Writing for Medications- Clinical Pearls

Transcription

1 Writing for Medications- Clinical Pearls Dr Pete Antonopoulos PharmD Clinical Pharmacist Specialist Stroger Hospital of Cook County UIC Assistant Clinical Professor

2 Inpatients Prescriptions Cerner PowerChart (Computer Order Entry COE) Exceptions Chemo, TPN, PCA orders Write Legibly (Pt name, signature, DX, ALL) If BSA or weight based dosing (write info)

3 Cerner PowerChart Ordering medications in PowerChart: Quick type first 3 letters Drugs listed by generic names Depakote = Divalproex sodium

4 NARCOTIC C 3-5 DEA number (attendings or if a resident has a perm license) Hand printed signature of MD with DEA C 3-5: = codeine, hydrocodone, alprazolam, phenobarbital, zolpidem, Lomotil (diphenoxylate) and Tramadol Write out quantity in name & number (#fifty (#50))

5 C-2 s The Big Ones Separate Prescription C-2 s only! i.e.morphine goes on a separate prescription sheet Physician s original signature Write quantity (sixty and 60) No refills!!! No faxes!!! No changes!!! (no exceptions) Morphine IR=immediate release Q2-4h Morphine SR= sustained release Q12h Fentanyl patch Q 72 hr

6 Medication Safety 5 Rights

7 Medication Errors Common occurrence and continue to be a problem in the health care industry Annual cost of drug-related morbidity and mortality is nearly $177 billion in the United States Approximately 7,000 deaths occur each year 1 of every 5 doses given in hospitals FDA :at least one death per day and 1.3 million people are injured each year due to medication errors

8 Medication Errors ~ 15% of the medication error occur from illegible handwriting problems with leading and trailing zeros, misinterpreted abbreviations, and incomplete medication orders. NEVER EVENTS GUESSING WEIGHTS, DOSING Allergies Extended Release vs Regular Release

9 ADJUSTMENTS DRUGS ARE METABOLIZED / ELIMINATED EITHER RENALLY OR HEPATICALLY ADJUST FOR EITHER OR BOTH RENAL AND HEPATIC INSUFFICIENCY CROCK-KOFF-GAULT EQUATION MDRD CHILDS-PUGH ELDERLY GENDER NATIONALITY

10 DRUG INTERACTIONS CYTOCHROME P-450 P-GLYCOPROTEINS DRUGS WITH MULTIPLE INTERACTIONS: HIV MEDS, COUMADIN, AMIODARONE, DIGOXIN, ANTIEPILEPTICS, ETC USE LEXICOMP IN UP-TO-DATE AND LOOK AT CERNER POP-UPS

11 Medication safety: Look Alike Sound Alike Drug names can often sound similar or appear similar. The appearance of the products can look similar enough to cause confusion. These can easily be confused contributing to adverse medication events. Stop and Verify spelling, Readback!

12 High Alert Medications The top 5 high-alert medications Insulin Opiates and narcotics Injectable potassium Anticoagulants (heparin, LMWH, warfarin, etc) Sodium chloride solutions above 0.9 percent

13 COMMON ERRORS METOPROLOL / TOPROL _ DAILY INSTEAD: METOPROLOL/TOPROL XL DECIMAL ERRORS COUMADIN 1.0MG GUESSING WEIGHTS WRONG PATIENT WRONG DRUG ANTICOAGULATION INSULIN ALLERGIES

14 Ulcer PROPHYLAXIS NOT NEEDED FOR EVERYONE INTUBATED ICU PATIENTS AND COAGULOPATHY PATIENTS START WITH H-2 BLOCKERS FIRST REMEMBER TO DISCONTINUE UPON DISCHARGE!! Prophylaxis can INCREASE PNEUMONIA RISK ALTERS MEDICATION/NUTRITION ABSORPTION

15 PROTOCOLS ANTICOAGULATION HEPARIN ENOXAPARIN INSULIN MED/SURG ICU ID GUIDELINES CONTRAST INDUCED NEPROPATHY CLOPIDOGREL SKIN BREAKDOWN

16 DVT PROPHYLAXIS DVT RISK ASSESSMENT ON EVERY PATIENT!!! PREFERRED PROPHYLAXIS: HEPARIN 5000 UNITS HEPARIN Q8 HRS (MOD- HIGH RISK) HEPARIN Q8 = ENOXAPARIN 40mg qd HIGH RISK (Intubated, CHF, COPD, MI, STROKE, CANCER, hx DVT/PE, SURGERY, etc) See DVT Guidelines

17 Anticoagulation Enoxaparin Actual bodyweight up to 200 kg 1.5 mg/kg daily for cancer, DVT, small PE Q12 hr dosing for other uses Fondaparinux Actual Body Weight 5-10 mg sc daily Dalteparin Actual Body Weight (100 Units/kg Q12 hr) Coumadin Clinic IRIS referral ph #4-6327

18 Anticoagulation Heparin (Based on IBW) DVT/PE/Bridging Dosing 80 u/kg bolus Max 10,000 units 18 u/kg/hr based on ideal body weight Max 2,000 units/hr initial dose, titrate up or down based on aptt aptt 2-3x baseline (60-90)

19 Contrast Renal Protection SCr 1.1 and above Stop diuretics, metformin Sodium bicarbonate drip in D5W or sterile water if diabetic 3ml/kg bolus over 1 hr before procedure 1ml/kg/hr during procedure and for 6 hr later If patient fluid overloaded check with attending Acetylcysteine 20% for renal protection 1200 mg po with cold juice night before, morning before and 2 doses after procedure separated by 4-6 hrs

20 New Changes Additions Carvedilol Q12hr Isosorbide mononitrate once daily Simvastatin all doses 5-80 mg qhs Amlodipine 5-20mg once daily Equivalence to Nifedipine Nifedipine 30mg = Amlodipine 5 mg Nifedipine 60mg = Amlodipine 10 mg Nifedipine 90mg = Amlodipine 20 mg

21 MAP Medication Assistance Program Helps patient apply for free medication from manufacturers Patients on costly drugs with no insurance See website on-line under Pharmacy in Departments sections (on intranet) List of pharmacies in area with low cost generics Monina Quindipan, PharmD, MAP Coordinator,

22 Services Medication Services available only for Cook County Residents. See list of zip-codes on-line. Non-Cook residents should contact local County Department of Health or MAP Service fee of $3 per medication up to $10 max per visit apply. Currently waived for LOL-H, Medicare, Medicaid If unable to pay patient should go to Finance Department at Room 1290 to apply for LOL-H

23 MEDICATION TIMING COUMADIN DOSED AT BEDTIME STATINS DOSED AT BEDTIME DRUGS THAT HAVE TO BE DOSED Q_HOURLY: ANTIBIOTICS, HEPARIN, ENOXAPARIN, ALL HYPERTENSION DRUGS EXCEPT ISOSORBIDE BID= 9AM/5PM TID= 9AM/1PM/5PM QID= 9AM/1PM/5PM/9PM QD=9AM Calcium before meals to bind Phosphorus Coumadin and NSAIDS, ANTIBIOTICS

24 Intern Survival Guide ID Guidelines on-line Diabetes hospital Guidelines Anticoagulation Guidelines

25 Pharmacy Numbers Inpatient Pharmacy Outpatient Stroger Pharmacy Pharmacy Manager Discharge Pharmacy Clinical On-call Ask for on-call Administrator Fantus Clinic Pharmacy / Pharmacy Manager

26 PHARMACY SERVICES NON-FORMULARY SERVICE PAGER: Inpt Pharmacy Outpt 4-16 PROTOCOLS/GUIDELINES/PAGER: GO TO MAIN CCH WEBPAGE AND UNDER DEPARTMENTS CLICK PHARMACY FORMUALRY PUBLISHED ONLINE ADR (Adverse Drug Reaction) NOT SURE? JUST ASK!!!!

27 Summary 5 rights Outpatient Rx = good handwriting Know Schedule for BID, TID If you are not sure, ASK!