Pharmacy Department Orientation

June 26, 2015

Brittany N. White, PharmD, BCPS

Pharmacy Ext. 7238

Pharmacy Department Main

Located on the 6th floor Open 24 hours a day 7 days a week

Children’s Located on 3rd floor of main campus Open 7am – 10pm daily – after hours served by main pharmacy

East Located on East campus Open 7am – 4pm 5 days weekly – after hours served by main

campus North

Located on North campus Open 7am – 3pm 5 days weekly – after hours served by main

campus Bledsoe

Located on Bledsoe campus (Central Time Zone) Open 7am – 3pm 5 days weekly – after hours served by main

campus

General Information UptoDate, MicroMedex – located on the intranet

Drug side effects, dosing, indications, guidelines

Therapeutic Substitutions Claforan to Rocephin Allegra to Claritin Zantac to Pepcid Prilosec, Aciphex, Nexium, Prevacid to Protonix Aranesp to Procrit Imipenem, Doripenem to Merrem Fragmin to Lovenox

Renal Dosing

Pharmacy Clinical Services

Internal Medicine Critical Care Infectious Diseases Anticoagulation Nutrition Emergency Medicine Pharmacokinetics Drug information

Pharmacokinetics Service Pharmacy doses all Vancomycin

Vancomycin dosing 20mg/kg loading dose, then 15mg/kg IV

q8-12h

Vancomycin troughs-caution interpretation of reported levels

Once daily aminoglycoside dosing 5mg/kg 7mg/kg

Random level 10 hours post dose

Service available 7 days per week in adults

Antibiotic Stewardship Program

Cyle White, PharmD, BCPS Pharmacist ext. 5063, Emergin messenger

Reviews antibiotic orders on a daily basis for adult

patients

Leaves suggestions on chart to streamline therapy, make dosages adjustments for better efficacy, stop unnecessary antibiotics

Antibiotic Stewardship

Prevent adverse events Examples

Clostridium difficile Line-related infections

Decrease resistance

Examples VRE MDR organisms (GN)

Decrease cost

Methods Antibiotic lists

Tigecycline, Zyvox ,Daptomycin, Micafungin, Voriconazole Antibiotics >11 days 2 or more Abx Vancomycin Fluconazole >3 days

Antibiotic recommendations

leave notes where appropriate suggests streamlining and discontinuation where appropriate

Stop Orders

Automatic 7 day stop dates in pharmacy system for abx Evaluate patients chart and place stop orders requesting MD to indicate

whether abx needs to be ctd and requests their signature

IV-to-PO List of patients receiving IV abx where PO available Automatic switch to PO when pt meets criteria

TPN

Available 7 days a week for adult patients

Write “Consult Nutrition Support Service”

Consults must be received by 2pm to be started that day

Do not order TPN to start after 2pm Not a stat/urgent therapy

Enteral feeding ALWAYS preferred

If can take sips/clears TPN not indicated If oral intake anticipated within 7 days, TPN not indicated NG/Dobhoff/PEG always preferred Reduced incidence line infections Reduced risk gut atrophy

Pharmacy Anticoagulation Service

Pharmacy Anticoagulation Service started October 2010

Reviews coumadin patients for an INR at least every 3 days

Reviews supra-therapeutic INRs

Reviews LMWH patients that are obese or under weight for appropriate dose

Available to dose and follow warfarin

To Consult write Pharmacy Anticoagulation Service to Dose and Follow

New ACCP guidelines require bridging therapy for 5 days when warfarin started except for a-fib

Adverse Drug Reactions

An adverse drug reaction is any unintended, undesirable, and unexpected effect of a prescribed medication or medication error that requires discontinuing a medication or modifying the dose.

4th-6th leading cause of death

Over 100,000 deaths occur annually due to ADRs

Adverse Drug Reactions

Reasons to Report Postmarketing Surveillance Manufacturing Errors Mandated by JCAHO

How to Report Write “notify pharmacy of reaction with____”

Occurrence Reporting

An Occurrence is any event that involves potential or actual harm to a patient or visitor or lost/damaged property.

Mandatory to report

Non-punitive

Anonymous

State the facts to avoid miscommunication

Dangerous Abbreviation Instead Write MgSO4 can be misinterpreted as morphine sulfate Instead write magnesium sulfate

MSO4 can be misinterpreted as magnesium sulfate Instead write morphine sulfate

µg can be mistaken for “mg” Instead write micrograms or mcg

U can be misread as a zero (0) or a (4) Instead write out units

IU can be misread as IV or 10 Instead write out international units

Q.D. can be misread as QID or QOD Instead write out daily

QOD can be misread as QID or QD Instead write out every other day

A zero was not used prior to a decimal dose (i.e., .25units) never leave a naked zero

Instead always use a leading zero with a decimal (i.e., 0.25 units)

A zero was used after a decimal (i.e., 2.0 units could be interpreted as 20 units

Instead never use a trailing zero with decimals (i.e., 2 units)

DO NOT USE ABBREVIATIONS

Order Sheets How do I find the Zyvox™ Order Sheet?

Go to the Intranet Go to Order sets Select Pharmacy Select Linezolid/Zyvox Order Sheet #4026 Select File then print

How do I find the Renal Protection Protocol Order Sheet?

Go to the Intranet Go to the Order sets Select Radiology Select Renal Protection Protocol #10015 Select file then print

How to Write a Medication Order

All medication orders should be printed/entered through CPOE

They require: A drug name A dose A route A frequency An indication is required for all prn medications A signature with printed name/pager number/6-digit ID

number

Writing PRN Medications

All PRN medications MUST have an indication written as part of the order

eg, “Labetalol 20 mg IV every hour prn SBP > 160”

eg, “Morphine 2 mg IV Q 4 hrs prn pain not relieved by Percocet”

Writing Orders Tennessee state law requires all medication orders

be printed

Please legibly for others to read

All prn orders MUST have an indications

Safer to include indications on all medications

Sign your name then print with 6-digit ID/use stamp

11 Rules for Preventing Medication Errors

Never use “U” for units

Never use chemical names

Never abbreviate drug names - MSO4

Never abbreviate once daily as QD may be read as right eye

Never abbreviate Q.D. may be read as QID

Never use µg, write out mcg

11 Rules for Preventing Medication Errors

Never leave a decimal point naked, such as .5mg - write 0.5mg

Never add a trailing 0, such as 2.0mg - write 2mg

Always use the metric system

Include indications with each order

Specify exact dosage strength rather than dosage form

Writing Pain Medications Many orders written as a range – example: Morphine 1-2mg

IV Q4-6h

Range orders not appropriate

Tie to pain scale

Need to specify for “what”

Nursing will start with lowest dose

Will be entered by pharmacy with shortest frequency Exp) q4-6hrs will be entered onto MAR as q4hrs

Pharmacy Ext: 7328, 7327

Pharmacy Department Orientation

June 26, 2015

Brittany N. White, PharmD, BCPS

Pharmacy Ext. 7238