Pharmacist Training

&Reference

Manual

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MISSION

The mission of Unity Health System is to make a positive difference in the lives and health status of individuals in the city of Rochester and

will educate our community, our providers, and future health care professionals in order to offer the highest quality care to all members

of our community, especially those who are underserved and most vulnerable.

OUR HOSPITAL SYSTEM

Unity is a 681-bed health care network serving the city of Rochester and western Monroe County. A wide range of specialty programs and services are available at Unity Hospital, the Unity St. Mary's Campus, and multiple sites across Monroe County. The primary clinical site will be at Unity Hospital which is a 360-bed community teaching hospital.

Pharmacists at Unity work with physicians, nurses, and other supportive personnel to provide cost-effective care through medication

selection, preparation, focused monitoring, outcome evaluation, and implementation of practice guidelines. Other responsibilities of pharmacists at Unity include working on process improvement

projects, providing education to other health care professionals, and severing on selected hospital committees.

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Current Project Team Leaders: Bob Adams Leo Cai Shashi Patel

Contributing Team Members Jill Graham Susan Kang Andrea Smith

Acknowledgement for Help and Input throughout Development:

Hamied Alkamil Pete Chakos Kevin Conlon Lisa Cringoli Paul Dahler Mavis Jasmine Jeff Kasten Cynthia Marx Natalie Kremer Patnawon Thung

Updated July 8, 2008

I. General Hospital Information

Pharmacy Department Organizational Chart 5 Map of Park Ridge Campus 6 Hospital Floors/Units/Departments 7

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Table of Contents

Pharmacy Staff 9 PAs, Hospitalists, Residents 11 When to page who 14

II. Pharmacist Duties Overall Checking Procedures 15 Medication Order Entry / Work Flow 16 Park Ridge Satellite

AM Shift 17 Afternoon Shift 19 Evening Shift 20

Main (basement) 21 St. Mary’s 24

III. Protocols Auto Substitute 26 TPN 32 PPN 36 PDQ Delivery 39 PRCD After hour delivery 39 Standard Narcotic Concentration 40 IV Manufacturing Standards 41

IV. Professionalism Articles “Believing what we know: Pharmacy provides value” “Pharmacy does provide value, but is the profession built to last?”

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V. Misc. Cerner Short Codes / order sets 58 Pyxis FAQs 60 Computer Resources / Links 61 Cerner/Label/Mars Printers 62 IVF with Potassium 63 IV Push Policy 64 Fax Downtime procedures 65 Meds Not Loaded Policy 66 Policy 9.11 Antineoplastic/Cytotoxic Drugs 67 Unity Health High Alert Medications 76 Unity Health look-a-like sound-a-like Drug list 77 Joint Commission Educational Booklet (See Pharmacy Shared Folder) Chempack Handbook (See Pharmacy Shared Folder)

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Pharmacy DepartmentOrganizational Chart

James Della Rocco, RPh, J.D.Director of Pharmacy

Services

Lisa CringoliAdministrative

Assistant

Shashi Patel, PharmD

Director of Clinical Services

VaccantDirector of Operations

Larry Green, RPh

SP St. Mary’s ApothecaryPharmacists

James Rapp, RPh

SP Park Ridge Apothecary

vacantSystem

Administrator

Pamela Dunning

Purchasing Agent

Technicians

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PlaceExtension Fax   Place Extension Fax

Hospital Phone Numbers

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2100 1100 7200   2nd PACU 1233 78482100 Clinical Nurse

Leader Nadine Knapp 4490     PACU Ext Stay 4156  2200 1200 7375   PACU Ext Stay 7186  

2200 Clinical Nurse Leader Monty Cox 4491     PACU Ext Stay 1707  

2300 1300 7395   PACU Ext Stay 5024  2300 Clinical Nurse

Leader Mary R. 4492     Pamela (purchasing) 7328  2400 1400 7409   Patty Miller (narcotics) 7333  

2400 Clinical Nurse Leader Trish McCann 4493     Pharmacy Main 7330  7047

3100 5100 7478   Pharmacy Main 7336  70473100 Clinical Nurse

Leader (Chemo) Linda Hagan 4494     Pharmacy Main 7331  7047

3200 5200 7271   Pharmacy Satellite 7310  78483200 Clinical Nurse

Leader Lisa Ladowski 4495     Pharmacy Satellite 1312  19403300 5300 7309   Pharmacy Satellite 2340  

3300 Clinical Nurse Leader Donna Soles 4496     Pharmacy IV Room 7332  

3400 5400 7734  PRCD Medication Room (evening hours ext.) 4034  

3400 Clinical Nurse Leader Vicki Wray 4497     PRCD PA, Richard Wilson 306-8318  

4100 3919  3918   PRCD 5477  78494300 3600  3915   PreAn 7955  

5100 Charge Nurse-Renee Jenkins or Pamela Daniels 3270 3649   PreAn 1188  

Director of 5100 Ivy Shelby 263-8001     PreAn 1429  

6300 3540    Resident Float Evenings/Nights 240-5500  

Cardinal Emergency375-445-5399     Respiratory 7176  

PR Apothecary 7340     Rochester General 922-4481  SM Apothecary 3928     SCU 7702  Admitting 5895     Security 7745  

Chief Resident Pager 240-5500     Shashi Patel

x: 4164 pg: 306-0097  

System Administrator vacant 7970     Southside Apoth. 271-7141  Dialysis (3500) 4295   SPD 7157  ED Charge Nurse 7270     St. Mary's 3395 3397

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ED 1029 Strong Hospital (inpatient) 275-5213ED 7070 7045   Strong Hospital (outpatient) 275-4931  ED 1770     Surgical PA Float pager 220-7880  ED 1288     TCU 1696 7392ED Quickcare 5190     TCU 7132  

Environmental Services 7145     James Della Rocco

x: 7337 pg: 239-4829  

Help Desk 3375     Walk-in Care Center 3531  Help Desk after hours 7417    Highland Hospital 341-6790 7141   PDQ 475-0033    Hospice 3540     Acct # 8580  Hospice 3565     Pharmacy Acct # 17178  ICU-S 1425     Cost Center #108200  ICU-S 1095     Courier Pick-ups 1-800-220-3146  ICU-S 7090    ICU-C 1079     Pyxis Support    ICU-C 7397     1-800-727-6100  ICU-C 1056     Customer #311    ICU-N 1409    ICU-N 7017    ICU-N 1417 7226  Jim Finucane (pyxis) 7348    Kevin Conlon (Cerner) 4951    Lakeside Hospital 395-6047    

Leo Cai

x: 7829 pg: 323-0049    

LDRP 4020 4019  Lisa Cringoli 7283    Maintenance 5888    MOU 7279    Night Nursing Supervisor 5021    Nursery 4030    

OR Main Desk7975 or 7191    

OR Tech 320-0206    OR Recovery 1194    PACU 7186    PACU 5024    

Pharmacy Department8

NameExtensi

on fax pagerHome Phone Cell

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Abel, Theresa 7310     467-5812 259-8085Adams, Bob 7310   220-5280 563-7183 455-2448Alkamil, Abedalhamied 7310     359-3461 703-1017Biletskiy, Roman     458-0316 820-1389Boland, Jennifer 7310       469-5123

Cai, Leo 7829 7047 323-0049 227-7751859-806-

3674Carnevale, Joyce 4952     225-5356  

Chakos, Pete 7310  323-0021 / 240-

5540716-833-

8653  Clark, Jim       414-4116  

Conlon, Kevin7310, 4951   220-5333 425-8141 943-8441

Coots, Alex     723-0717 269-8813

Cringoli, Lisa 7283723-7047   413-0747 506-2185

Csati, Jordan 7310   323-0030  716-923-

3212Dahler, Paul 7310     586-9551  

Della Rocco, Jim 7337   239-4829  240-377-

7371Diep, Tuong 7310     334-3942  

Dockrell, Tom 7337723-7047     278-4405

Dunning, Pamela 7328   453-2350 720-9519  Fafinski, Kristine 7310     259-8447  Finocchio, Jacklyn 7310     429-6971 752.9266Finucane, Jim 7348   320-0208 247-6299  Graham, Jill 7310   323-0219 671-8402 507-7871Halpin, Kevin 7310       455-6056Hayward, Amanda 7310     392-5856 330-8105Hosenfeld, Andrew 7310       750-0231

Jackson, Jennifer 7310  320-0206 (OR

Tech)   208-9235

Jasmine, Mavis 7310      716-908-3887

Kang, Susan 7330   220-7355   415-3491Kasten, Jeffrey 7310     594-0503  Kokanowich, Kate 7310       314-6900Kremer, Natalie 7310   462-0033   802-6422Letendre, Michael 7310     269-9284  

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Lessard, Lyn 7310     247-8953 766-1813Lewish, Erik 7310     473-4844 697-4967Lewish, Katie 7310     473-4844 721-7520Marble, Lucas 7310     723-9224 613-5180McElroy, Richard 7310     227-0230 415-3115Miller, Patty 7333     889-5636  Moore, Jeremiah 7310     662-3738  Munawar, Daud 7310   921-0052 244-9885 749-3501Nasim, Muhammad 7310     381-5313 733-7446Patel, Shashi 4164   306-0097 442-2505  Scalzo, Joyce       429-6394  Scorgie, Kevin 7310       802-9591Sifain, Evelyn 1993     964-7029  Smith, Andrea       486-4217 208-0822Stevenson, Rabia 7310   220-3943  

716-400-2182

Thung, Patnawon 7310   238-0081   305-8347Ulrich, Mary 7310     964-8607 322-3493Vogt, Joan       227-6419  Vora, Priya 7310       414-6166Vuciterna, Bukurijue 1993     663-8937  

White, Debbie 7310  320-0206 (OR

Tech) 865-7327  ***St. Mary's RPh Pager 238-0049***

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MEDICAL - PA/NP PAGER #BAILEY, JULIE 263-8060CARL, LEAH 220-5371CASTRO, SARA 306-9277CAVEN, JOHN 306-9271CUPOLO / TIFFANY / POPIELARZ / TUTTLE 238-0147 238-0184FARLEY, DOREEN 220-5697HERNBERG, KRISTIN 291-0160IGBOELI, ADAOBI 291-0011KENYON, ELIZABETH 306-9273PARKER, MARY 238-0776POPIELARZ, CHRIS 240-0486RICH, JANET 306-9274SAPORITO, BRENDA 306-9278SCHULTZ, PATRICIA 220-5573SIFAIN, CLAUDINE 306-9272TRAN, NHUNG 220-5575TUTTLE, KIM 323-0267WOOSTER, JENNIFER 238-0083STUDENT PAGER 291-1403as of 12/19/07

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SURGICAL HOUSESTAFF

Pager #s: Home #s:Dr. Cardin…………….. 220-9677……. 899-9813Dr. Golijanin………….. 220-4562…….c-507-9529Dr. Grieger……………. 240-6478……c- 354-3135Dr. Madeb…………….. 220-4573…….. 244-3641Dr. Marshall…………... 220-9678…….. 442-5212Dr. Nicholson………… 220-4551…….. 670-0437Dr. Patel………………. 220-5300…….. 414-6376Dr. Polomsky………... 220-7605…….. 571-4306Dr. Singer…………….. 220-2646……c. 278-8743Catie Benjamin, PA… 240-6594..c.1-716-481-9367Kendra Bigham, PA…. 291-2568……c-259-1691Kelly Burgess, PA…… 291-2596……c-747-5136Katie Ciurca, PA……… 240-1364…….. 271-5089Timothy Crowe, PA…. 320-2443………473-9984Kristi Edmunds, PA…. 240-0408…1-315-383-5353Theresa Garbach, PA.. 306-0119………217-8641Jennifer Kuhner, PA... 291-2595.......c- 737-3032Candi Napolitano, PA.. 323-0206…….. 455-8352Dan O’Hara, PA........… 320-2430..…… 387-9982David Perry, PA........ 291-2592..……. 338-2705Tina Reinhardt,PA… 291-2598..1-716-863-3534Sue Sargent,PA……….306-0142………442-6467Debra Smith, PA.......... 291-2593..……. 889-7061Leslie Sonders, PA…. 306-0107………749-3075Christine Tensley,PA...291-2591………313-2576

FLOATER PAGER – X-4788

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PAGING THE FLOOR TEAMS:

In an effort to aid communication to the resident team on-call, we have instituted “Team Pagers”. From 7:30 a.m. to 5:00 p.m. please call the team pager # listed below. After 5:00 p.m. please page 306-8497.This applies on both weekdays and weekends.

BLUE TEAM: 220-7407GREEN TEAM: 220-7400ORANGE TEAM: 220-7408PURPLE TEAM: 220-7409RED TEAM: 220-5354YELLOW TEAM: 220-7101

PLEASE DO NOT page residents (unless for emergency) during the following times:

Noon Conference: Mon-Fri: 12 N-1:00 P.M. Grand Rounds: Tuesdays: 8:00 A.M. – 9:00 A.M. Attending Rounds: Mon/Wed/Fri: 10:00 A.M. – 11:30 A.M. Specialist Rounds: Thursdays: 10:00 A.M. – 11:30 A.M.

If you have any questions, please contact the Chief Resident at ext. 4037. This person can also be very helpful if for some reason your pages are not being returned, for example if a resident is not aware that his/her pager is not functioning.

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WHEN TO PAGE WHOORDER WRITTEN BY

TIME ORDER WRITTEN LOCATION OF PATIENT

PAGER

Medical PA 7am – 7pm

7pm – 7am (Night Float PA)

ED,TCU, 2nd floor

3rd floor

238 – 0147

238 – 0184

Surgical PA 7am – 5pm

5pm – 7am 220 – 7880 or X4788

TCU PA Daytime

Night

Call TCU X1696, ask sec to tx to PA covering

238 – 0147

EOU/SCU PA EOU/SCU X4294 or X4797

Resident 7am – 5pm

5pm – 7am All locations 306 – 8497

ICU Resident ICU Call ICU x1079, sec will tx to resident line

Resident Teams

Blue: 220-7407Green: 220-7400Orange: 220-7408Purple: 220-7409Red: 220-5354Yellow: 220-7101

LDRPOrder written by PA

Order written by NP, other

LDRP 240 – 7834

Call LDRP X4020, sec can often tx to NP on floor

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II. Pharmacist Duties

CHECKING PROCEDURESIV’s Homemade IV’s Patient Specific Meds.

Patient name Drug name Drug dose Frequency Solution Rate Exp. Date

(especially frozen)

Syringe tech used to prepare IV

Diluents Drug IV fluid Patient name Drug name Drug dose Frequency Solution Rate Exp. Date

1 patient name per zip-lock bag

Verify dose in bag with dose on label

Drug name Drug dose Frequency Being sent

appropriately vs. being loaded in Pyxis

Pyxis Drug name and strength (careful-solumedrol and depomedrol) Dosage form Quantity

Prepacking Drug name and strength-refer to regular med bottle Expiration date Lot number Quantity (especially narcotics) Narcotic label must have NDC number and schedule (II,III, IV, V) Make sure each packaged med is fully sealed

Satellite Patient name (make sure each bag has labels for the same patient Check both sides of bag Patient rm number Drug name Drug strength Dosage form Directions Expiration date Quantity (how much to send where)

o SCU/EUO – 2 day

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o ED – 1 dayo Floors – load most medications into pyxiso Final list for IVs in the basement is printed at 2:30- when sending

initial doses of IVs before 2:30 make sure enough doses are sent to get patient through until around 5 (when meds are delivered); when sending initial doses of IVs after 2:30 send a 24 hour supply

MEDICATION ORDER ENTRY / WORK FLOW

No Problems Found

Order EntryFind Patient – based on MRN or Floor + Patient NameScan order for potential problems

Orders Arrive in Satellite Pharmacy

Via faxVia door

Sorted orders placed in

Pharmacist Order Entry BinSTATNew AdmitsFloors

Techs retrieve and sort orders

Enter Order

Problem Found

Medication Stocked in

Pyxis Information

transferred to pyxis and nursing staff may retrieve medication from

floor Pyxis terminal

Medication Not Stocked in Pyxis

Pharmacist changes Qty to 0 or appropriate Qty if not being loaded into PyxisLabel Prints in SatelliteTechs Load Medication into Pyxis or Deliver to Pharmacy Bins in Med Room at Units

Enter Orders that

can be entered

No Intern Then…Page Provider (if provider Known)Take Verbal OrderIf Provider Not KnownCall Floor to find out coverageFill out green Nursing Communication sheet and send to floor

If Pharmacy Intern present

then pass problem along to Pharmacy

Intern to follow-up

Problem Solved

Pharmacist Checks Patient Specific MedicationMeds-Not-Loaded

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Park Ridge Satellite

AM Shift (7:00-3:30) Daily Pharmacy Operations

7:00 AMo Check Night Log Book for orders – verify that all meds that were taken

match up with a valid order, if not contact the night nursing supervisor before she leaves and place night log book back in cabinet

o Remove orders from the fax machineo Sort/prioritize orders (techs generally retrieve and sort)

1. Admissionsa. EOU & MOUb. ICUc. All others

2. Single ordersa. STATsb. Antibioticc. EOU & MOUd. ICUe. All others

o Check Cerner for admitted patients held in the E.D. (E.D. boarders). If not all of the orders have been received, contact the E.D. Clinical Leader at x7270

7:30-12:00o Enter orderso Print patient MARs in satellite for new admits except for TCU (no

MARs). Labor and delivery, PRCD, 4100 and 5100 MARs should all be printed to the specific unit printer.

o Check patient meds and pyxis meds loadedo Check IV hoodo Check IV compatibilities and answer other phone related problemso Check any Vancomycin 1st time doses and record in Antibiotic review

charto Fax down any TPN orders to main pharmacy and also call down to

verify receipt of TPN orders

Lunch – Start lunch rotation

12:00-3:30o Enter orders

Techs Deliver / Load MedicationsTop and Middle of every Hour Starting at 8:00 AMSTATs when completed and checked by Pharmacist

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o Print patient MARs in satellite for new admits except for TCU (no MARs). Labor and delivery, PRCD, 4100 and 5100 MARs should all be printed to the specific unit printer.

o Check patient meds and pyxis meds loadedo Check IV hoodo Check IV compatibilities and answer other phone related problemso Check any Vancomycin 1st time doses and record in Antibiotic review

charto Fax down any TPN orders to main pharmacy and also call down to

verify receipt of TPN orderso Discuss any unresolved problems with night pharmacists

Notes:

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Afternoon Shift (1:00 – 9:30)Daily Pharmacy Operations

1:00 – 5:00o Enter orderso Print patient MARs in satellite for new admits except for TCU (no

MARs). Labor and delivery, PRCD, 4100 and 5100 MARs should all be printed to the specific unit printer.

o Check patient meds and pyxis meds loadedo Check IV hoodo Check IV compatibilities and answer other phone related problemso Check any Vancomycin 1st time doses and record in Antibiotic review

charto Discuss any unresolved problems with AM pharmacists

Dinner - start covering dinner with night pharmacists

5:00-9:30o Enter orderso Print patient MARs in satellite for new admits except for TCU (no

MARs). Labor and delivery, PRCD, 4100 and 5100 MARs should all be printed to the specific unit printer.

o Check patient meds and pyxis meds loadedo Check IV hoodo Check IV compatibilities and answer other phone related problemso Check any Vancomycin 1st time doses and record in Antibiotic review

charto Check Pyxis tech (around 7ish but pyxis tech will call when ready)o Pull Narcotics (around 7ish – pyxis tech will call when ready for check)o Make any Narcotic drips or pull meds for Narcotic drips to be made in

the satellite Notes:

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Evening Shift (3:30 – 12:00 Monday-Friday & 2:30-11:00 on weekends)

Daily Pharmacy Operations

3:30o Receive report from AM shift about any unresolved problems or

potential issues that may come up during the evening shift

3:30-12:00o Enter orderso Print patient MARs in satellite for new admits except for TCU (no

MARs). Labor and delivery, PRCD, 4100 and 5100 MARs should all be printed to the specific unit printer.

o Check patient meds and pyxis meds loadedo Check IV hoodo Check IV compatibilities and answer other phone related problemso Check any Vancomycin 1st time doses and record in Antibiotic review

charto Pull Narcotics (around 10:30 Make any Narcotic drips or pull meds for

Narcotic drips to be made in the satelliteo Sort Pink Buckets if time permits

o Group problem orders by prescribero Make sure problem orders are clear to the person reading them.

o Put out Night log booko Turn off lighto Make sure pharmacy door is lockedo Check pharmacy on call list

Notes:

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Main (basement) Pharmacy (7:30-4:00)Daily Pharmacy Operations

7:30 amo Unlock doors (front and back)

o To open door ______o To unlock _______o Tech code 3532

o Take phones off of forward o press CheckFW then CanclFw on phone

o Check for Chemo orderso If chemo confirm with patient nurse before compounding ANY

chemoo Check Voice Mail (Top of phone blinks red when you have Voice Mail)

o Dial: 7749o Login: 7336#o Password: 7336#o Follow prompts

7:30-12:00o Check OR tech medso Check TPN rm numbers/call remind floors/nurses/providers to write TPN

ordero Check IV room (9:30ish)o Check Pyxis meds (10ish)o Check Narcoticso Check PRCD pyxiso Compound any Narcotic drips or chemo orders

o Remember to verify need and time with patient nurse before compounding

o Enter TPNo Enter Orders (if possible call satellite to see if they need help and enter

some of those orders)o Check Pre-packing meds, especially narcotics and return to vaulto Natrecor dripso EP lab order/drips

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Take lunch when you are caught up

12:30-3:00o Check TPNso Check IV room refrigerated meds (IV tech delivers cart by 3:30-3:45)o Check IV room updateso Check afternoon Pyxis meds

3:00-4:00o Check anesthesia kits and put back in vault when finishedo Check code carts (if any – do not leave code carts in pharmacy over

night)o Check Pre-pack meds (if needed)

4:00 (Closing)o Forward Phones

o 6 phones – pharm desk phone, 2 tech phones, checking counter phone, pyxis phone and pre-pack checking counter phone

o Hit Forward then 7310 then doneo Turn off light in Vault, close gate and shut vault dooro Turn off lights in IV roomo Log off computero Back up TPN fileso Turn off fax machineo Lock door

o Code _________

MISC:o Make protonix suspensiono Make other compounds as needed from compounding manual

On the weekends o Pull narcotics once in the am and once in the pm.o Order entry for St. Mary’s (4100, 4300 and 5100)o Pkwy Tech carries the “ Pyxis pager” (220-5171) during shift

(Felicia’s pager)o PR Inpatient pharmacist enters an order for St. Mary’s and prints at

Zebra printer in Parkway Apothecary break room. (printer is: PHARZEB5)

o PR Pharmacist pages Pkwy Tech with notification of new order/label via code: 1111

o Cut off time for orders/labels to print at Pkwy Apothecary is 1pm.o Pkwy Tech will check the printer hourly for labels.

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o Pkwy Tech will prepare meds, Pkwy pharmacist will check, tech will deliver.

If needed meds are not available at Parkway or must be delivered after 1pm, Inpatient Pharmacy staff will contact PDQ for delivery to specific unit at St. Mary’s Campus. PDQ phone #: 475-0033Acct #: 8580

Notes:

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St. Mary’s Pharmacy (8:30-5:00)Daily Pharmacy Operations

***See chemo product reference in Pharmacist Area***8:30-12:00

o Check Voice mail (if light on phone is blinking)o Dial: 7749o Login: 3395#o Password 1234#o Follow prompts

o Turn on Chemo clinic pager (clinic phone #3404)o Run IV labels for St. Mary’s floorso Enter orders (watch for Chemo orders)o Print patient MARs to floor for new admits o Check patient meds and pyxis tech meds o Check IV compatibilities and answer other phone related problemso Pull Narcotics (around 10ish)o Enter Chemo orderso Clean chemo hoodo Compound Chemo orders and deliver to infusion center (either you

deliver or have a tech run it over)

Take Lunch when all caught up

12:30-5:00o Check Voice mail (if light on phone is blinking)

o Dial: 7749o Login: 3395#o Password 1234#o Follow prompts

o Enter orderso Print patient MARs to floor for new admits

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o Check patient meds and pyxis tech meds (around 4ish)o Check IV compatibilities and answer other phone related problemso Pull Narcotics (around 4ish)o Enter Chemo orderso Compound Chemo orders and deliver to infusion center (either you

deliver or have a tech run it over)o Order replacement chemo products and supplies – see chemo supply

order sheet on the S:drive in the St. Mary’s foldero Clean chemo hood at end of shift and turn on antimicrobial UV lighto Enter Pass meds (if any)o Fax Clozaril Patient Monitoring form (on Fridays only)o Narcotic Monthly Inventory

Notes:

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III. Protocols

APPROVED THERAPEUTIC SUBSTITUTIONANALGESICS Lortab® (hydrocodone/acetaminophen):The following tablets will be substituted as indicated below:

THERAPEUTIC SUBSTITUTION WILL BE:

ADMINISTERED DOSE OF SUBSTITUTION MEDICATION:

IF MEDICATION ORDERED AS:

Any (tab/cap) combination of:Hydrocodone 2.5mg w/ APAP 500 Hydrocodone/APAP 5/500 ( Vicodin ) ½ tabletHydrocodone 5mg w/ APAP 500 (Hydrocodone/APAP) 5/500 (vicodin ) 1 tablet

Hydrocodone 7.5mg w/ APAP 500 Hydrocodone/APAP 5/500 1 1/2 tabletHydrocodone 10mg w/ APAP 500 Hydrocodone/APAP 10/650 (Lorcet) 1 tablet

Percocet® & Tylox® (oxycodone/acetaminophen):

The following Percocet® tablet(s) and Tylox® capsules will be substituted as indicated below:IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE: ADMINISTERED DOSE OF

SUBSTITUTION MEDICATION:

Tylox® 5/500 Percocet® 5/325 1 tabletPercocet® 2.5/325 Percocet® 5/325 ½ tabletPercocet® 5/325 Percocet® 5/325

Percocet® 5/3251 tablet

1 and ½ tabletsPercocet® 7.5/325Percocet® 7.5/500

Perlocet® 5/325 2 tabletsPercocet® 10/325Percocet® 10/650

Ultracet® (Tramadol/Acetaminophen):Ultracet® will be substituted as indicated below:

IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE: ADMINISTERED DOSE OF SUBSTITUTION MEDICATION:

Ultracet® Tramadol 50 mg 1 tablet(Tramadol 37.5mg/Acetaminophen 325mg) Acetaminophen 325 mg 1 tablet

ANTACIDS:The following antacids will be substituted as indicated below:

IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE:Any liquid aluminum/magnesium combination Maalox Regular Strength

Any liquid aluminum/magnesium w/simethicone Mylanta

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Alu-Tab Alternagel 600 mg/5mlAmphogel Alternagel 600 mg/5ml

Riopan MaaloxRiopan Plus Mylanta

Calcium Carbonate TumsDicarbosil Tums

Titralac Liquid Tums ( 2 tabs)Gaviscon Liquid/Tab Gaviscon Tab

CALCIUM SUPPLEMENTATION PREPARATIONS:IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE:

Calciday-667 Tums 500 Os-Cal 500 Os-Cal 500

Oyst-Cal 500 Os-Cal 500Oystercal 500 Os-Cal 500

Oyster Shell Calcium-500 Os-Cal 500Cal-Plus Os-Cal 500

Caltrate 600 Os-Cal 500Gencal 600 Os-Cal 500

Nephro-Calci Os-Cal 500Caltrate, Jr. TumsCalci-Chew Os-Cal 500Oysco 500 Os-Cal 500

Citracal Tums 500Cal-Guard Softgels Os-Cal 500

Florical Tums 500Calcium Carbonate 600mg + Vitamin D Caltrate 600mg/Vit D 200 units

Calcium 600 + D Caltrate 600mg/Vit D 200 unitsPosture D Tablets Caltrate 600mg/Vit D 200 units

Caltrate 600 + D Tablets Caltrate 600mg/Vit D 200 unitsCaltrate Plus Tablets Caltrate 600mg/Vit D 200 units

Super Calcium ‘1200’ Softgels Caltrate 600mg/Vit D 200 unitsCalcium 600 with Vitamin D Tablets Caltrate 600mg/Vit D 200 units

Calel D Tablets Caltrate 600mg/Vit D 200 unitsDesert Pure Calcium Caltrate 600mg/Vit D 200 units

Os-Cal 500 + D Caltrate 600mg/Vit D 200 unitsOyster Calcium 500mg + D Tablets Caltrate 600mg/Vit D 200 units

Oyster Calcium Tablets Caltrate 600mg/Vit D 200 unitsCitracal Caplets + D Caltrate 600mg/Vit D 200 units

Caltro Tablets Caltrate 600mg/Vit D 200 unitsOs-Cal 250 + D Caltrate 600mg/Vit D 200 unitsOysco D Tablets Caltrate 600mg/Vit D 200 units

Oyst-Cal-D Tablets Caltrate 600mg/Vit D 200 unitsOystercal-D 250 Caltrate 600mg/Vit D 200 units

Amino-Min-D Capsules Caltrate 600mg/Vit D 200 unitsFemcal Caltrate 600mg/Vit D 200 units

Calcet Tablets Caltrate 600mg/Vit D 200 unitsSuper CalciCaps Tablets Caltrate 600mg/Vit D 200 units

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Dical-D Wafers Caltrate 600mg/Vit D 200 unitsDical-D Tablets Caltrate 600mg/Vit D 200 unitsDical Cap Tabs Caltrate 600mg/Vit D 200 units

Diostate D Tablets Caltrate 600mg/Vit D 200 unitsViactiv Calcium Chews Caltrate 600mg/Vit D 200 units

CalciCaps Tablets Caltrate 600mg/Vit D 200 unitsBone Meal Tablets Tums 500

IRON SUPPLEMENTS:IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE:

Fergon all strengthsFerrous sulfate 324 mg/325 mg trade/generic

(Feosol, lFerodan, Slow Fe, Fero-grad )

Ferrous Gluconate 300 mg tabFerrous Sulfate 325 mg tab

Fer-In-Sol drops Ferrous Sulfate 75 mg/0.6 ml solutionFerrous sulfate 300 mg/5 ml elixir Ferrous Sulfate 300 mg/5 ml elixir

ESTROGEN PATCHES:IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE:

Estraderm (Estradiol)-b/w 0.05/0.1 mg/24 hr Vivelle & Vivelle Dot (Estradiol) 0.05, 0.075, 0.1

Climara (Estradiol) 0.05 mg/24 hr weekly0.075 mg/24 hr

0.1 mg/24 hr weekly

Alora 0.05, 0.07, 0.1 twice a week Climara equivalent dose once a week

Esclim 0.05, 0.075, 0.1 twice a week Climara equivalent dose once a week

HYPNOTIC/SLEEPING AIDS:IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE:

Zolpidem (Ambien) 5 mg)Eszopiclone (Lunesta)Zolpidem (Ambien CR)Ramelteon (Rozerem)

INSULINS:IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE:

Novolog (Insulin Aspart) Humalog (Insulin Lispro)

GASTROINTESTINAL AGENTS:Laxatives:

IF MEDICATION ORDERED AS:Fibercon , Fiberall ( 500 mg,625,1000 mg).

(Polycarbophill )Citrucel ( methylcellulose )Citrucel ( methylcellulose )

THERAPEUTIC SUBSTITUTION WILL BE: Metamucil ( psyllium ) 1 gm powder

HISTAMINE2 ANTAGONISTS:The following H2 antagonists will be substituted as indicated below unless otherwise prescribed as “do not

substitute”:IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE:

Ranitidine (Zantac) 150 mg oral QD Famotidine (Pepcid) 20 mg oral HSRanitidine (Zantac) 150 mg oral BID Famotidine (Pepcid) 20 mg oral BIDRanitidine (Zantac) 300 mg oral QD Famotidine (Pepcid) 40 mg oral HSRanitidine (Zantac) 300 mg oral BID Famotidine (Pepcid) 40 mg oral BIDRanitidine (Zantac) 50 mg IV QD Famotidine (Pepcid) 20 mg IV HS

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Ranitidine (Zantac) 50 mg IV BID Famotidine (Pepcid) 20 mg IV BIDRanitidine (Zantac) 50 mg IV TID Famotidine (Pepcid) 20 mg IV BIDRanitidine (Zantac) 150 mg IV Q24H Consult PrescriberRanitidine (Zantac) all other regimens Consult PrescriberNizatidine (Axid) 150 mg oral QD Famotidine (Pepcid) 20 mg oral HSNizatidine (Axid) 150 mg oral BID Famotidine (Pepcid) 20 mg oral BIDNizatidine (Axid) 300 mg oral QD Famotidine (Pepcid) 40 mg oral HS

PROTON PUMP INHIBITORS:The following Proton Pump Inhibitor will be substituted as indicated below unless otherwise prescribed as

“do not substitute”:IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE:Omeprazole (Prilosec) 10 mg QD Pantoprazole (Protonix®) 40 mg QDOmeprazole (Prilosec) 20 mg QD Pantoprazole (Protonix®) 40 mg QDOmeprazole (Prilosec) 20 mg BID Pantoprazole (Protonix®) 40 mg QDOmeprazole (Prilosec) 40 mg QD Pantoprazole (Protonix®) 40 mg QDOmeprazole (Prilosec) 40 mg BID Pantoprazole (Protonix®) 40 mg BID

Rabeprazole (AcipHex®) 20 - 40 mg QD Pantoprazole (Protonix®) 40 mg QDLansoperazole (Prevacid) 15 mg QD Pantoprazole (Protonix®) 40 mg QDLansoperazole (Prevacid) 15 mg BID Pantoprazole (Protonix®) 40 mg QDLansoperazole (Prevacid) 30 mg QD Pantoprazole (Protonix®) 40 mg QDLansoperazole (Prevacid) 30 mg BID Pantoprazole (Protonix®) 40 mg BID

Esomeprazole (Nexium) 20-40 mg QD Pantoprazole (Protonix®) 40 mg QD

Patients with a feeding tube will be switched to Pantoprazole suspension.

TOPICAL ANTIFUNGAL POWDERS:IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE:

Nystatin Miconazole

Brand I Generic inhaler ordered Brand I Generic formulary substitution(non-formulary) (approved by the Drug Usage Committee)Advair 100/50 Pulmicort ( Budesonide) respules via neb. 0.25 mg bid(Fluticazone 100 mcg/ Salmeterol 50 mcg) and

or Foradil ( Formoterol ) 1 inhalation ( 12 mcg ) bid Advair 250/50

(Fluticazone 250 mcg/ Salmeterol 50 mcg)

Dose: 1 inhalation bid 

Advair 500/50  Pulmicort ( Budesonide) respules via nebulizer 0.5 mg bid

(Fluticazone 500 mcg/ Salmeterol 50 mcg)

  andDose: 1 inhalation bid Foradil ( Formoterol) 1 inhalation ( 12 mcg ) bid

Serevent (Salmeterol 50 mcg) Foradil ( Formoterol ) 1 inhalation ( 12 mcg ) bidDose: 1 inhalation bid or q 12 hours  

Atrovent inhaler (Ipratropium 18 mcg) Spiriva (Tiotropium ) 1 inhalation ( 18 mcg ) q day

Dose: 2 inhalation qid 

Combivent inhaler Albuterol neb via nebulizer 2.5 mg qid(albuterol 90 mcg/ ipratropium 18 mcg)

Except ventilator patients andDose: 2 inhalation qid Spiriva (Tiotropium ) 1 inhalation ( 18 mcg ) q day

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Albuterol inhaler 2 inhalations (180 mcg) Albuterol 2.5 mg nebulizer solution Dose: Dose:

TOPICAL CORTICOSTEROIDS:LOW POTENCY

Aclometasone/Dexamethasone/FluoromethaloneLOW POTENCY

Hydrocortisone Cream/Ointment 0.5% / 1% / 2.5%

MEDIUM POTENCY MEDIUM POTENCYDesoximetasone,fluocinolone,fluticasone, hydrocortisone valerate &butyrate

Triamcinolone Cream/Ointment

0.025% / 0.1%

HIGH POTENCY HIGH POTENCY Fluocinonide/Halcinonide   Amcinonide/Dexoximetasone Betamethasone 0.05% Cream/Ointment

VERY HIGH POTENCYDiflorasone,Betamethasone dipropionate

VERY HIGH POTENCY Clobetasol 0.05% Cream/Ointment Halobetasol 0.05% Cream/ointment

VAGINAL ANTIFUNGALS:  IF MEDICATION ORDERED AS: THERAPEUTIC SUBSTITUTION WILL BE:

Mycostatin (Nystatin Cream) Monistat-7 (Miconazole Cream

Gyne-Lotrimin (clotrimazole Supp),Mycostatin supp

Monistat-3 (Miconazole Supp)

Vagistat-1 (tioconazole) cream Monistat-7 (Miconazole Cream Mycelex-3 (butaconazole) Monistat-7 (Miconazole Cream

VITAMINSIF MEDICATION ORDERED AS: THERAPEUTIC

SUBSTITUTION WILL BE:Abdec One-A-Day Plus Iron One-A-Day + Minerals THERAGRAN MAllbee with C Optilets-500Allbee C-800 Plus Iron Allbee-T Optilets-M-500Becotin with C Probec-TBerocca Protegra Sigtab MultivitaminBerocca Plus Stress Caps Multivitamin LiquidCefol Stresstab-500 w/Iron Stresstabs-600 Prenatal VitaminCentrum Stresstabs 600 w/ Zinc Folbesyn Tabs Surbex-750 w/IronFero-Folic 500 StuartinicFerosol-Plus Surbex-CFortespan Surbex-TFumatinix Surbex 750 w/ ZincGeritol Tablet Theragran Hematinic Theragran-Z Ger-I-Bon Tablets Thera-MHepicebrin Therapeutic B&CHexavitamin Theravitamin“High-Potency Multivitamin” Unicaps

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Iberet-500 Unicap-TIberol Unicap-MMicebrin Unicap Plus IronMicebrin-T Vigram tabMulticebrin Via-Daylin tab

Multivitamin Vicon-C

Multivitamin + Iron Multivitamin w/ Minerals Multivitamin w/ Zinc

Vicon Forte

Myadec Vicon Plus XymacapOcuvite Z-Bec

One-A-Day Zentinic  Chromagen Nephrocap

Nephrovite Rx.

Trinsicon Nephro-Vite

   

'Statin' Automatic Therapeutic Substitution June 2007

Automatic therapeutic substitution to Simvastatin approved by the Drug Usage Committee:

*Pravachol will be substituted with Simvastatin with the EXCEPTION OF PATIENTS ON POTENT INHIBITORS OF CYP3A4:CyclosporineAntifungalsErythromycinClarithromycinHIV protease inhibitorsNefazodoneGemfibrozil (particularly with high dosesOf Vytorin and Simvastatin)

Atorvastatin Pravastatin Simvastatin( Lipitor) ( Pravachol ) ( Zocor )

  *see exception  10mg 40mg 20mg20mg 80mg 40mg

> 20 mg   No substitution

Lovastatin Simvastatin(Mevacor) ( Zocor )

10mg 5 mg20 mg 10 mg40 mg 20 mg80 mg 40 mg

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TPN ORDER ENTRY *High Alert Medication*

New Patient1. Make a folder with the following: (in this order)

a. Patient Nameb. MRN #c. FIN#d. DOBe. Room #f. Date patient was startedg. Allergies (if known)h. Note Central or Peripheral linei. Not if patient is NOT to receive Vitamin K on Mondays

2. Check Cerner to see if TPN is in profile and the patient was charged today if not add TPN to patient profile (which will charge the patient)

3. Log on to TPN computer4. Hit F2 for patient data5. Hit Insert6. Add the patient info (use folder for reference)7. Verify Central or Peripheral Line8. F10 to accept9. F9 to exit patient data screen

Entering Order: Note: Watch for “Standard Formulas” as these are “Per Liter” not per 24

hours and do not contain any fat. Should contact provider when the lipid field is blank to verify no fat.

o Select patiento Hit enter until box appears with type of TPN

o Choose formulao Or F2 (continue as previous solution then type the number of the

previous solution)o Verify Central or Peripheral Lineo Enter TPN componentso Chloride/Acetate: to change Anion Part hit F3, Balance is 5 and 50 %,

min or max choose accordingly use 2% b/c computer does not allow 0 – F10 to accept changes

o Double Check33

o F10 to print labelo Check againo Write E (enter), C (checked) and M (mixed) at the bottom of the labelo Initial next to the “E”

Formulation problems: Document all changes1. Check most recent patient labs against the order each day and make

sure the electrolytes chosen by the provider are appropriate. The ranges listed below each electrolyte on the order form are not absolutes; they are recommendations as to what the normal range of most orders will be. For example, if you receive an order for a patient with a potassium level of 5.7 mmol/L, potassium should not be included in the bag even though the range on the worksheet is (60-150) mEq. Keep in mind that the provider may be managing the patient’s electrolytes with methods other than the TPN. It may be appropriate for a patient with a low K+ level to have only 60 mEq of K+ in the bag if the provider is also following an electrolyte protocol or infusing potassium runs. Use your clinical judgment when evaluating these orders.

2. Look back at previous orders to make sure orders are being completely rewritten every 3 days. Many times providers will check off that the date of last order written was the previous day, even if the order that day was just a “continue previous order”. Evaluating the effects that previous TPN formulations have had on the patient’s electrolytes can also be helpful in determining the appropriateness of the current order.

3. Check to see if patient is on warfarin, as per order form all patients on warfarin will not receive vit K on Mondays (whether or not box is checked).

4. When evaluating calcium levels, remember to calculate the “corrected calcium”. This will provide a more accurate level than the serum calcium in patients with low serum albumin. The formula for calculating a corrected calcium level is:

Total serum calcium (mg/dL) = measured serum calcium (mg/dL) + 0.8*(4 – measured serum albumin (g/dL))

5. Before contacting the provider, test out whatever recommendations you may have by entering the TPN formula you will recommend into the computer to rule out any formulation problems.

6. Contact/page Provider who wrote the order7. Write up verbal order form (only if absolutely necessary) make a photo

copy of verbal order and staple to original order.8. Make changes to original order, initial and note to see verbal order.9. Send original verbal order to floor with TPN bag10. Contact floor if provider does not return page

34

Patient Discontinued1. Write D’cd on folder with name of nurse or copy of order and date2. Put TPN folder in box next to pharmacy desk with other D’cd TPN

orders3. Remove patient from active list.

a. Hit F2 patient dateb. Find and select patientc. Change the Y to an Nd. F10 to accepte. F9 to exitf. Patient should not appear on the active list if they are still active

try to remove patient again.

Patient “On-Hold” Leave patient in computer Leave folder with the rest of the active folders Note on folder: Hold & date

Backup TPN: Must be done everyday Exit out of TPN entry field Double click TPNPC backup icon Select appropriate floppy disk (for odd or even days of the week) Hit “ok” Takes 2-3 minutes Take out of computer Leave computer on and disk nearby

Misc:Calculating Osmolarity of PPN1. Multiply grams of protein per liter by 10

i.e. 40g x 10 = 400 mOsm/L2. Multiply grams of dextrose per liter by 5

i.e. 100g x 5 = 500 mOsm/L3. Lipids are isotonic, therefore do not contribute to osmolarity4. Electrolytes would further add to osmolarity

Na+ 2 mOsm per mEq K+ 2 mOsm per mEq

5. Add together #1 and #2 plus a rounded number of 200 for eletrolytes and divide by the number of liters to find the PPN solution Osmolarity

6. Limit final PPN Solution Osmolarity to <900 mOsm/L35

7. Max Dextrose Load per patient: 5mg/kg/min8. Max lipid rate: 2.5g/kg/day

Notes:

36

Total Parenteral Nutrition Order Form (Central Line Required)**Orders must be sent to Pharmacy by 2pm**

Initial Orders (phone Pharmacy @ x7330) Formulation/Rate change (Please rewrite form with ALL requirements to be administered) Continue previous order as of (date of last full form completion) __/__/__ ALL orders must be re-written once every 3 days Discontinue (taper rate at least one hour, or replace with D10)Indication for TPN (Total Parenteral Nutrition) : Non-availability of enteral route Supportive parenteral nutrition with chemotherapy and/or Anticipation of non-availability of enteral route >7 days radiation therapy when GI tract cannot be used Complete bowel rest for therapeutic/supportive purpose Recommendation of Registered Dietitian based on

complete assessmentEstimated Needs**see backHeight: ______Weight: _____kg Caloric Need: ________Protein Need: ________Fluid Need: ________

AdministrationTotal Volume =______________ ml/24 hours Continuous Infusion @ __________ml/hour Cyclic Infusion @ ___________ml/hour x __________ hours Tapered to ___________ml/hour x __________ hours

Standard TPN Formula Standard Central Formula(40 gm amino acids, 200 gm dextrose/liter) No lipids unless ordered below.Custom Formula

Amino Acids (4kcal/gm) Dextrose (3.4kcal/gm) Lipids (10kcal/gm) 50 gm/24hours 200 gm/24 hours Three-in-one ________gm/24 hr 75 gm/24 hours 300 gm/24 hours No lipids 100 gm/24hours 400 gm/24 hours______gm/24 hours 500 gm/24 hours

______gm/24 hours Standard Electrolytes/24 HoursNa 113 mEq K 89mEq Ca 11.25mEq Mg 12.5mEq PO4 30mmol CI-balanced MVI 1 vial Trace Metals (M.T..E.) 1ml Custom Electrolytes/24 HoursNa_____ mEq K___mEq Ca___mEq Mg____mEq PO4____mmol CI-minimu MVI 1 vial Trace Metals (M.T.E.) 1ml (60-150) (60-150) (10-20) (8-30) (15-50) maximum

balanced (Circle one)

Regular Insulin __________Units/bag Vitamin K: 5 mg added Monday unless box checked (Will be omitted in patients receiving Warfarin)

Additional additives/medications:_________________________________________________Recent Labs Standing Orders Custom Orders-see chart

(unless custom orders are provided) (MD must write orders on Physician Order Form)Date _________ Day # 0; then every Mon.: Prealbumin, TriglyceridesNa__________ Mg__________ Day # 1; then every Mon.:Chem 14, CBC/diff, PT, APTT MandatoryK___________ Phos_________ Day # 2 and # 3; then every Thurs.: Chem 8 Weigh dailyCl___________ Corrected Ca________ Capillary BG @ initiation: every 6 hours x 48 hours Nutrition consultCO2________ Intake and Output every shift BUN________ Temperature every 4 hoursCr___________Glu__________

Provider Signature _____________________ MD/PA/NP Pager # ____________ Date: ____________Time: _______

RN Signature _______________________________________________ Date: _________________ Time: _____ Refer to back of sheet for practice guidelines and indications for parenteral nutrition

37

PS # 200066 05/07 FAX TO PHARMACY 723-7047Peripheral Parenteral Nutrition (PPN) Order Form**Orders must be sent to Pharmacy by 2pm**

o Initial Orders (phone Pharmacy @ x7330)o Formulation/Rate change (Please rewrite form with ALL requirements to be administered)o Continue previous order as of (date of last full form completion) __/__/__ ALL orders must be re-written

once every 3 dayso Discontinue (taper rate at least one hour, or replace with D10)

Indication for PPN:o Non-availability of enteral route o Supportive parenteral nutrition with chemotherapy and/oro Anticipation of non-availability of enteral route o radiation therapy when GI tract cannot be usedo Complete bowel rest for therapeutic/supportive purpose o Recommendation of Registered Dietitian .

based on complete assessmentPPN Standard Formulas

0 1560 mL/24 hr @ 65mL/hr 0 2400 mL/24 hr @ 100mL/hr 0 3000 mL/24 hr @ 125mL/hr 40 gm amino acids/24 hours 75 gm amino acids/24 hours 90 gm amino acids/24 hours 120 g m dextrose/24 hours 200 gm dextrose/24 hours 280 gm dextrose/24 hours 40 g m lipids/24 hours 55 g m lipids/24 hours 65 gm lipids/24 hours O No lipids O No lipids O No lipidsO Standard Electrolytes/24 HoursNa 113 mEq K 89 mEq Ca 11.25 mEq Mg 12.5 mEq PO4 30 mmol CI-balanced MVI 1 vial Trace Metals (M.T.E) 1 ml O Custom Electrolytes/24 HoursNa____mEq K___mEq Ca____mEq Mg_____mEq PO4_____mmol CI-minimum MVI 1 vial Trace Metals (M.T.E.) 1ml (60-150) (60-150) (10-20) (8-30) (15-50) maximum

balanced (Circle one)

Regular Insulin __________Units/bag Vitamin K: 5 mg added Monday unless box checked O (Will be omitted in patients receiving Warfarin) Additional additives/medications: _____________________________________________________________Recent Labs Standing Orders o Custom Orders-see chart (unless custom orders are provided) (MD must write orders on Physician Order Form)Date __________ Day # 0; then every Mon .: Prealbumin, TriglyceridesNa__________ Day # 1; then every Mon.:Chem 14, CBC/diff, PT, APTT MandatoryK___________ Day # 2 and # 3; then every Thurs.: Chem 8 Weigh dailyCl___________ Capillary BG @ initiation: every 6 hours x 48 hours Nutrition consultCO2________ Intake and Output q shift BUN________ Temperature every 4 hours Cr___________Glu__________Mg__________Phos_________Corrected Ca___________Provider Signature ________________________________________ MD/PA/NP Pager # ____________________ Date: _____Time: __________

RN Signature _______________________________________________ Date: _________________ Time: _________________

Refer to back of sheet for practice guidelines and indications for parenteral nutrition

FAX TO PHARMACY 723-7047

PS # 200067 05/07

38

Practice Guidelines & Indications For Parenteral NutritionTotal parenteral nutrition is indicated if the small intestine is dysfunctional, obstructed, or inaccessible or the colon is severely dysfunctional or obstructed and this condition is expected to continue a minimum of 7 days. The following are examples of indications for Parenteral Nutrition:

Intractable vomiting---e.g., severe acute pancreatitis, hyperemesis gravidarum, chemotherapy.Severe diarrhea---(>500ml of stool) or malabsorption, e.g., severe, acute flare of inflammatory bowel disease, graft versus host disease, severe sprue or sprue-like conditions, short-bowel syndrome (<50-60cm of remaining bowel), radiation enteritis with weight loss.Severe mucositis/esophagitis---e.g., chemotherapy, graft versus host disease.Ileus---e.g., severe trauma/major abdominal surgery or pseudo-obstruction, when enteral nutrition, including feeding jejunostomy cannot be used for at least 7 days.Small bowel or colon obstruction---e.g., cancer, adhesions, infectious, pseudo-obstruction.“Bowel Rest”---e.g., enterocutaneous or entero-enteric fistula, anastomotic leak. Crohn’s disease of the small intestine.Preop---e.g., only in cases of severe malnutrition, otherwise surgery should not be delayed.

Peripheral Parenteral Nutrition provides hydration and initiates calorie and protein replenishment. Peripheral Parenteral Nutrition is not appropriate for long-term use. It does not usually meet total caloric requirements for the patient or provide an appropriate balance of carbohydrate, protein and fat. If a patient has a PICC line with confirmed central access, use the Total Parenteral Nutrition Order Form.

When a patient has a functional GI tract but is unable to in gest adequate nutrients orally, enteral feedings are indicated.

Estimation of Nutrition NeedsIdeal Body WeightFemale: 5 ft @ 100 lbs + 5 lbs for every inch above 5 ftMale: 5 ft @106 lbs + 6 lbs for every inch above 5 ftTo determine weight in kilograms, divide weight in pounds by 2.2For actual weight >125% of the ideal body weight, adjustments will be made by the Registered Dietitian (R.D.)

Caloric NeedsNo/Mild Nutrition Impairment 25-28 Kcal/kg Body Weight/dayModerate Nutrition Impairment 28-32 Kcal/kg Body Weight/daySevere Nutrition Impairment 30-35 Kcal/kg Body Weight/day

Protein NeedsNo Nutrition Impairment 0.8-1.0 gm/kg Body Weight/dayMild Nutrition Impairment 1-1.2 gm/kg Body Weight/dayModerate Nutrition Impairment 1.2-1.3 gm/kg Body Weight/daySevere Nutrition Impairment 1.3-1.5 gm/kg Body Weight/day

Fluid NeedsNormal Requirements 30 mL/kg Body Weight/dayDehydration 35 mL/kg Body Weight/dayRenal/CHF needing fluid restriction 25 mL/kg Body Weight/day

39

PDQ Delivery

If needed…Call: 585-475-0033Acct #: 8580

o Place objects to be delivered in Satellite Pharmacy for pick up and inform the techs and pharmacists in the satellite of the planned pick up.

PRDC After Hours Deliveryo Label a 24 hour supplyo Call Security to deliver medication to PRCDo Leave a not for PRCD tech to load medication in Pyxis the next day

40

Standard Narcotic ConcentrationsNote:Narcotics- must fill out narcotic request form (“Controlled Substance Order Form”)

CADD pumps o only send to 3100 NO EXCEPTIONS o Expiration date is 7 days for all CADD pumps

Morphine : 10:1 , 5:1, 25:1o Type in “CADD” at drug search

Dilaudid (hydromorphone): 10:1, 5:1 o Type in “CADD” at drug search

Narcotic dripso enter under continuous , rate as “per protocol”, but use infusion

rate to calculate 24 hour supply

Versed (midazolam):o 1:1 – 100 mg midazolam in 100 mLs of saline

Morphine drip:o 1:1 – 100 mg of morphine in 100 mLs of saline o 1:5 – 50 mg of morphine in 250 mLs of saline

Fentanyl (available premixed, will not generally have to make):o 10:1- 2000 mcg of fentanyl in 200 mLs of saline (remove 50

mLs from 250 mL bag)o 20:1- (only do for ICU – will ask for double-concentrate

fentanyl); 2000 mcgs of fentanyl in 100 mLs of saline Ativan (lorazepam) drips: need to use EXCEL (clear plastic) bags

o 1:1- The PAB bag is 50 ml + 7 ml overfill= 57 ml total. Remove 27 ml to give 30 ml volume. Add lorazepam 60 mg/30 ml to the bag.= 60 mg/60 ml. Use 0.22 micron filter on the label.

o Cerner short code: lora60d5w

Try searching ICUIV under drug search for all of these

Epiduralso See compounding recipes

41

IV Manufacturing Standards

In an effort to standardize procedures, an IV manufacturing card file is maintained in the satellite. Please check against the appropriate drug card when checking/making IVs. This card file is a work in progress. If an IV needs to be made which is not in this file, make the IV according to the appropriate literature and submit the information that was used to Shashi to be verified and added to the file. These files may also be used in the future for “batch manufacturing”. The following example illustrates the format used for the cards:

Caspofungin 70 mg/250 mL NS Drug (source bottle concentration/volume): 70 mg single use vialDiluent (s): 10.5 mL NS or SWFIVolume from bag removed (if any):n/a Volume of drug injected into bag: 10 mLInfuse over: 1 hourExpiration: 24 hours at room temp, 48 hours if refrigerated.Misc. info: 1) Allow vial to come to room temperature before reconstituting2) 70 mg dose CANNOT go in 100 ml3) After reconstitution vial is good for one hour when stored ≤ 77 deg F. (25 deg C)

42

IV. Professionalism

43

44

V. MiscellaneousCurrent Order Sets in Cerner (Bold sets are most useful) *subject to

change*ACS Acute Coronary SyndromeAMI Acute MI Order SetAlbunsneb Albuterol/NS neb comboAlcohol Alcohol Withdrawal Order SetAm10d Amlodipine 10 mg dailyAm5d Amlodipine 5 mg dailyAsa325d Aspirin 325 mg dailyAsa81d Aspirin 81 mg dailyA25d Atenolol 25 mg dailyA50d Atenolol 50 mg dailycadd CADD pumpsAIV Common antibiotic order sets (use this whenever possible as

there are prebuilt notes pertaining to each med included)CIV Common IV order sets (this includes Protonix I.V.)Cosopt Cosopt componentsCVA CVA order setdarvct Darvocet N-100 order setDig.125d Digoxin 0.125mg dailyDig.25d Digoxin 0.25 mg dailyDss100bid Docusate 100mg bidEcasa325d Enteric coated aspirin 325 mg dailyEcasa81d Enteric coated aspirin 81 mg dailyEpidural Epidural/spinal order setF325bidm Ferrous sulfate 325 mg bid w/mealsF325dm Ferrous sulfate 325 mg qday w/mealsF325tidm Ferrous sulfate 325 mg tid w/mealsF20d Furosemide 20 mg PO dailyF40d Furosemide 40 mg PO dailyFi40d Furosemide 40 mg IV dailyHctz12.5d HCTZ 12.5 mg dailyHctz25d HCTZ 25 mg dailyHctz50d HCTZ 50 mg dailyHeppicc Heparin flush for open-ended PICCHepcvl Heparin for CVL flushHSC8 Heparin SC q8hHSC12 Heparin SC q12hHospPR Hospice – park ridge order sethospStM Hospice – St. Mary’s order setIcuiv ICU IV order setKcl10b Kcl 10 meq po BIDKcl10d Kcl 10 meq po qdayKcl20bid Kcl 20 meq po bidKcl20d Kcl 20 meq po qday

45

Kcl30d Kcl 30 meq po qdayLorcetset Lorcet order setmomqhsprn Milk of magnesia 30ml po qbedtime prnMvid Multivitamin dailyNausea Nausea order setNebs Nebulizers for hospital patientsNebstcu Nebulizers for TCU patientsNephd Nephrovite dailyNsfpicc NS flush for close-ended PICCP40bid Pantoprazole 40 mg bidP40d Pantoprazole 40 mg dailyPCA PCA order setPercocet Percoset order setP124 Phenergan 12.5mg IV q4hr prn n/vP126 Phenergan 12.5 mg IV q6h prn n/vPlav300 Plavix 300 mg x1 dosePlav75d Plavix 75 mg dailyPneumonia Pneumonia order setCsection Post-op C-sectionJOINT Post-op joint order set *has many flaws use with caution*PTCA Post-PTCA/stentLabor Post-vaginal deliveryPRCD PRCD admission ordersPSY Psychiatry admission ordersSennbid Senokot 1 tab bidSennd Senokot 1 tab dailySenn2bid Senokot 2 tabs bidSenn2d Senokot 2 tabs dailySensbid Senokot-S 1 tab bidSensd Senokot-S 1 tab dailySens2bid Senokot-S 2 tabs bidSens2d Senokot-S 2 tabs dailyTcujoint Tcu joint admissions order setTele Telemetry order setT100hs Trazodone 100mg po qbedtimeT50hs Trazodone 50mg po qbedtimeTq4hpf Tylenol 650mg po q4h prn feverTq4hpp Tylenol 650mg po q4h prn painTq6hpf Tylenol 650mg po q6h prn feverTq6hpp Tylenol 650mg po q6h prn painVanco Vancomycin order setVicodin Vicodin order set

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FAQs re: Pyxis Access

1. New Nurse Hires at Unity Health System : New nurse hires must pass an exam before receiving access to Pyxis medstation(s). Consequently, only Clinical Education staff can authorize Pyxis access for a newly hired Unity Health System nurse. Cindy Marx (or designee) forwards access.

2. Agency Nurses (e.g. Nurse Finders, InteliStaf): Employee name is provided by agency via email request. If contracted to a specific nursing unit, Cindy Marx (or designee) forwards Pyxis access

info to Nurse Manager. Nurse Manager disseminates to nurse. Access expires at end of contract. (Agency contacts Cindy Marx with any contract extensions/renewals.)

If contracted as a floater, agency nurse contacts NM, Clinical Leader, or Charge Nurse at beginning of each shift to be assigned temporary user Pyxis status.

3. EMS Techs (ambulance): The Office of Pre-Hospital Care sends Cindy Marx a written request for EMS tech Pyxis

access. No access is provided without this request. If an EMS tech calls the Pharmacy for access, refer him/her to the Office of Pre-Hospital Care or to Cindy (585-723-7970).

If needed, provide EMS tech with info for Office of Pre-Hospital Care:Sheri Strollo, BSN, EMT-P telephone: 585-273-3961

4. How to find information about kits in the Pyxis console?

1. log in2. click “System Setup”3. Click “Formulary Management”4. Click “Kits”

Nurse Managers, Charge Nurses, and Clinical Nurse Leadershave the ability to create temporary users in Pyxis.

Instructions to Add a Temporary User: Log in to Pyxis medstation Choose: User Menu Choose: Activate User Choose: Add Temp User (at bottom of screen)

To that end, Pharmacy personnel should not provide initial or additional areas to a current Pyxis account at the request of the employee. Instead, speak to the Nurse Manager, Charge Nurse, or Clinical Nurse Leader and ask them to provide temporary access. Contact Jim Finucane (723-7348) during the next business day with any questions/ concerns.

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Computer Resources

S: Drive – A place for shared documents and folders items saved on the S: drive are visible by all Pharmacists

H: Drive – A place to store materials that only you have access to.

http://gateway.nlm.nih.gov/gw/Cmdhttp://hivinsite.ucsf.edu/http://medem.com/MedLB/medlib_entry.cfmhttp://online.factsandcomparisons.com/

o Login: unityhealtho Password: Pharmacy

http://unitynet/Documents/Medical/Formular...http://unitynet/Documents/Medical/Vancomyc...

o Unity Vancomycin 1st Dose formulahttp://unitynet/Documents/Unitdose/http://unitynet/MedDirNews/Protocols/HIT%2...http://www.cdc.gov/http://www.emedicine.com/http://www.epocrates.com/http://www.globalrph.com/http://www.healthfinder.gov/http://www.healthweb.org/http://www.mayoclinic.com/http://www.medterms.com/script/main/hp.asphttp://www.nih.gov/http://www.nlm.nih.gov/http://www.statref.com/http://extranetcitrix.viahealth.org/Citri...http://w3prqs01/OBLink_Login.asphttp://www.acmlis.com/opquery/http://www.theidegroup.com/http://www.utdol.com/utd/content/search.doThe National Women's Health Information Center -- 1-800-994-9662

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Cerner/Label/MAR Printers

Med LabelsIV Room: PHARZEB1Main: PHARZEB2Satellite: PHARZEB3 and PHARZEB4St. Mary’s: PHARZEB5

MARs Printers Print MARs in Satellite to be delivered to floors, however, sometimes the

floors will ask to print directly to their printer. Exceptions 4100, 5100, PRCD, labor and delivery (LDRP) need to

be printed to the floor printers.

Satellite: PSATP1Central: PHARUNET12100: PN21P12200: PN22P12300: PN23P12400: PN23P1ICU: PICUC13100: PN31P13200: PN32P13300: PN33P13400: PN34P13500: PN35P1MOU: PSPRP1LDRP: PLDRP1Nursery: PLDRP1TCU: Do not print MARs for TCU4100: SN41P1 St. Mary’s4300: SN43P1 St. Mary’s5100: SN51P1 St. Mary’sPRCD Adol: PGRCP3PRCD Adult PGRCP3

49

IVF with POTASSIUM

10 20 30 40D5 ½ NS X X X X

D5 X X XNS X XD5NS X X

These are the pre-mixed IVF with

Potassium. If the fluid you need is not on the chart, it will need to be ordered from Pharmacy.

Please double check label on IV bag to ensure you have the correct solution

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++ CAUTION ++IV PUSH DRUGSCHECK POLICY

Drug Dose FrequencyBumetamide 1 mg Q2hChlorthiazide 1 Gm MDD 2 GMDexamethasone 40 mgDigoxin 0.25 mgDihydroergotamine 2 mg MwD 6 mgDiphenhydramine 50 mg Q4-6hDroperidol 1.25 mg TELEMETRY ONLYD50W 25 Gm MR x 1Ethacrynate Sodium 50 mgFamotidine 20 mg MDD 40 mgFurosemide 200 mg MDD 600 mgHeparin 10 MuHydrocortisone Sodium

2 Gm

Hydromorphone 1 mg Q4h MR q30min x 2Max 3 mg / 4 hoursRate 1 mg over 2 min

Ketorolac 30 mg Q6h 5 day maxLorazepam 2 mg ETOH Protocol 4 mgMeperidine 75 mg Q3-4hMethylprednisolone 2 GmMetoclopramide 10 mgMorphine Sulfate 3 mg Q2-4hNalbuphine 20 mg Q3-6hNaloxone 0.4mg 3 dose maxPhenobarbital 240 mg MR x 1Prochlorperazine 10 mg MDD 40 mgPromethazine 12.5 mg Q4-6h MR x 1Torsemide 100 mg MDD 200 mg

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Fax DowntimeProcedure

Pharmacy Technicians are to pick-up medication orders from units when Pharmacy fax machine is not receiving faxes (see table below with unit assigned fax line).Only stat orders will be faxed to the fax machine that is operating. Due to Park Ridge Chemical Dependency and St. Mary’s being off-site they will be called and informed that they are to fax to x1940.

x1940 x78482nd floor 1st floor3rd floor Park Ridge Chemical

Dependency-Mon – Fri, 430pm – 12amSat & Sun, 430pm – 11pm

TCU St. Mary’s Campus-Mon - Fri, 5pm – 12amSat, 430pm - 8amSun, 430pm - 11pm

Ordered Meds Not Loaded

This procedure is effective 8/27/07 and applies only to Unit Dose Meds in Patient Profile Medstations at Unity Campus, exception: EOU and St. Mary’s CampusWhen a label prints, that is the “trigger” that a med must be loaded in Pyxis. The RPh will always generate label with zero (0) doses so that you will not have to credit patient. Load a three (3) day supply unless the RPh advises otherwise. Max = three (3) day supply; Min = one (1) day supply. Patches – load two (2) eachTCU – load meds in both medstationsNever load chemo meds. Non-Formulary meds cannot be loaded.

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Contact Jim Finucane for operational issues; Tom, Shashi or Leo with clinical questions.

InstructionsLog into Pyxis Click Inventory, select Floor Click Select or hit EnterClick on Assign New Med TabFind desired med, click Select or hit EnterSelect available PocketEnter max & min and click on outdate tracking tabDo not click the standard stock tabclick save

-OR-If No Available PocketsLog into PyxisClick Inventory, select FloorHighlight a med that does not have an S (standard pyxis med) or O (active order)If there are no meds listed without S or O, see the charge RPh for instructionsClick new med tab in upper right cornerFind desired med, click select or hit enterEnter max (three day supply) & min (one day supply) and click on outdate tracking tabDo not click the standard stock tabClick savethis will P (pend) the med

Unloading Meds No Longer Being Used (this report shows S meds)Log into PyxisChoose ReportsChoose Run ReportChoose InventoryChoose Meds Without RemovalChoose UnitChoose No Removals Since: first enter date of 6 months in past; if nothing, then 4 monthsReport will show which cubies can be freed.

Review of Inventory will show the S and O meds Log into PyxisChoose Inventory

9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS

PREAMBLE:The increasing use of antineoplastic drugs and the growing awareness of potential hazards requires special attention to the procedures utilized in the handling, preparation and administration of these drugs. Equally important is the proper disposal of chemical residues and

53

wastes. Policies are intended to provide information for the protection of personnel participating in the clinical process of chemotherapy. The mutagenic and carcinogenic potential of many antineoplastic agents is well established and is a possible hazard to the health of exposed individuals. It is the responsibility of institutional and private health care providers to adopt and use appropriate procedures for protection and safety.

Policies and procedures provide the basis for safe handling of antineoplastic agents. There is no substitute for individual awareness and consistent application of the highest standard of performance regarding personnel protection.

POLICY: A pharmacist shall compound antineoplastic-cytotoxic drugs in the Department of Pharmacy in accordance with accepted professional standards and as promulgated and approved by the Executive Committee of the medical staff to insure patient and professional employee safety through proper handling, compounding, delivery, administration and disposal of these compounds. Pregnant females, or those intending to become pregnant, will not be allowed to compound antineoplastic medications due to potential hazard to the fetus. In the out-patient clinic, a certified Oncology Nurse under the direction of the Oncologist may prepare the antineoplastic agents utilizing the same guidelines and standards as listed above in the unlikely event that the pharmacist is unavailable.

PROCEDURE:

1. Orders written for antineoplastics at Park Ridge Hospital will be carefully reviewed and entered into the computer system by the pharmacist.

a. Pharmacist will confirm the chemotherapy regimen and the patient identification with the chemo nurse.

b. Pharmacist will enter the chemotherapy order in the Cerner computer system.c. A second pharmacist will check the orders and the label.d. The first pharmacist will prepare the chemo; following compounding procedure. e. Pharmacist will package chemo in chemo spill bags.f. Pharmacy Technician will deliver the chemo directly to chemo nurse.

At the Genesee Street Campus, the orders will be handed directly to the pharmacist.

9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d)

2. Compounding of antineoplastics for hospitalized patients and the patients at the Oncology Center at Genesee Street Campus shall be done in the pharmacy or in the Outpatient Oncology

54

Center utilizing the Vertical Laminar Flow Hood by pharmacists or certified oncology nurses in the out-patient oncology center under the supervision of the oncologist

3. Preparation and supplies,reference, and registry protocol information shall be available in the pharmacy and at the Genesee Street Campus.

4. Disposable chemo safety gloves must be worn for all procedures involving antineoplastic drugs. Double gloving is recommended for cleaning up spills.

5. Disposable protective barrier garments should be worn for all procedures. These garments should have a closed front, long sleeves, and closed cuff (either elastic or knit). Disposable protective garments and chemo gloves should only be worn while preparing neoplastic agents.

6. A manual will be located on selected units, in the pharmacy, and in other areas as designated which will include a simple summary of policies, procedures, and

protocol.

7. Special aseptic techniques and precautions must be utilized because of the vertical (downward) airflow.

8. No other IV admixture should be prepared in Biological Safety Cabinets designated for the mixing of antineoplastic agents.

9. The Biological Safety Cabinets will be certified by qualified personnel annually, or any time the cabinet is physically moved.

10 The biological Safety Cabinet must be operated with blower on for at least 5 minutes prior to using the hood.

11 Drug preparations shall be performed only with the viewing window at the required access opening.

12 Compounded cancer drugs shall be sent/taken to the floor at Park Ridge, properly labeled and packaged. This will include a green "antineoplastic material” caution sticker and the use of a chemotherapy drug ziplock bag. In the GSC Oncology Clinic, chemo preparations remain in the Biohazard hood until the administering Nurse verifies the preparation. The Nurse then removes the chemo preparation and administers it directly to the patient.

A comprehensive protocol is available to the Department of Pharmacy and in designated areas. See following expanded information.

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9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d)

SAFE HANDLING AND DISPOSAL OF CHEMOTHERAPEUTIC DRUGS

INTRODUCTION

Current practices in the preparation, storage, administration and disposal of the widely used group of antineoplastic (anti-new growth; anti-cancer) drugs, also called cytotoxic drugs (CDs) because they are toxic to cells, may expose pharmacists, nurses, physicians, and other health care workers to high environmental levels of these drugs.

. Although little research has been done on the long-term risks at the levels of exposure encountered by unprotected health care workers, these drugs have been associated with human cancers at high (therapeutic) levels of exposure and are carcinogens and teratogens in many animal species.

. Under current work practices, CDs have demonstrated the ability to cause elevations in sister chromatid exchanges and chromosome breakage in circulating lymphocytes and mutagenic activity in urine.

. In addition, many of these drugs have been shown to cause a variety of acute effects in humans, such as localized skin necrosis after surface contact with abraded skin or damage to normal skin.

These drugs were known to be potentially harmful to workers dealing with them. The nitrogen mustard drugs are extremely irritating to mucous membranes, eyes and skin. Other agents developed later on, such as fluorouracil, also have well-known topical effects. Spills of agents such as doxorubicin onto abraded skin can lead to severe soft-tissue injury, such as necrosis and sloughing of exposed areas as well as possible effects on the fetus. Symptoms such as lightheadedness, dizziness, nausea, headache, and possible allergic reaction also have been described in nurses after the preparation of antineoplastic drugs, and their subsequent administration, in unventilated areas.

The potential for harmful effects developing over a longer term is also well-known. Most CDs either bind directly to genetic material, in the cell nucleus, or affect cellular protein synthesis, and may therefore damage growth and reproduction of normal cells as well.

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9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d)

The risks to workers handling CDs are a combined result of the drugs’ inherent toxicity and the extent to which workers are directly exposed to CDs on the job. The main routes of exposure are through the inhalation of drug dusts or droplets, absorption through the skin, and ingestion through contact with contaminated food or cigarettes. Opportunity for exposure may occur at many points in the handling of these drugs.

Long term risks are uncertain with low level exposure to drugs known to be mutagenic, carcinogenic and teratogenic. Therefore, precautionary measures as defined below are recommended for the particular drugs of concern.

I. DRUG PREPARATION GUIDELINES

Access to preparation area should be limited to authorized personnel. Eating, drinking, smoking, chewing gum, applying cosmetics, and storing food in or near the preparation area should be forbidden.

A. Biological Safety Cabinets

• All mixing of neoplastic drugs shall be performed in a vertical Laminar Flow Biological Safety Cabinet.

• Special aseptic techniques and precautions must be utilized because of the vertical (downward) airflow.

• No other I.V. admixtures should be prepared in Biological Safety Cabinets designated for the mixing of antineoplastic agents.

• The Biological Safety Cabinets should be certified by qualified personnel annually, or any time the cabinet is physically moved.

• The Biological Safety Cabinet must be operated with blower on at least 5 minutes prior to using the hood.

• Drug preparations shall be performed only with the viewing window at the required access opening.

• All I.V. bags must carry the following label to identify contents as a Chemotherapy Agent. This is in addition to the regular I.V. label.

—CAUTION—Antineoplastic Material

Handle Properly

9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d)

B. Gloves and protective gowns

• Disposable surgical latex gloves or special chemo safety gloves must be worn for all procedures involving antineoplastic drugs. Double gloving is recommended when cleaning up spills.

• Disposable protective barrier garments should be worn for all procedures. These garments should have a closed front, long sleeves and closed cuff (either elastic or knit). Disposable protective aprons may be worn as a barrier in lieu of closed front garments.

• A disposable mask should be worn when exposure to particles is anticipated such as when compounding in areas other than that specified under “A. Biological Safety Cabinets”, i.e., when BSC is not available.

• All potentially contaminated garments must not be worn outside the work area.

C. Compounding Techniques

• Hands must be washed thoroughly before gloving and after removal.• Care must be taken to avoid puncturing of gloves and possible self-inoculation.• Syringes and I.V. sets with luer-lock fittings should be used whenever possible.

Syringes should always be large enough so that they are never more than three-fourths full.

• The work surface should be thoroughly cleaned before daily use and after any spillage.• Vials should be vented to eliminate internal pressure on vacuum.• Before opening ampules, care should be taken to insure that no liquid remains in the tip

of the ampule. A sterile gauze sponge should be wrapped around the neck of the ampule while opening.

• Final drug measurement should be performed prior to removing the needle from the stopper of the vial.

• A non-splash collection vessel should be available in or next to the Biological Safety Cabinet to discard excess drug solution.

• The external surface of final I.V. containers should be wiped with alcohol soaked sponges prior to removal from the Biological Safety Cabinet.

• Special procedures should be followed for major spills or acute exposures.

9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d)

D. Disposal Recommendations

• All disposable items that have potentially come in contact with antineoplastic drugs during compounding or administration must be disposed of in specifically designated containers. These are plastic “Biohazard” or “Contaminated Material” buckets. Care must be taken to insure that the lid and the vial opening are securely closed before the buckets are removed for disposal.

• All hazardous waste containers shall be collected for disposal by housekeeping staff (environmental policy procedure).

• General cleaning of the work area must be performed using dust containment procedures.

E. Personnel Policy Recommendation

• All personnel must receive special training in working with antineoplastic agents.• The number of personnel working with these agents should be minimized.• Eating, drinking, smoking, application of cosmetics, or similar activities are not

permitted during compounding or drug administration procedures.• Access to the compounding area must be limited to only necessary authorized personnel.• The personnel working with these agents should be observed regularly by supervisory

personnel to insure compliance.• Acute exposure episodes must be documented. The employee must be referred for

professional examination.

II. ADMINISTRATION OF CHEMOTHERAPEUTIC AGENTS ON PATIENT UNITS

Proper handling of drugs is important to minimize contact to skin, mucus membranes and eyes for nurses and for patients.

• Wash hands with soap and water before and after changing bags or tubing.• Disposable surgical latex gloves are required to be worn when changing bags and

tubing.• Syringes and I.V. sets with luer-lock fittings should be used whenever possible.

9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d)

• To prime I.V.set at Genesse campus,use compatible solution and double clamp the iv tubing. Add the chemo to the base solution.

• To prime I.V.set at Park Ridge Campus,chemo nurse back primes primary solution of D5W or NS into drip chamber of chemotherapy secondary tubing by lowering chemotherapy bag and unclamping tubings.Reclamp when primed.

III. STORAGE AND TRANSPORT

A. Storage Areas

• Access to areas where CDs are stored should be limited to authorized personnel

B. Receiving Damaged CD Packages

• Damaged cartons should be opened in an isolated area by an employee wearing the same protective equipment as is used in preparation without a hood.

• Broken containers and contaminated packaging mats should be placed in a puncture-resistant receptacle and then in CD disposal bags, which should be closed and placed into appropriate receptacles.

C. Transport

• Within the medical facility, drugs should be securely capped or sealed and properly packaged.

• Personnel involved in transporting CDs should be cautioned and trained in the necessary procedures should a spill occur, including sealing off the contaminated area and calling for appropriate assistance.

• All drugs should be labeled with a warning label and clearly identified as cytotoxics.

IV. DRUG SPILLAGE

A. Skin Contact

• Immediate thorough washing of area with soap and water.

9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d)

B. Eye Contact

• Flush affected eye with copious amounts of water.• Seek medical attention immediately.

C. Floor Drug Spillage

• Open a “Spill Kit”, put on gloves, gown, etc., goggles and mask are also available and should be used for large spills. Absorbent materials are also available. After spill is absorbed, the contaminated materials should be disposed of in the plastic biohazard recepticles and the area washed as indicated below.

• When a “Chemo Spill Kit” is not immediately available, apply two pair of latex gloves. (Surgical gowns and masks are recommended for large spills to minimize skin/clothing/vapor contact.)

• Use paper towels to wipe up spill.• Follow by rinsing area with water to remove any excess drug.• Dispose of all materials as contaminated material.• If linen is involved, it should be changed as soon as possible. The patient should be

protected from skin contact with the spill until the linen is changed. Linen should be double bagged and marked as contaminated.

D. Spills in Hoods

• Decontamination of all interior hood surfaces may be required after the above procedures have been followed. If the HEPA filter of a hood is contaminated, the unit must be labeled “Do not use — Contaminated”, and the filter must be changed and disposed of properly as soon as possible by trained personnel wearing protective equipment. Protective goggles should be cleaned with an alcohol wipe after the cleanup.

V. DISPOSAL OF MEDICATION AND RELATED SUPPLIES

.All supplies, including syringes, needles, I.V. bags and tubing, alcohol swabs, gloves, paper towels, etc., should be treated as “contaminated,” i.e., placed in red plastic trash buckets marked for contaminated materials.

.Medication remaining in vial or ampule after preparation is also disposed of in the plastic trash buckets. (See above)

. I.V. bags containing chemo medication should be clamped off (i.e., leave tubing attached with tubing clamps closed) and disposed of by placing in containers, double bagged and marked for “contamination or biohazard.”

.Disposable containers may be placed in patient rooms for the disposal of such drugs and related supplies.

9.11 ANTINEOPLASTIC/CYTOTOXIC DRUGS (Cont’d)

VI. MANAGEMENT OF PATIENT EXCRETA

1. Precautions are recommended particularly on those specific days the patient has received chemotherapy (see list of drugs VII).

2. Wear gloves to dispose of urine and stool.3. Hand washing is essential following contact with or without gloves.4. In emptying and rinsing containers, use toilet, avoiding spray of contents onto toilet seat, skin or eyes. Clean all areas of possible contact after rinsing the container.

5. For peritoneal drainage containing chemotherapy, the system must be kept closed and discarded intact.

VII. THE PARTICULAR DRUGS OF CONCERN INCLUDE:A. I.V. Drugs

Bleomycin Doxorubicin MitoxantroneCarboplatin Etoposide Paclitaxel

Carmustine Fludarabine PlicamycinChlorozotocin Ifosfamide StreptozotocinCisplatin Investigational drugs Thio TEPACytatabine Mechlorethamine VinblastineCyclophosphamide Mercaptopurine VincristineDacarbazine Methotrexate VinorelbineDaunorubicin Mitomycin(5-FU does not require special precautions other than good hand washing)B. Oral DrugsBusulfan Etoposide MelphalanChlorambucil Hydroxyurea MethotrexateCyclophosphamide Lomustine Procabazine

revised:6/26/03 reviewed:3/31/06Revised:6/1/07

Unity Health SystemHigh Alert Medications

High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error with these medications are clearly more devastating to patients. Based on literature, ISMP Medication Errors Reporting Program and Unity Health System Medication Safety Reporting Program, a comprehensive list of identified high-alert medications has been constructed.

Specific Medications IV amiodarone Colchicines injection Heparin, low molecular weight, injection Heparin, unfractionated, IV Insulin, subcutaneous and IV IV lidocaine Magnesium sulfate injection Methotrexate, oral, non-oncologic use Nesiritide Nitroprusside, sodium, for injection Potassium chloride for injection concentrate Potassium phosphates injection Sodium chloride injection, hypertonic, more than 0.9% concentration Warfarin

Classes, categories of medicationsAdrenergic agonists, I.V. (e.g., epinephrine) Adrenergic antagonists, I.V. (e.g., propranolol) Anesthetic agents, general, inhaled and I.V. (e.g., propofol) Antidiabetic agents, oral Cardioplegic solutions Chemotherapeutic agents, parenteral and oral Dextrose, hypertonic, 20% or greater Dialysis solutions, peritoneal and hemodialysis Epidural or inrathecal medications Glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide) Inotropic medications, I.V. (e.g., digoxin, milrinone) Liposomal forms of drugs (e.g., liposomal amphotericin B) Moderate sedation agents, I.V. (e.g., midazolam) Narcotics/opioids, I.V. and oral (including liquid concentrates, immediate-and

sustained-release formulations) Neuromuscular blocking agents (e.g., succinycholine) Radiocontrast agents, I.V. Thrombolytics/fibrinolytics, I.V. (e.g., alteplase)

May 2006

UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST

HOSPITAL LIST

Potential Problematic Drug Names

Generic (lowercase) and Brand Name(s) (uppercase)

Potential Errors and Consequences

Specific Safety Strategies * Safety Strategies in place at Unity Hospital

Concentrated liquid morphine products vs. conventional liquid morphine concentrations.

Concentrated:ROXANOL, MSIR

Conventional:Morphine oral liquid

Concentrated forms of oral morphine solution (20mg/ml) have been confused with the standard concentration (listed as 10mg/5ml or 20mg/5ml), leading to serious errors. Accidental selection of the wrong concentration, and prescribing/labeling the product by volume, not milligrams, contributes to these errors, some of which have been fatal. For example, “10mg” haw been confused with “10ml”. If concentrated product is used, this represents a 20-fold overdose.

Dispense concentrated oral morphine solutions only when ordered for a specific patient (not as unit stock). Segregate the concentrated solution from the other concentrations wherever it is stored. Purchase and dispense concentrated solutions in dropper bottles (available from at least two manufacturers) to help prevent dose measurement errors and differentiate the concentrated product from the conventional products. Verify that patients and caregivers understand how to measure the proper dose for self-administration at home. For inpatients, dispense concentrated solutions in unit doses.

Concentrate solutions are dispensed in unit dose to the Pyxis. Not available in Pyxis unless patient specific.

ephedrine and epinephrine

ADRENALIN(epinephrine)

ephedrine

The names of these two medications look very similar, and their clinical uses make storage near each other likely, especially in obstetrical areas. Both products are available in similar packaging (1ml amber ampuls and vials).

See general recommendations below. Ephedrine in vial. Stored in Pharmacy under generic name on separate shelves. Epinephrine ampoule. Medications labeled with sound alike look alike labels.

fentanyl and sufentanil

SUBLIMAZE(fentanyl)

SUFENTA(sufentanil)

The products are not interchangeable. Confusion has resulted in episodes of respiratory arrest due to potency differences between these drugs. Some errors occurred when using sufentanil during drug shortages of fentanyl.

Do not stock sufentanil in patient care units outside OR/PACU settings. Do not store these agents near one another if both products are available (e.g., pharmacy, anesthesia supplies).

Medication name printed using tall man lettering. Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels.

Updated: 5/2008 Reviewed: 5/2008

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UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST

Potential Problematic Drug Names

Generic (lowercase) and Brand Name(s) (uppercase)

Potential Errors and Consequences

Specific Safety Strategies * Safety Strategies in place at Unity Hospital

hydromorphone injection and morphine injection

DILAUDID(hydromorphone)

ASTRAMORPH,DURAMORPH,INFUMORPH(morphine)

Some health care providers have mistakenly believed that hydromorphone is the generic equivalent of morphine. However, these products are not interchangeable. Fatal errors have occurred when hydromorphone was confused with morphine. Based on equianalgesic dose conversion, this may represent significant overdose, leading to serious adverse events. Storage of the two medications in close proximity to one another and in similar concentrations may contribute to such errors. Confusion has resulted in episodes of respiratory arrest due to potency differences between these drugs.

Stock specific strengths for each product that are dissimilar. For example, stock units with hydromorphone 1mg unit dose cartridges, and morphine in 2mg unit dose cartridges. Ensure that health care providers are aware that these two products are not interchangeable.

Medication name printed using tall man lettering. Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels.

Insulin products:

Lantus and LenteHumalog and HumulinNovolog and NovolinHumulin and NovolinHumalog and NovologNovolin 70/30 and Novolog Mix 70/30

LANTUS (insulin glargine)LENTE (insulin zinc susp)

HUMULIN (human insulin products)HUMALOG (insulin lispro)

NOVOLIN (human insulin products)NOVOLOG (human insulin aspart)

Similar names, strengths and concentration ratios of some products (e.g., 70/30) have contributed to medication errors. Mix-ups have also occurred between the 100 units/ml and 500 units/ml insulin concentrations.

Limit the use of insulin analog 70/30 mixtures to just a single product. Limit the variety of insulin products stored in patient care units, and remove patient-specific insulin vials from stock upon patient discharge. For drug selection screens, emphasize the word “mixture” or “mix” along with the name of the insulin product mixtures. Consider auxiliary labels for newer products to differentiate them from the established products. Also apply bold labels on atypical insulin concentrations.

Only Stock:LantusHumulin 70/30HumalogHumulin NHumulin RMedications labeled with sound alike look alike labels. Insulin stored in individual labeled containers in the medication refrigerators on patient floors and in Pharmacy.

Updated: 5/2008 Reviewed: 5/2008

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UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST

Potential Problematic Drug Names

Generic (lowercase) and Brand Name(s) (uppercase)

Potential Errors and Consequences

Specific Safety Strategies * Safety Strategies in place at Unity Hospital

Lipid-based amphotericin products vs. conventional forms of amphotericin

Lipid-based:

AMBISOME(amphotericin B liposomal)

ABELCET (amphotericin B lipid complex)

AMPNOTEC(amphotericin B. cholesteryl sulfate complex for injection:

Conventional:

AMPHOCIN, FUNGIZONE INTRAVENOUS (amphotericin B desoxycholate)

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. Lipid-based formulation dosing guidelines differ significantly from conventional dosing. Conventional amphotericin B desoxycholate doses should not exceed 1.5mg/kg/day. Doses of the lipid-based products are higher, but vary from product to product. If conventional amphotericin B is given at a dose appropriate for a lipid-based 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 lipid-based product in patient care areas and automated dispensing cabinets is highly discouraged. To reduce potential for confusion, consider limiting lipid-based amphotericin B products to one specific brand.

Medications labeled with sound alike look alike labels. Stored in Pharmacy under generic name on separate shelves in refrigerator.

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UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST

Potential Problematic Drug Names

Generic (lowercase) and Brand Name(s) (uppercase)

Potential Errors and Consequences

Specific Safety Strategies * Safety Strategies in place at Unity Hospital

Avandia and Coumadin

AVANDIA (rosiglitazone)

COUMADIN(warfarin)

Poorly handwritten orders for Avandia (used for type II diabetes) have been misread as Coumadin (used to prevent blood clot formation), leading to potentially serious adverse events. Mix-ups originally occurred due to unfamiliarity with Avandia – staff read the order as the more familiar Coumadin. However, mix-ups between these two products continue to occur. Neither medication is safe without appropriate monitoring that is specific to the drug.

See general recommendations below. Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels. High Alert label on Coumadin.

Celebrex and Celexa and Cerebyx

CELEBREX(celecoxib)

CELEXA(citalopram hydrobromide)

CEREBYX(fosphenytoin)

Patients affected by a mix-up between these three drugs may experience a decline in mental status, lack of pain or seizure control, or other serious adverse events.

See general recommendations below. Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels.

Clonidine and clonazepam (Klonopin)

CATAPRES(clonidine)

KLONOPIN(clonazepam)

The generic name for clonidine can easily be confused as the trade or generic name for clonazepam.

See general recommendations below. Stored in separate areas in the Pharmacy.Medications labeled with sound alike look alike labels.

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UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST

Potential Problematic Drug Names

Generic (lowercase) and Brand Name(s) (uppercase)

Potential Errors and Consequences

Specific Safety Strategies * Safety Strategies in place at Unity Hospital

Lamisil and Lamictal LAMISIL(terbinifine hydrochloride)

LAMICTAL(lamotrigine)

Patients with epilepsy who do not receive Lamictal due to an error would be inadequately treated and could experience serious consequences. Conversely, patients erroneously receiving Lamictal would be unnecessarily subjected to a risk of potential side effects (including serious rash) and would miss important antifungal therapy.

See general recommendations below. Pharmacy does not stock Lamisil. Medications labeled with sound alike look alike labels.

Zyprexa and Zyrtec ZYPREXA(olanzapine)

ZYRTEC(cetirizine)

Name similarity has resulted in frequent mix-ups between Zyrtec, an antihistamine, and Zyprexa, an antipsychotic. Patients who receive Zyprexa in error have reported dizziness, sometimes leading to a related injury from a fall. Patients on Zyprexa for a mental illness have relapsed when given Zyrtec in error.

See general recommendations below. Medication name printed using tall man lettering.

Updated: 5/2008 Reviewed: 5/2008

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UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST

CHEMO LIST

Potential Problematic Drug Names

Generic (lowercase) and Brand Name(s) (uppercase)

Potential Errors and Consequences

Specific Safety Strategies * Practices in place at Unity Hospital

Cisplatin and carboplatin

PLATINOL(cisplatin)

PARAPLATIN(carboplatin)

Similarity in names can lead to confusion between these two products. Doses appropriate for carboplatin usually exceed the maximum safe dose of cisplatin. Severe toxicity and death has been associated with accidental cisplatin overdoses.

Install maximum dose warnings in computer systems. A boxed warning notes that cisplatin doses greater than 100mg/m² once every 3 to 4 weeks are rarely used and that the package insert should be consulted for further information. Use safe handling recommendations and safety stickers for cisplatin as provided by manufacturer. Do not store these agents next to each other. Use generic names when prescribing and not chemical names or abbreviations.

Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels. Maximum dose warning in Cerner system. High alert medication labeling. Dispensed chemo medications are clearly labeled with “Cytotoxic Dispose of Properly”. Dispensed and secured in special chemo bags.

Updated: 5/2008 Reviewed: 5/2008

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UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST

Potential Problematic Drug Names

Generic (lowercase) and Brand Name(s) (uppercase)

Potential Errors and Consequences

Specific Safety Strategies * Safety Strategies in place at Unity Hospital

Lipid-based daunorubicin and doxorubicin products vs. conventional forms of daunorubicin and doxorubicin.

Lipid-based:

DOXIN(doxorubicin liposomal)

DAUNOXOME(daunorubicin citrate liposomal)

Conventional:

CERUBIDINE(daunorubicin, conventional)ADRIAMYCIN, RUBEX(doxorubicin, conventional)

Many drugs now come in liposomal formulations indicated for special patient population. Confusion may occur between the liposomal and the conventional formulation because of name similarity. The products are not interchangeable. Lipid-based formulation dosing guidelines differ significantly from conventional dosing. For example, a standard dose of doxorubicin liposomal is 20mg/m² given at 21 day intervals, compared to doses of 50 to 75mg/m² every 21 days for conventional drugs.Doses of liposomal daunorubicin are typically 40mg/m² repeated every 2 weeks, while doses of conventional daunorubicin vary greatly and may be administered more frequently. Accidental administration of the liposomal form instead of the conventional form has resulted in severe side effects and death.

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, patents 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 lipid-based products in patient care areas and automated dispensing cabinets is highly discouraged. Include specific method of administration for these products.

Medication name written using tall man lettering. Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels. Maximum dose warning in Cerner system. High alert medication labeling. Dispensed chemo medications are clearly labeled with “Cytotoxic Dispose of Properly”. Dispensed and secured in special chemo bags.

Updated: 5/2008 Reviewed: 5/2008

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UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST

Potential Problematic Drug Names

Generic (lowercase) and Brand Name(s) (uppercase)

Potential Errors and Consequences

Specific Safety Strategies * Safety Strategies in place at Unity Hospital

Taxol and Taxotere

TAXOL(paclitaxel)

TAXOTERE(docetaxel)

Confusion between these two drugs can result in serious adverse outcomes since they have different dosing recommendations and use in various types of cancer.

Install maximum dose warnings in computer systems to alert staff to name mix-ups during order entry. Do not store these agents near one another.

Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels. Maximum dose warning in Cerner system. High alert medication labeling. Dispensed chemo medications are clearly labeled with “Cytotoxic Dispose of Properly”. Dispensed and secured in special chemo bags.

Vinblastine and Vincristine

VELBAN(vinblastine)Oncovin(vincristine)

Fatal errors have occurred, often due to name similarity, when patients were erroneously given vincristine intravenously, but at the higher vinblastine dose. A typical vincristine dose is usually capped at around 1.4mg/m² weekly. The vinblastine dose is variable but, for most adults, the weekly dosage range is 5.5 to 7.4mg/m².

Install maximum dose warnings in computer systems to alert staff to name mix-ups during order entry. Do not store these agents near one another. Staff involved in handling these products should be aware of the differences. Use brand names or brand and generic names when prescribing and do not use abbreviations for these drug names

Medication name written using tall man lettering. Stored in Pharmacy under generic name on separate shelves. Medications labeled with sound alike look alike labels. Maximum dose warning in Cerner system. High alert medication labeling. Dispensed chemo medications are clearly labeled with “Cytotoxic Dispose of Properly”. Dispensed and secured in special chemo bags.

These safety strategies are not inclusive of all possible strategies to reduce name-related errors. Also see General Recommendations for Preventing Drug Name Mix-ups.

Updated: 5/2008 Reviewed: 5/2008

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UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST

General Recommendations for Preventing Drug Name Mix-ups

What prescribers can do:

Maintain awareness of look-alike and sound-alike drug names as published by various safety agencies. Clearly specify the dosage form, drug strength, and complete directions on prescriptions. These variables may help staff differentiate products. With name pairs known to be problematic, reduce the potential for confusion by writing prescriptions using both the brand and generic name. Include the purpose of medication on prescriptions. In most cases drugs that sound or look similar are used for different purposes. Alert patients to the potential for mix-ups, especially with known problematic drug names. Advise ambulatory care patients to insist on

pharmacy counseling when picking up prescriptions, and to verify that the medication and directions match what the prescriber has told them. Encourage inpatients to question nurses about medications that are unfamiliar or look or sound different than expected. Give verbal or telephone orders only when truly necessary, and never for chemotherapeutics. Include the drug’s intended purpose to ensure

clarity. Encourage staff to read back all orders, spell the product name, and state its indication.

What organizations and practitioners can do:

Maintain awareness of look-alike and sound-alike drug names as published by various safety agencies Regularly provide information to professional staff.

Whenever possible, determine the purpose of the medication before dispensing or drug administration. Most products with look or sound-alike names are used for different purposes.

Accept verbal or telephone orders only when truly necessary, and never for chemotherapy. Encourage staff to read back all orders, spell the product name, and state it’s indication.

Consider the possibility of name confusion when adding a new product to the formulary. Review information previously published by safety agencies.

Computerized prescribing. Use preprinted orders or prescriptions as appropriate. If possible, print out current medications daily from pharmacy computer system and have physicians review for accuracy.

When possible, list brand and generic names on medication administration records and automate dispensing cabinet computer screens. Such redundancy could help someone identify an error.

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UNITY HEALTH LOOK-A-LIKE, SOUND-A-LIKE DRUG LIST

Change the appearance and look-alike product names on computer screens, pharmacy and nursing units shelf labels and bins (including automated dispensing cabinets), pharmacy product labels and medication administration records by highlighting, through bold face, color, and/or tall man letters, the part of the names that are different (e.g. hydroxyzine, hydralazine).

Install and utilize computerized alerts to remind providers about potential problems during prescription processing. Configure computer selection screens and automated dispensing cabinet screens to prevent the two confused drugs from appearing

consecutively. Affix “name alert” stickers to areas where look or sound-alike products are stored. Store products with look or sound-alike names in different locations in pharmacies, patient care units, and in other settings, including patient

homes. When applicable, use a shelf sticker to help locate the product that has been moved. Continue to employ independent double checks in the dispensing process (one person interprets and enters the prescription into the computer

and another reviews the printed label against the original prescription and the product prior to dispensing). Encourage reporting of errors and potentially hazardous conditions with look and sound-alike product names and use the informationto

establish priorities for error reduction. Also maintain awareness of problematic product names and error prevention recommendations provided by ISMP, FDA and USP.

References:

1. ISMP. What’s in a name? Ways to prevent dispensing errors linked to name confusion. ISMP Medication Safety Alert! 7(12) June 12, 2002

2. JCAHO, Sentinel Event Alert. Issue 19-May 2001

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