RPH profiles a medication order from ED, he/she reviews for appropriateness. 170. Question: Do you have 24 hour radiology coverage? Answer: Yes 171. Question: Talk to me about medications for anesthesia? Answer: Medications are stored in the Pyxis® machines. Pharmacy technicians and anesthesia technicians share responsibilities in restocking the Pyxis® machines. Anesthesia dept has rolling carts that can be used as a back-up in the event an OR Pyxis® machine fails or if they need to perform a procedure outside of the ORs.

69

PHARMACY DEPARTMENT These carts are not stocked with controlled medications. There is a central Pyxis® machine in the Main OR area that can also be used in the event an OR Pyxis® machine fails during a procedure. This central machine is not mobile. 172. Question: What about controlled substance wastage? Answer: Pharmacy dept. reviews the anesthesia controlled substance wastage records on a monthly basis for compliance with UH narcotic wastage policy. Any compliance issues are reported to anesthesia chief who follows up with staff. The compliance rates are also reported to P&T committee and QA/PI dept. on a monthly basis. 173. Question: Do you monitor Heparin in nursery? Answer: Yes, we monitor closely APTT on heparin orders by residents. 174. Question: Pharmacy Power Outage. What is your backup? Answer: Please refer to pharmacy system downtime policy #707-600-129 175. Question: Do you have IV push policy? Answer: Please refer to IV push policy # 707-700-105 176. Question: Do you have a process for "first dose" medication evaluation? Answer: Please refer to "Monitoring effects of medication" policy 707-1400-111

70

PHARMACY DEPARTMENT 177. Question: Do you have a coumadin clinic in the area? Answer: Yes, Anti-Coag Practice. It is located in the ACC Building on FLevel, at 140 Bergen. Operational days are M, Tue, Thurs, AM/PM Sessions and Fri AM Session only. 178. Question: How are you using the data to improve performance? E.g. DUE, ADR/ME, etc.... Answer: P&T, nursing pharmacy steering subcommittee, QA/PI track and trend this data and implement the analysis to improve performance. Due to increased reporting of red man syndrome, when vancomycin was infused, it was decided to infused vancomycin 1g over at least 1hr. 179. Question: Do you have standardized orders for insulin? Answer: Yes, Please refer to "guideline for blood glucose monitoring" 600-100-1102, orderset # UH 6774- Blood glucose management order set for medical & surgical patients and Orderset #6830Adult ICU insulin infusion orders 180. Question: Tell me how you process chemotherapy from receipt of order to distribution for administration to patient? Answer: Please refer to 707-500-114, Once the chemotherapy order is received, the order is reviewed by two pharmacists When patient is ready for the treatment, pharmacist checks the labs to ensure medications are appropriate and profiles the orders in the computer. Labels are given to 2nd pharmacist for verification against the order and preparation of the chemotherapy. Before the drug

71

PHARMACY DEPARTMENT is added to the bag, a double check is done by 2nd pharmacist to ensure proper drug, volume and solution before mixing. Once the chemotherapy is mixed, it is put in a chemotherapy bag along with the order and any other medication ordered for the treatment. The nurse picks up the bag for administration to patient. 181. Question: Describe what needs to be included in an order for chemotherapy. Answer: Please refer to" administering of IV chemotherapy/biotherapy agents for adults"policy #601-100-0946 182. Question: How are the orders checked for accuracy, appropriateness, etc...? Answer: Two RPHs individually review all oncology orders for accuracy, appropriateness. Before administration, two RNs verify and document the orders. Please refer to policy "#601-100-0946, 707-500114" 183. Question: Who can write orders for chemotherapy? Answer: Only the physician authorized to prescribe chemotherapy. This list is updated annually by oncology subcommittee and approved by P&T and MEC. 184. Question: Can verbal orders for chemotherapy be accepted? Answer: No verbal orders for chemotherapy are allowed. Policy # 707500-114.

72

PHARMACY DEPARTMENT 185. Question: How is staff trained to prepare chemotherapy? How is their competency checked? Answer: The staff is recquired to complete the course "Safe Compounding of Hazardous Drugs" designed to educate supervisory and technical personnel involved in the Hazardous Compounding process in both the theory and practices that assure the safety and efficacy of the IV products they compound and dispense, and the protection of operative personnel and the environment. The manual ("Safe Compounding of Hazardous Drugs") is designed to provide a basis for the training, testing, and validation of compounding operative personnel required by OSHA. A written test is given at the completion of the course. A practical exam testing for proper aseptic technique and manipulation of hazardous drugs is also given using a Chemoteq kit. Both written test and practical are done on an annual basis. 186. How is chemotherapy delivered to the Infusion center? Answer: Either an oncology RN picks the order from the satellite oncology pharmacy or the oncology pharmacy technician delivers the medication. 187. Question: How is the medication checked before it is administered to the patient? Answer: All chemotherapy/biotherapy agent (s) are verified using a four point check process prior to administration. This includes verification by a Registered Nurse, Pharmacist and the treating RN/MD, and the patient identifier (licensed healthcare professional. At the time of administration, two licensed healthcare professionals must verify right patient, right agent, right dose, right

73

PHARMACY DEPARTMENT frequency, and route. This is done by checking the labeled agent against the original Physician order and the patient. Complying with the Patient Identification (Policy # 831-200-301). At the time of administration, two licensed healthcare professionals must verify the pump program with the prescribed rate. 188. Question: How are the chemo-related supplies handled after administration of chemotherapy? Answer: The chemo-related supplies are placed in the chemotherapy bag and discarded in the chemotherapy disposal bin located in the dirty utility room in In-patient oncology. (D-Green). 189. Question: How do you ensure patient safety for medications that have a black box warning? Answer: We are currently working on a policy ( Medication orders with black box warning) that addresses this issue. As per the policy, pharmacy will provide an alert to be displayed in the electronic MAR as a reminder to the physician and the nurse when one of the medications with black box warnings is prescribed: "MEDICATION WITH BLACK BOX WARNING. REFER TO MICROMEDEX OR CONTACT PHARMACY". Product information will be available through a hyperlink on the electronic MAR to access Micromedex drug information database. Also, the drug list with black box warnings will be reviewed and updated periodically when necessary in consistent with the adverse drug event reports, new black box warnings and/or clinical data.

74

UMDNJ-University Hospital High Risk/ High Alert Medications 2008-09

1. 2. 3. 4. 5. 6. 7.

Chemotherapeutic Agents (e.g. Methotrexate, Cisplatin, Carboplatin, Paclitaxel, Docetaxel, Vinblastine, Vincristine etc.) Heparin Fosphenytoin/ Phenytoin IV Digoxin IV Neuromuscular Blocking Agents (e.g. Norcuron®, Pavulon®, Quelicin®, Nimbex®, Zemuron® etc.) Colchicine IV Insulin Products (e.g. Novolin R, Novolin N, Novolog, Lantus, Novolog Mix 75/25, ULTRAlente, Lente)

75 8. 9. 10. 11.

The concentrated electrolyte solutions that have been removed from the patient care areas at University Hospital are: 1. Concentrated Potassium Chloride Injection (Vials) 2. Potassium Phosphate Injection (Vials) 3. Sodium Phosphate Injection (Vials) 4. Magnesium Sulfate Injection (Greater than 2ml) 5. Sodium Chloride (Greater than 0.9%)

Look Alike/ Sound Alike Medications 2008-09 Heparin and Hespan Retrovir and Ritonavir Pitocin and Pitressin Insulin Products ( e.g. Lantus and Lente, Humalog and Humulin Novolog and Novolin, Humulin and Novolin, Humalog and Novolog, Novolin 70/30 and Novolog Mix 70/30) 12. Folic Acid and Folinic Acid (leucovorin calcium) 13. HydrOXYzine and HydrALAzine

1. Chemotherapeutic Products (e.g. Cisplatin and Carboplatin, Taxol and Taxotere, Vinblastine and Vincristine) 2. Lipid-based Amphotericin products vs. Conventional Forms of Amphotericin 3. Avandia and Coumadin 4. Celebrex, Celexa and Cerebyx 5. Clonidine and Clonazepam 6. Dopamine and Dobutamine 7. Diflucan and Diprivan

High Risk/High Alert Medications PHARMACY ACCOMPLISHMENTS 2008-09

Drugs

Pharmacy Preventive Measures

Nursing Preventive Measures

Prescriber Preventive Measures

Chemotherapy Agents (e.g. Methotrexate, Cisplatin, Carboplatin, Paclitaxel, Docetaxel, Vinblastine, Vincristine, etc.)

76

· All chemotherapeutic agents are stored separately from other medications and NOT in alphabetical order. · All chemotherapy orders are checked by two registered pharmacists. · The Calvert Formula was approved by the Oncology subcommittee as the standard format for calculating Carboplatin dosing. · Computer alerts are generated for all chemotherapeutic agents. · Chemotherapy protocols are being developed by pharmacy in conjunction with nursing on a number of agents that are used in the facility. Protocols will be available on all nursing stations as part of the formulary manual as well as in the Pharmacy Policy and Procedure manual.( Ongoing) · All chemotherapeutic orders will

· Chemotherapy protocols being developed by pharmacy in conjunction with nursing on a number of agents that are used in the facility. Protocols will be available on all nursing stations as part of the formulary manual as well as in the Pharmacy Policy and Procedure manual. · Failure Mode Effective Analysis (FMEA): Pharmacists in collaboration with nurses and physicians developed guidelines and protocols for proper chemotherapy ordering, mixing, dispensing, administration and monitoring. Oncology subcommittee consisting of RPHs, RNs and MDs meets on a bimonthly basis and monitors patient safety goals periodically. · Standardized chemotherapeutic agent concentrations and compati-

· Prescribing is restricted to credentialed providers. · Failure Mode Effective Analysis (FMEA): Pharmacists in collaboration with nurses and physicians developed guidelines and protocols for proper chemotherapy ordering, mixing, dispensing, administration and monitoring. Oncology subcommittee consisting of RPHs, RNs and MDs meets on a bimonthly basis and monitors patient safety goals periodically. · Preprinted chemotherapy order forms to be employed (starting April 2005) by physicians with information on standardized antineoplastic concentrations, compatible diluents and rate of administration printed on the back of the order sheets. · Preprinted antiemetic order

·

·

·

77

·

·

·

be written on newly revised preprinted order forms (starting April 2005) approved by the Oncology Subcommittee, P&T and MEC. On-line resources and current drug reference texts readily available for reference. Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. All chemotherapeutic products are labeled and sent separately in clearly identifiable oncology bags to patient care areas. Competency assessments of RPHs and pharmacy technicians periodically. Standardized chemotherapeutic agent concentrations with compatible diluents posted in oncology pharmacy. Use of "Phaseal system" in chemotherapy mixing area to prevent worker exposure to antineoplastics. ble diluents posted on nursing units. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted in nursing units which include high risk/high alert medication list, look alike/alike medication list, unacceptable dangerous abbreviations, UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations and UH standardized drug concentrations) and drug formulary are also available on the UH web

forms categorized by emetogenic potential of chemotherapy to be used by physicians.( Ongoing) · In-services provided to physicians, residents and fellows on a regular basis for high alert medications, dangerous abbreviations unacceptable in medication orders/notes, and look alike/sound alike medications. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted in nursing units which include high risk/high alert medication list, look alike/alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/alike medication list, dangerous abbreviations, UH standardized drug concentrations) and drug formulary are also available on the UH web.

Drugs

Pharmacy Preventive Measures

Nursing Preventive Measures

Prescriber Preventive Measures

78

· Prescribing is restricted to privileged providers. List of prescribers credentialed posted in oncology pharmacy. · Failure Mode and Effects Analysis (FMEA): Pharmacists in collaboration with nurses and physicians developed guidelines and protocols for proper chemotherapy ordering, mixing, dispensing, administration and monitoring. Oncology subcommittee consisting of RPHs, RNs and MDs meets on a bimonthly basis and monitors patient safety goals periodically. · As part of the overall Patient Safety initiatives NO VERBAL ORDERS FOR CHEMOPTHERAPY AGENTS WILL BE ACCEPTED. · All antineoplastic agents dispensed with following sticker CAUTION: CHEMOTHERAPY HANDLE WITH GLOVES DISPOSE OF PROPERLY

79

Drugs

Pharmacy Preventive Measures

Nursing Preventive Measures

Prescriber Preventive Measures

Heparin

80

· Elimination of multiple strengths carried by pharmacy. Heparin available in limited strengths in hospital pharmacy. · Heparin storage area in pharmacy marked with "high alert" medication stickers. · Pharmacy triggered computer pop-up alerts indicating dosage/drug/ strength checks for pharmacists profiling the drug. · Essential patient information such as allergies, age, weight, pregnancy, lactation status, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by

· In pyxis the individual heparin vials and pyxis pockets carrying heparin are labeled with "high alert" sticker. · Laminated sheets with standardized heparin drip concentration posted in patient charts and nursing units. · In-services provided to nurses on a regular basis for high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the physician order and MAR on a regular basis. · Mandatory training for health care professionals in UH on patient safety goals, high risk and look alike/sound alike medications. · All units have a copy of drug formulary on the floor and laminated sheets in patient care

· In-services provided to physicians, residents and fellows on a regular basis for high alert medications, UH dangerous abbreviations not acceptable in medication orders/notes, and look alike/sound alike medications. · Residents and physicians encouraged to order standardized heparin drips. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted in nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations, UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized

Heparin

(Continued)

2 pharmacists before dispensing. · When heparin dispensed from pharmacy, it is accompanied by a "high alert" sticker. · Daily monitoring of aPTT by unit based pharmacists for patients on heparin and subsequent consultation with physicians on any dose changes and drug interactions. · Competency assessments of RPHs and pharmacy technicians periodically.

drug concentrations) and drug formulary are also available on the UH web. · Preprinted heparin order sheets for hemodialysis patients available. · 24 hr stop time on heparin drips prompting physicians to monitor the rates and aPTT daily before reordering.

81

charts & posted in nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations, UH standardized drug concentrations · This patient safety information(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations). · Monthly floor inspections by pharmacy staff to check if stocking of heparin in the pyxis is in accordance with UH policy.

Drugs

Pharmacy Preventive Measures

Nursing Preventive Measures

Prescriber Preventive Measures

Fosphenytoin/ Phenytoin IV

82

· Fosphenytoin/ phenytoin IV storage bin/area in pharmacy marked with "high alert" medication stickers. · Pharmacy triggered computer pop-up alerts indicating dosage/drug/ strength checks for pharmacists profiling the drug. · Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. · Mandatory training for health care professionals in UH on patient safety goals, high risk and look alike/sound alike medications. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted in nursing units which include high risk/high alert medication list, look alike/alike medication list, unacceptable dangerous abbreviations and UH stan-

· Preprinted tabulated handouts for correlating observed and corrected phenytoin levels with plasma albumin available for a quick reference. · In-services provided to physicians, residents and fellows on a regular basis for high alert medications, dangerous abbreviations not acceptable in medication orders/notes, and look alike/sound alike medications. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted in nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations, and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous

Fosphenytoin/ Phenytoin IV dardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations) and drug formulary are also available on the UH web.

abbreviations, UH standardized drug concentrations).

(Continued)

· When Fosphenytoin/ phenytoin IV dispensed from pharmacy, it is accompanied by "high alert" sticker. · Daily monitoring of Phenytoin and albumin levels and interacting medications by unit based pharmacists and reporting any abnormal findings to physicians. · Competency assessments of RPHs and pharmacy technicians periodically.

83

Drugs

Pharmacy Preventive Measures

Nursing Preventive Measures

Prescriber Preventive Measures

Digoxin IV

84

· Digoxin IV storage area marked with "high alert" stickers in pharmacy. · Pharmacy triggered computer pop up alerts indicating dosage/ drug/ strength checks for pharmacists profiling the drug. · Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. · When Digoxin IV is dispensed from pharmacy, it is accompanied by a "high alert" sticker. · Pockets in pyxis carrying digoxin are marked with "high alert" stickers. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and, UH standardized drug concentrations.

· In-services provided to physicians, residents and fellows on a regular basis for high alert medications, dangerous abbreviations not acceptable in medication orders/notes, and look alike/sound alike medications. · Clinical pharmacy department involved in regular inservicing of residents, and doctors about pharmacokinetic monitoring, proper dosing of digoxin, and its high alert status. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted in nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert med-

Digoxin IV · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations) and drug formulary are also available on the UH web. · Monthly floor inspections by pharmacy staff to check if digoxin is stocked in pyxis in accordance with UH policy.

(Continued)

· Abnormal serum digoxin levels reviewed by pharmacists daily and physicians informed of any dosing changes or drug interactions. · Competency assessments of RPHs and pharmacy technicians periodically.

ication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations) and drug formulary are also available on the UH web.

85

Drugs

Pharmacy Preventive Measures

Nursing Preventive Measures

Prescriber Preventive Measures

Neuromuscular Blocking Agents (e.g. Nimbex®, Norcuron®, Pavulon®, Quelicin®, Zemuron® etc.)

86

· Paralyzing Agent" sticker placed on all neuromuscular blocker vials prior to dispensing unless illustrated by manufacture. · Epic pharmacy computer entry system gives pop up alerts to pharmacists profiling the drug warning them of their high risk status. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. · Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · Competency assessments of RPHs and pharmacy technicians periodically. · Pockets in pyxis carrying neuromuscular blockers are marked with "paralyzing agent" stickers. · Mandatory training for health care professionals in UH on patient safety goals, high risk, and look alike / sound alike medications. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts which include high risk/high alert medication list,

· In-services provided to physicians, residents and fellows on a regular basis for high alert medications, dangerous abbreviations not acceptable in medication orders/notes, and look alike/sound alike medications. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and, UH standardized drug concentrations. The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations) and drug formulary are also available on the UH web.

Neuromuscular Blocking Agents (e.g. Nimbex®, Norcuron®, Pavulon®, Quelicin®, Zemuron® etc.) look alike/sound alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations) and drug formulary are also available on the UH web.

(Continued)

87

Drugs

Pharmacy Preventive Measures

Nursing Preventive Measures

Prescriber Preventive Measures

Colchicine IV

88

· Colchicine IV storage area marked with "high alert" stickers in pharmacy. · Pharmacy triggered computer pop up alerts indicating dosage/ drug/ strength checks for pharmacists profiling the drug. · Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. · When Colchicine IV is dispensed from pharmacy, it is accompanied by a "high alert" sticker. · Pockets in pyxis carrying Colchicine IV are marked with "high alert" stickers. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations, and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert med-

· In-services provided to physicians, residents and fellows on a regular basis for high alert medications, dangerous abbreviations not acceptable in medication orders/notes, and look alike/sound alike medications. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

Colchicine IV (Continued) ication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations). Monthly floor inspections by pharmacy staff to check if Colchicine IV is stocked in pyxis in accordance with UH policy.

· Competency assessments of RPHs and pharmacy technicians periodically.

89

Drugs

Pharmacy Preventive Measures

Nursing Preventive Measures

Prescriber Preventive Measures

Insulin Products (e.g. Novolin R, Novolin N, Novolog, Lantus, Novolog Mix 75/25, ULTRAlente, Lente)

90

· Each type of insulin clearly identified by auxiliary labeling(R, N, Ultralente, Novolog, Lantus etc.) in pharmacy. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. · Pharmacy triggered computer pop up alerts indicating dosage/drug/ strength checks for pharmacists profiling the drug. · Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · All Humulin products removed from the formulary to avoid confusion with Novolin products.

· Monthly floor inspections by pharmacy staff to check if insulin vials on the floors are stored in accordance with UH policy. · Insulin products arranged and categorized in the refrigerator on nursing units to prevent potential mix ups. · Each insulin vial carries the bright colored "identifying sticker" differentiating it from other insulin products on the floor. · Preprinted sliding scales for Novolog available to standardize the dosing. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the

· Preprinted hyperglycemic and hypoglycemic protocols available for use to standardize ordering by physicians. · Residents and doctors inserviced about formulary products and standard sliding scale protocols in the hospital.(Ongoing) · In-services provided to physicians, residents and fellows on a regular basis for high alert medications, dangerous abbreviations not acceptable in medication orders/notes, and look alike/sound alike medications. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations, and UH standardized drug concentrations.

Insulin Products (e.g. Novolin R, Novolin N, Novolog, Lantus, Novolog Mix 75/25, ULTRAlente, Lente) (Continued)

· Competency assessments of RPHs and pharmacy technicians periodically.

· The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

91

physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations, and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

LOOK ALIKE/SOUND ALIKE MEDICATION LIST PHARMACY ACCOMPLISHMENTS 2008-09

RN Preventive Measures MD Preventive Measures

Drug

RPH Preventive Measures

Chemotherapeutic Products (e.g. Cisplatin and Carboplatin, Taxol and Taxotere, Vinblastine and Vincristine) (Continued) · Chemotherapy protocols were developed by pharmacy in conjunction with nursing on a number of agents that are used in the facility. Protocols are available on all nursing station as part of the formulary · Failure Mode Effects Analysis (FMEA): Pharmacists in collaboration with nurses and physicians developed guidelines and protocols for proper chemotherapy ordering, mixing, dispensing, administration and monitoring. Oncology subcommittee consisting of RPHs, RNs and MDs and meets on a monthly basis and monitors patient safety goals periodically. · Standardized chemotherapeutic agent concentrations and compatible diluents posted on nursing units.

92

· All chemotherapeutic agents are stored separately from other medications and NOT in alphabetical order. · All chemotherapy orders are checked by two registered pharmacists. · Computer alerts are generated for all chemotherapeutic agents. · All chemotherapeutic orders will be written on newly revised pre-printed order forms approved by the Oncology Subcommittee, P&T and MEC starting April 2005. · All chemotherapeutic products are labeled and sent separately in clearly identifiable oncology bags to patient care areas. · Standardized chemotherapeutic agent concentrations with compatible diluents posted in oncology pharmacy.

· Prescribing is restricted to credentialed providers. · Failure Mode Effects Analysis (FMEA): Pharmacists in collaboration with nurses and physicians developed guidelines and protocols for proper chemotherapy ordering, mixing, dispensing, administration and monitoring. Oncology subcommittee consisting of RPHs, RNs and MDs meets on a monthly basis and monitors patient safety goals periodically. · Preprinted chemotherapy order forms to be employed (starting April 2005) by physicians with information on standardized antineoplastic concentrations, compatible diluents and rate of administration printed on the back of the order sheets. · Preprinted antiemetic order forms categorized by emeto-

Chemotherapeutic Products (e.g. Cisplatin and Carboplatin, Taxol and Taxotere, Vinblastine and Vincristine) (Continued)

93

· Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · As part of the overall Patient Safety initiatives NO VERBAL ORDERS FOR CHEMOPTHERAPY ACCEPTED. · Failure Mode Effective Analysis (FMEA): Pharmacists in collaboration with nurses and physicians developed guidelines and protocols for proper chemotherapy ordering, mixing, dispensing, administration and monitoring. Oncology subcommittee consisting of RPHs, RNs and MDs meets on a bimonthly or monthly basis and oversees patient safety goals periodically. · Competency assessments of RPHs and pharmacy technicians periodically. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/ strengths/administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations, and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

genic potential of chemotherapy to be used by physicians. (Ongoing) · In-services provided to physicians, residents and fellows on a regular basis for high alert medications, dangerous abbreviations not acceptable in medication orders/notes, and look alike/sound alike medications. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

Drug

RPH Preventive Measures

RN Preventive Measures

MD Preventive Measures

94

Lipid-based · Lipid-based: AMBISOME Amphotericin products (amphotericin B liposomal) vs. Conventional Forms ABELCET (amphotericin B lipid of Amphotericin complex) · Conventional: AMPHOCIN, FUNGIZONE INTRAVENOUS (amphotericin B) · Many drugs now come in liposomal formulation indicated for special patient populations. Confusion may occur between the liposomal and the conventional formulations because of name similarity. The products are not interchangeable. · UH Pharmacy carry Abelcet as a formulary · Lipid-based formulation dosing guidelines differ significantly from conventional dosing. Conventional amphotercin B desoxycholate doses should not exceed 1.5 mg/kg/day. Doses of the lipid-based products are higher, but vary from product to product. If conven· Mandatory training quizzes mandatory for health care professionals in UH on patient safety goals, high risk and look alike/ sound alike medications. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/ strengths/ administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations, UH standardized drug concentrations.

· In-services provided to physicians, residents and fellows on a regular basis for look alike/ sound alike medications and to write these orders in a legible manner, with clear specification of dosage form, drug strength, complete directions and with indication, brand & generic names if possible and about dangerous abbreviations not acceptable in medication orders/notes. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations, and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound

Lipid-based Amphotericin products vs. Conventional Forms of Amphotericin (Continued) · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

alike medication list, dangerous abbreviations, UH standardized drug concentrations).

·

·

95

·

·

tional amphotericin B is given at a dose appropriate for a lipidbased product, a severe adverse event is likely. Confusion between these products has resulted in episodes of respiratory arrest and other dangerous, sometimes fatal outcomes due to potency differences between these drugs. Staff involved in handling these products should be aware of the differences between conventional and lipid-based formulations of these drugs. Encourage staff to refer to the lipid-based products by their brand names and not just their generic names. Stop and verify that the correct drug is being used if staff, patients or family members notice a change in the solution's appearance from previous infusions. Lipid based products may be seen as cloudy rather than a clear solution. Storage of lipidbased

Drug

RPH Preventive Measures

RN Preventive Measures

MD Preventive Measures

Avandia and Coumadin

96

· Separate location for both of these drugs in the pharmacy. · "Look alike/ Sound alike" stickers attached to the medication bins/areas. · Dispensing of these drugs with "Look alike/ Sound alike" stickers. · Pharmacy triggered computer pop up alerts indicating dosage/ drug/ strength checks for pharmacists profiling the drug. · Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. · Mandatory training quizzes mandatory for health care professionals in UH on patient safety goals, high risk and look alike/ sound alike medications. · Pockets in pyxis carrying these drugs are marked with "Look alike/ Sound alike" stickers. · Both generic and brand name medication list available on the pyxis screen. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care

· Preprinted oral hyperglycemic management protocols for physician reference. · Concerns encountered in reading the physician orders incorrectly for Avandia-Coumadin pair. In-services provided to physicians, residents and fellows on a regular basis for Look alike/ Sound alike medications and to write these orders in a legible manner, with clear specification of dosage form, drug strength, complete directions and with indication, brand & generic names if possible and about dangerous abbreviations not acceptable in medication orders/notes. · 24 hr stop time for warfarin requiring physicians to monitor the dosing and INR daily before reordering. · All units have a copy of drug formulary on the floor and lami-

Avandia and Coumadin (Continued) charts & posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

· All medications labeled with brand and generic names before dispensing. · Only one manufacturer brand `Coumadin' stocked in the pharmacy to avoid confusion. · Phytonodione (Vitamin K) included in the ADR trigger medication list to address potential warfarin overdose. · Regular INR monitoring performed by unit based pharmacists and abnormal findings reported to physicians. · Clinical pharmacy department involved in regular inservicing of residents, and doctors about INR monitoring, proper dosing of warfarin and potential drug interactions and its "look alike/ sound alike" potential. · Competency assessments of RPHs and pharmacy technicians periodically.

nated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and, UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

97

Drug

RPH Preventive Measures

RN Preventive Measures

MD Preventive Measures

Celebrex, Celexa and Cerebyx

98

· Separate location for both of these drugs in the pharmacy. Celexa stored in non formulary section, Cerebyx stored in the refrigerator, and Celebrex stored in "Look alike/ Sound alike" medication area.· "Look alike/ Sound alike" stickers attached to the medication shelves. · Dispensing of these drugs with "Look alike/ Sound alike" stickers. · Pharmacy triggered computer pop up alerts indicating dosage/drug/ strength checks for pharmacists profiling the drug. · Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · Web based CT quizzes mandatory for health care professionals in UH on patient safety goals, high risk and look alike/ sound alike medications. · Pockets in pyxis carrying these drugs are marked with "Look alike/ Sound alike" stickers. · Both generic and brand name medication list available on the pyxis screen. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted on nursing

· In-services provided to physicians, residents and fellows on a regular basis for look alike/ sound alike medications and to write these orders in a legible manner with clear specification of dosage form, drug strength, complete directions and with indication brand & generic names if possible and about dangerous abbreviations not acceptable in medication orders/notes. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and, UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound

Celebrex, Celexa and Cerebyx (Continued) units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations, and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

· All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. · All medications labeled with brand and generic names before dispensing. · Competency assessments of RPHs and pharmacy technicians periodically.

alike medication list, dangerous abbreviations, UH standardized drug concentrations).

99

Drug

RPH Preventive Measures

RN Preventive Measures

MD Preventive Measures

Clonidine and Clonazepam

100

· Separate location for both of these drugs in the pharmacy. Clonazepam stored in C2 safe and Clonidine stocked in "Look alike/ Sound alike" medication area. · "Look alike/ sound alike" stickers attached to the medication shelves. · Dispensing of these drugs with "Look alike/ sound alike" stickers. · Pharmacy triggered computer pop up alerts indicating dosage/drug/ strength checks for pharmacists profiling the drug. · Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · Pockets in pyxis carrying these drugs are marked with "Look alike/ Sound alike" stickers. · Mandatory training quizzes mandatory for health care professionals in UH on patient safety goals, high risk and look alike/ sound alike medications. · Both generic and brand name medication list available on the pyxis screen. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care

· In-services provided to physicians, residents and fellows on a regular basis for look alike/ sound alike medications and to write these orders in a legible manner, with clear specification of dosage form, drug strength, complete directions and with indication brand & generic names if possible and about dangerous abbreviations not acceptable in medication orders/notes. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound

Clonidine and Clonazepam (Continued) charts & posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

· All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. · All medications labeled with brand and generic names before dispensing. · Competency assessments of RPHs and pharmacy technicians periodically.

alike medication list, dangerous abbreviations, UH standardized drug concentrations).

101

Drug

RPH Preventive Measures

RN Preventive Measures

MD Preventive Measures

Dopamine and Dobutamine

102

· Shelves containing these drugs are labeled with "identifying" stickers. Use of tall man letter "P" on DoPamine stickers and tall letter "B" on DoButamine stickers. · Proposal to limit strengths available on these 2 products.(Ongoing). · Pharmacy triggered computer pop up alerts indicating dosage/drug/ strength checks for pharmacists profiling the drug. · Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · Dispensing these drugs with auxiliary "identifying" stickers. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharma-

· Pockets in pyxis carrying these drugs are marked with "identifying" stickers. · In-services provided to nursing on a regular basis to identify Look alike/ Sound alike medications. · Both generic and brand name medication list available on the pyxis screen. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/ strengths/administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted on nursing units which include high risk/high alert medication list,

· Physician ordering of standardized premixed concentrations encouraged by pharmacy. · List of standardized concentrations posted on nursing units, in patient care charts and handed out to residents and doctors during inservices. · In-services provided to physicians, residents and fellows on a regular basis for look and to order both of these drugs with standardized concentrations in a legible manner and about dangerous abbreviations not acceptable in medication orders/notes. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH stan-

Dopamine and Dobutamine (Continued) look alike/sound alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

cists before dispensing. · All medications labeled with brand and generic names before dispensing. · Competency assessments of RPHs and pharmacy technicians periodically.

dardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

103

Drug

RPH Preventive Measures

RN Preventive Measures

MD Preventive Measures

Heparin and Hespan

104

· Both drugs stored in physically separated location in pharmacy. · "Look alike/ sound alike" stickers attached to the medication shelves. · Pharmacy triggered computer pop up alerts indicating dosage/ drug/ strength checks for pharmacists profiling the drug. · Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. · Dispensing of these drugs with "Look alike/ Sound alike" stickers.

· Standardized premixed concentrations for both drugs available and encouraged. · Mandatory training quizzes mandatory for health care professionals in UH on patient safety goals, high risk and look alike/ sound alike medications. · Pockets in pyxis carrying these drugs are marked with "Look alike/ Sound alike" stickers. · Both generic and brand name medication list available on the pyxis screen. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the physician order and MAR on a regular basis.

· In-services provided to physicians, residents and fellows on a regular basis for look alike/ sound alike medications and to write these orders in a legible manner, with clear specification of dosage form, drug strength, complete directions and with indication if possible and about dangerous abbreviations not acceptable in medication orders/notes. · Pharmacy will inservice SICU physicians/residents to document indication on Hespan orders to distinguish from heparin orders. (Ongoing). · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH stan-

Heparin and Hespan (Continued)

· All medications labeled with brand and generic names before dispensing. · Competency assessments of RPHs and pharmacy technicians periodically.

dardized drug concentrations. The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

105

· All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

Drug

RPH Preventive Measures

RN Preventive Measures

MD Preventive Measures

Retrovir and Ritonavir

106

· Stored in physically separate locations in pharmacy (Ritonavir in refrigerator and Retrovir under "high alert look alike/ sound alike" section.) · Computer generated alerts to warn pharmacists profiling these drugs. · Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. · Accompanied by a look alike sound alike labels when dispensed from pharmacy. · Pockets in pyxis carrying these drugs are marked with "look alike/ sound alike" stickers. · Mandatory training quizzes mandatory for health care professionals in UH on patient safety goals, high risk and look alike/ sound alike medications. · Both generic and brand name medication list available on the pyxis screen. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care

· In-services provided to physicians, residents and fellows on a regular basis for look alike/ sound alike medications and to write these orders in a legible manner, with clear specification of dosage form, drug strength, complete directions and with indication if possible and about dangerous abbreviations not acceptable in medication orders/notes. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

Retrovir and Ritonavir (Continued) charts & posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

· All medications labeled with brand and generic names before dispensing. · Competency assessments of RPHs and pharmacy technicians periodically.

107

Drug

RPH Preventive Measures

RN Preventive Measures

MD Preventive Measures

Pitocin and Pitressin

108

· Pharmacy changed manufacturers on these drugs to procure vials with dissimilar colors for Pitressin and Pitocin. · Pharmacy prepares Pitocin bags on a daily basis and delivers to L&D. · QI project for Anesthesiology for IV bag labeling developed with performance measurement and trend.(Ongoing) · Stored in physically separate locations in pharmacy. · Computer generated alerts to warn pharmacists profiling these drugs. · Essential patient information such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen available to RPh profiling and dispensing the medication. · On-line resources and current drug reference texts readily available for reference. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders

· Pitocin removed from Anesthesia Carts and stocked exclusively in the Anesthesia OR workroom. · Pockets in pyxis carrying these drugs are marked with "Look alike/ Sound alike" stickers. · Red "Medication added" labels will be stocked in the OR and preprinted medication labels removed. (Completed 06/21/04) · Education to reinforce policy for correct medication labeling conducted for CRNAs and anesthesiologist. · Standardization of procedures for handling of IV medication in the SICU for patients arriving from the OR. · Mandatory training quizzes mandatory for health care professionals in UH on patient safety goals, high risk and look alike/ sound alike medications. · Both generic and brand name medication list available on the pyxis screen.

· Education to reinforce policy for correct medication labeling conducted for CRNAs and anesthesiologist. · In-services provided to physicians, residents and fellows on a regular basis for look alike/ sound alike medications and to write these orders in a legible manner, with clear specification of dosage form, drug strength, complete directions and with indication, brand & generic names if possible and about dangerous abbreviations not acceptable in medication orders/notes. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH stan-

Pitocin and Pitressin (Continued)

are double checked by 2 pharmacists before dispensing. · Accompanied by "look alike/ sound alike" labels when dispensed from pharmacy. · All medications labeled with brand and generic names before dispensing. · Competency assessments of RPHs and pharmacy technicians periodically.

dardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

109

· In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/ strengths/administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations, and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

Drug

RPH Preventive Measures

RN Preventive Measures

MD Preventive Measures

Insulin Products (e.g. Lantus and Lente, Humalog and Humulin, Novolog and Novolin, Humulin and Novolin, Humalog and Novolog, Novolin 70/30 and Novolog Mix 70/30) · Monthly floor inspections by pharmacy staff to check if insulin vials on the floors are stored in accordance with UH policy. · Insulin products arranged and categorized in the refrigerator on nursing units to prevent potential mix ups. · Each insulin vial carries the bright colored "identifying" sticker differentiating it from other insulin products on the floor. · Preprinted sliding scales for Novolog available to standardize the dosing. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the

110

· Each type of insulin clearly identified by auxiliary labeling(R, N, Ultralente, Novolog, Lantus etc.) in pharmacy. · All insulin vials are labeled with "identifying" stickers prior to dispensing. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. · Pharmacy triggered computer pop up alerts indicating dosage/drug/ strength checks for pharmacists profiling the drug. · All Humulin products removed from the formulary to avoid confusion with Novolin products. · Competency assessments of RPHs and pharmacy technicians periodically.

· Preprinted hyperglycemic and hypoglycemic protocols available for use to standardize ordering by physicians. · Residents and doctors inserviced about formulary products and standard sliding scale protocols in the hospital. · In-services provided to physicians, residents and fellows on a regular basis for high alert medications, dangerous abbreviations not acceptable in medication orders/notes, and look alike/sound alike medications. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations.

Insulin Products (e.g. Lantus and Lente, Humalog and Humulin, Novolog and Novolin, Humulin and Novolin, Humalog and Novolog, Novolin 70/30 and Novolog Mix 70/30) (Continued)

· The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

111

physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

Drug

RPH Preventive Measures

RN Preventive Measures

MD Preventive Measures

Folic Acid and Folinic Acid (leucovorin calcium)

112

· Both drugs stored in physically separated location in pharmacy. · "Look alike/ sound alike" stickers attached to the medication shelves. · Pharmacy triggered computer pop up alerts indicating dosage/drug/ strength checks for pharmacists profiling the drug. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. · Dispensing of these drugs with "Look alike/ Sound alike" stickers. · All medications labeled with brand and generic names before dispensing. · Competency assessments of RPHs and pharmacy technicians periodically. · Pockets in pyxis carrying these drugs are marked with "Look alike/ Sound alike" stickers. · Both generic and brand name medication list available on the pyxis screen. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable danger-

· In-services provided to physicians, residents and fellows on a regular basis for look alike/ sound alike medications and to write these orders in a legible manner, with clear specification of dosage form, drug strength, complete directions and with indication if possible and about dangerous abbreviations not acceptable in medication orders/notes. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing unitswhich include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous

Folic Acid and Folinic Acid (leucovorin calcium) (Continued) ous abbreviations and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

abbreviations, UH standardized drug concentrations).

113

Drug

RPH Preventive Measures

RN Preventive Measures

MD Preventive Measures

HydrOXYzine and HydrALAzine

114

· These drugs in the pharmacy stored at separate location with "tall man" characters · "Look alike/ Sound alike" sticker attached to their medication shelves. · Dispensing of these drugs with "Look alike/ Sound alike" stickers. · Pharmacy triggered computer pop up alerts indicating dosage/drug/ strength checks for pharmacists profiling the drug. · All medications are initialed by a technician and a pharmacist prior to dispensing. All pediatric orders are double checked by 2 pharmacists before dispensing. · All medications labeled with brand and generic names before dispensing. · Pockets in pyxis carrying these drugs are marked with "Look alike/ Sound alike" stickers and stored in different locations · Both generic and brand name medication list available on the pyxis screen. · In-services provided to nurses on a regular basis for high risk/high alert medications, UH dangerous abbreviations unacceptable in medication orders/notes/ MAR, and look alike/sound alike medications and to verify the drug/dosages/strengths/ administration routes against the physician order and MAR on a regular basis. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts & posted on nursing units which include high risk/high alert medication list, look alike/sound alike medica-

· In-services provided to physicians, residents and fellows on a regular basis for look alike/ sound alike medications and to write these orders in a legible manner, with clear specification of dosage form, drug strength, complete directions and with indication, brand & generic names if possible and about dangerous abbreviations not acceptable in medication orders/notes. · All units have a copy of drug formulary on the floor and laminated sheets in patient care charts and posted on nursing units which include high risk/high alert medication list, look alike/sound alike medication list, unacceptable dangerous abbreviations, and UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound

HydrOXYzine and HydrALAzine (Continued) tion list, unacceptable dangerous abbreviations, UH standardized drug concentrations. · The national patient safety goals(high risk/high alert medication list, look alike/sound alike medication list, dangerous abbreviations, UH standardized drug concentrations).

alike medication list, dangerous abbreviations, UH standardized drug concentrations).

115

Concentrated Electrolyte Solutions Removed From Patient Care Area at the University Hospital

RATIONALE Administering by direct IV push without diluting can be fatal. PREVENTIVE MEASURES

MEDICATION

Concentrated Potassium Chloride injection

116 Potential for overdose to be administered by IV push using multi-dose vial.

· Concentrated Potassium Chloride has been removed from all patient care areas. · Potassium chloride IV policy was formulated to provide concentration and administration guidelines. · Pharmacy will provide premixed potassium chloride 10mEq 100ml and 20mEq 100ml IVPB bags. · All potassium chloride extemporaneous solutions are prepared in the pharmacy. · Commercially available premixed solutions are used whenever possible. · Potassium phosphate and sodium phosphate are not available in any of the patient care areas. · Potassium phosphate and sodium phosphate are mixed extemporaneously in the pharmacy department. · Potassium phosphate and sodium phosphate are limited to one strength in the

Potassium Phosphate and Sodium Phosphate

Magnesium sulfate injection

Potential for overdose to be administered by IV push using multi-dose vials

· Magnesium sulfate 1 gram /2ml single dose vial is the only dose available in patient care areas. · Pharmacy supplies Labor & Delivery with pre-mixed magnesium sulfate 4 gram and 40 gram IV bags.

Concentrated sodium chloride 3% 500ml IVPB or 23.4% 50ml vial

Potential for medication error if used for flushing IV lines or for diluting medications

· The 3% 500ml IVPB bag is dispensed only as patient order. · The 23.4% 50ml vial is used only by the pharmacy department for compounding.

117 Limit confusion when ordering intravenous calcium preparations. · Calcium orders require metric weight, they are not ordered by volume or ampoule. · Calcium products and concentrations have been limited in all patient care areas. · The pharmacy department has provided the smallest size package (concentration) for floor stock use.

Calcium gluconate * and Calcium chloride *

* Only Available on patient care areas in smallest size package(1gram vials)

UMDNJ-University Hospital · JCAHO Patient Safety Goals · Pharmacy Department Process

· Ongoing

JACHO Patient Safety Goal

Follow Up

2(B): Improve the effectiveness of communication among caregivers

JACHO recommendation: Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to be used

118

· List of UH Dangerous Abbreviations meets JACHO 2003-2004 recommendations · List of abbreviations, acronyms and symbols not to be used in the UH posted on the UHNet, nursing stations, hospital formulary, individual patient's chart and Medical Record Office. · Laminated cards placed in every patient's medical record and mouse pads with dangerous abbreviation lists distributed to residents, doctors, fellows, RN's and placed hospital wide on the nursing units. · More than 85 inservices in year 2003 and 50 inservices in year 2004 given to nursing, doctors and pharmacists. · Mandatory tranings Education on Patient Safety Goal for all physicians, residents and nurses developed. · Monthly data collection for compliance of Medication Orders. Reports presented to monthly P&T meetings.

Concentrated Electrolyte Solutions Removed From Patient Care Area at the University Hospital

· Monthly inspections of hospital units by pharmacy staff to monitor for high risk medications, outdates and inappropriate storage conditions. · Pharmacist initiated prescriber notification if IV drips available in Standardized Drug Concentration. · Ongoing Project

3(A) Improved safety of using High Alert Medication

JACHO recommendation: Remove Concentrated electrolytes( potassium chloride, potassium phosphate, sodium chloride) from patient care units and standardize and limit number of drug concentrations in hospital.

119

· A list of high alert medications is available on the pharmacy website and hospital formulary. · Laminated high alert medication list and standardized drug concentrations list were posted in each patient's chart and nursing unit. · About 300 new residents( 2006-07) were given inservices. · Over 80 inservices given to house staffs, nursing, and pharmacy staff. · FMEA completed for chemotherapy · All concentrated electrolyte solutions( Concentrated Potassium Chloride Injection, Potassium Phosphate Injection, Sodium Phosphate Injection, Magnesium Sulfate Injection (Greater than 2ml), Sodium Chloride (Greater than 0.9%) have been removed from the patient care areas at University Hospital. These are only dispensed to units after proper dilution. · Mandatory training Education on Patient Safety Goal for all physicians, residents and nurses developed

Concentrated Electrolyte Solutions Removed From Patient Care Area at the University Hospital

· Cerner® pharmacy computer prints out abnormal lab result daily. Pharmacists follow up with these abnormal lab results. They make recommendations to prescribers about dosage adjustment, drug interactions and adverse effects etc. · Data collections are done daily and reported to Pharmacy and Therapeutic Committee every month. · Ongoing Project

2(C): Improve the effectiveness of communicating among caregivers.

JACHO Recommendation: Measure, assess and if appropriate take action to improve the timeliness of reporting and the timeliness of receipt by the responsible licensed caregiver of critical test results and values · Pharmacy will buy all premixed items. · Ongoing Project

3( C):Improve the safety of using medications · Multidisciplinary Team did the FMEA (6 sections) New Chemo Standard Preprinted form approved by Medical Record Committee (in process). · Mandatory training on Patient Safety Goal for all physicians, residents and nurses developed

120

JACHO Recommendation: Identify and ,at minimum , annually review a list of lookalike/sound-alike drug used in the organization, and take action to prevent errors involving the interchange of these drugs

File: 2008 YT 707-500-110 High Risk, High alert med, look alike sound alike med accomplishment list 010108atest

Information

2008 Medication management

120 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

36908


You might also be interested in

BETA
p598-606 copy
Care of Patients II
2008 Medication management