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January 2013

Educational memo from your Pharmacy and Therapeutics Committee Editor: Ed Rainville, PharmMS (655-7331)

New Order Set, Protocol and Policy:

The following were recently approved by the OSF System Pharmacy and Therapeutic’s Committee. Pleaseallow 1-2 months for implementation.

Pediatric Cystic Fibrosis Admission order setPediatric Renal Replacement ProtocolPerflutren Lipid Microspheres (Definity®) Policy

DVT Risk Score Revised:

To meet CMS regulatory requirements, the verbiage for a DVT Risk Score of 1 will be changed to ‘Nopharmacologic or mechanical VTE prophylaxis needed. Ambulate patient per activity order.’

Formulary Actions:

Guanabenz, an oral antihypertensive medication is no longer manufactured and was removed from theFormulary.

Human Milk Fortifier (Prolact + H2MF®), which is associated with less necrotizing enterocolitis in neonatesunder 1000gms, was added to the Formulary.

Hydroxyethyl starch 6% (Volvuven®) was denied Formulary addition due to lack of clear benefit overcurrently available products.

Safety Warning Regarding Varenicline (Chantix®):

Varenicline is an oral medication used to help adults quit smoking by blocking the effects of nicotine on thebrain. A recent report from the FDA described a higher occurrence of major adverse cardiovascular events (acombined outcome of cardiovascular-related death, nonfatal heart attack, and nonfatal stroke) in users of thisproduct.

Use Peminic® to Report Adverse Drug Events (ADE):

If you are aware of any adverse drug reactions, be sure to report them in Peminic®. These reports aretabulated and are used in evaluating drug product selection within the hospital and throughout the OSFsystem. Easy access to the Peminic® System is available on the lower right side of the SFMC Home Page.

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Drug Information Service – (Mon-Fri; 7 am – 3 pm)

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January 22, 2013


CRITICAL DRUG SHORTAGES

Sodium Bicarbonate Injection

Atropine Lifeshield Syringes

Sodium Bicarbonate:

A continuing shortage of sodium bicarbonate injection (vials and syringes) 1meq/ml (8.4%) has resulted in acritical shortage of the SFMC Pharmacy inventory.

This ongoing shortage also affects the availability of sodium bicarbonate 150meq in 1000ml D5W.

Priority will be given to maintaining emergency cart supplies.

Possible alternatives:

For prevention of contrast-associated nephropathy:

Normal Saline Infusions

Oral acetylcysteine: Cerefolin NAC® (contains 600mg/tablet)

Sodium Acetate: Use a 1:1 conversion

Atropine Syringes 1mg in 10ml:

The supply of atropine 1mg/ml 10ml syringes, which are stocked for cardiac emergencies, is in critically lowsupply. Currently there is no estimate of resupply from the manufacturer.

Atropine 1mg in 1ml vials will be used as the supplies of syringes are depleted.

We apologize for this shortage, which is beyond our control.

Mark Getz, MD, Pharmacy and Therapeutics Committee Chairman

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Jerry Storm, RPh, Pharmacy Director

Ed Rainville, Pharm MS, Pharmacy Clinical Coordinator



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January 25, 2013


CRITICAL SHORTAGE

DEXTROSE 50% SYRINGES and VIALS

There is a nationwide shortage of dextrose 50% syringes and vials.. This product is commonly used to treatemergent hypoglycemia.

Some new supplies are expected in the next 2-3 weeks, however conservation of current inventory is neededduring this time.

The Pharmacy is currently maintaining Blue Alert cart supplies.Some Pyxis stations have depleted their inventory. The Blue Alert cart supply will need to be accessedif intravenous dextrose is needed emergently.Please limit prescribing to true emergent situations.ORAL GLUTOSE® is available if this is a safe option.

· CHOI: For neonate/infant/child with hypoglycemia requiring IV administration – Use “Bolus IV fluidpediatric” (ERX#95054)- D10W is an option (if defaults to NS) and use dosing of 5-10ml/kg/dose

Marc Getz, MD, Pharmacy and Therapeutics Committee Chairman





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February 2013


Order Set Changes:

The following ordersets were recently revised and approved by the OSF System Pharmacy andTherapeutics’ Committee. Please allow 1-2 months for implementation.

OB Cesarean Section – Antibiotic changesAdult Patient Controlled Analgesia – Changes include respiratory rate for intervention, naloxone dose,NSAID reminder and request for pharmacy consult

CHOI Pharmacokinetic Dosing Protocol Changes:

The following Pharmacy protocol changes were recently approved:

Allow for once-daily dosing in pregnant patientsExpanded use of once daily dosing in patients with cystic fibrosis aged 10 and older.

Factor X Assay Confused with Anti-Factor Xa Test:

A Factor X assay may be used when assessing a coagulation disorder, but this test is being confused with ananti-factor Xa level to measure the level of anticoagulation with enoxaparin (Lovenox®). An alert has beenrequested to guide prescribers to the appropriate laboratory order.

New Indications for Rivaroxaban (Xarelto®):

Rivaroxaban, an oral factor Xa inhibitor, has received FDA approval for treating DVT and pulmonaryembolus. As dosing differs for each approved indications, an order set is in development.

Protocol for Rounding Chemotherapy Doses Approved:

In order to reduce drug waste and costs, without affecting therapeutic efficacy, a new protocol was approvedto allow pharmacists to round orders to within 5% of the ordered dose on selected chemotherapeutic agentsfor adult patients. A second order with the revised dose is required to assure order accuracy.

FDA Lowers Zolpidem (Ambien®) Dose:

In some patients, blood levels of zolpidem, a drug used to treat insomnia, are high enough the morning afteruse to impair activities that require alertness, including driving. Based on this information, the FDArecommends the dose of zolpidem for women be lowered from 10 mg to 5 mg for immediate-releaseproducts and from 12.5 mg to 6.25 mg for extended-release products.

The P&T Committee approved the regular-release zolpidem substitution dose for both doses of thenon-formulary extended –release product to be reduced to 5mg.

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March 2013


Formulary Additions:

Progesterone vaginal gel 8% (Crinone®) – approved to prevent premature births in the following situations:

- Multiple gestations

- Preterm contractions with preterm labor

- After an episode of arrested preterm labor

- Short cervix

Cefuroxime (Zinacef®) – approved for intracameral use.

Baclofen intrathecal (Gablofen®) – replaces Lioresal® which is more costly and requires filtration

Formulary Deletion;

Methenamine with sodium phosphate (Uroquid #2) removed from Formulary due to low use andunavailability.

Strategies to Reduce Inappropriate Subcutaneous Vitamin K:

To reduce inappropriate subcutaneous (Subq) vitamin K use, the following changes will be made in Epic:

‐ An alert will fire when subq vitamin K is ordered

‐ Remove automatic 10mg dose in dose field

‐ Remove subq vitamin K order in Factor VII Order Set

‐ Provide Chest Guidelines which advocate oral and IV vitamin k for reversal of vitamin k antagonists

Order Set Revision Approved:

Revisions to the Urology Post Op order set were approved to reflect current post-operative antibioticguidelines and will be submitted for change.

Intravenous Drug Administration Reference (Drug Matrix) Updates:

Ø Administration of continuous IV morphine and hydromorphone (Dilaudid®) on adult general care unitsmust use PCA pumps.

Ø Administration of bortezomib (Velcade®) and alemtuzumab (Campath®), which are used to preventrejection of kidney transplants, may be administered on the urology patient care unit (2400).

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Etomidate Removed from Blue Alert Cart:

Etomidate has been removed from all Blue Alert Carts, but is available in the adult ICUs, Trauma Rooms andSurgery Pyxis® machines, or by calling the Main or CHOI Pharmacies.


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April 5, 2013


CRITICAL SHORTAGE

DEXTROSE 50% SYRINGES and VIALS

There is a nationwide shortage of dextrose 50% syringes and vials.. This product is commonly used to treatemergent hypoglycemia.

Some new supplies are expected in the next 2-3 weeks, however conservation of current inventory is neededduring this time.

Changes to stock supplies:

Blue Alert cart supplies will remain the same.Pyxis stations supplies will be removed.ORAL GLUTOSE® 15gm is available through the Main Pharmacy

The Pharmacy has been authorized to substitute:

· ORAL GLUTOSE for IV Dextrose if the patient is able to take oral medications

· 10% 250ml IV Dextrose if the oral route is not appropriate.

ADULTS:

- Call the Main Pharmacy if IV Dextrose is needed.

- Either 50% IV Dextrose or 10% 250ml IV Dextrose will be dispensed immediately depending onavailability.

- If the patient is able to take oral medications, instructions will be given to use the ORAL GLUTOSE®.

- The pharmacist will enter the new order into Epic for appropriate charting in the EMR

CHOI:

For neonate/infant/child with hypoglycemia requiring IV administration –

Use “Bolus IV fluid pediatric” (ERX#95054)- D10W is an option (if defaults to NS) and use dosing of5-10ml/kg/dose

James Graumlich, MD, Drug Analysis Work Group Chairman


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April 2013



Torsemide (Demedex®) is an oral loop diuretic which has improved bioavailability over furosemide (Lasix®).

Iloprost (Ventavis®) is a prostacyclin analog, administered by nebulizer (provided by the patient) and used totreat pulmonary hypertension.

Rectally administered indomethacin (Indocin®) was approved as a one-time, pre-procedure dose to preventpancreatitis associated with ERCP.

Non-egg based influenza vaccine (Flucelvax®) was approved for use in people with a documented eggallergy.

Poractantalfa (Curosurf®), a porcine lung surfactant, is easier to administer and requires less frequentdosing.

Formulary Deletions:

Methyldopate injection (Aldomet IV®) and methyldopa with hydrochlorthiazide - due to low use.

Calfactant (Infasurf®) - will be replaced by poractantalfa

Formulary Denials:

Insulin detemir (Levemir®) - due insulin standardization and availability of dose conversion to insulinglargine (Lantus®). A 1:1 dose conversion to insulin glargine will be suggested when ordering insulindetemir in Epic.

Methylnaltrexone (Relistor®) – due to low use, dosing concerns, and availability of less costly alternatives.

‘High-Dose’ Fluzone® - lack of added clinical efficacy data

Banned – Insulin Pens:

Due to potential errors in administrating correct doses, risk of needle sticks and other safety concerns, insulinpens will not be allowed for in-patient use. Alternative insulin or insulin vials will be made available forpatients who use insulin pens at home.

Pulmonary Embolism (PE) Thrombolytic Order Set Revisions Approved:

PE Thrombolytic Order Set revisions include holding the heparin infusion during alteplase administration,resumption after the alteplase and checking a PTT two hours after resuming heparin.

Product Change for Dry Mouth (Xerostomia):

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Moi-Stir® has replaced Entertainers’ Secret® for the treatment of xerostomia.


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April 17, 2013


Critical SHORTAGE OF

Hydroxyzine (Vistaril®) Injection

A national shortage of injectable hydroxyzine has resulted in a critical shortage in the SFMC pharmacyinventory. Unless a new supply is received, the current supply will likely run out within the next seven days.

If hydroxyzine is being used to treat nausea and vomiting, consider the following alternative parenteralmedications:

Ondansetron (Zofran®)

Prochlorperazine (Compazine®)

Trimethobenzamide (Tigan®)

Metoclopramide (Reglan®)

Oral hydroxyzine is still available if the patient is able to take oral medications.

Healthcare providers will be notified when supplies become more readily available

We apologize for this shortage which is beyond our control.

Mark Getz, MD, Pharmacy and Therapeutic Committee Chairman


Ed Rainville, MSPharm, Pharmacy Clinical Coordinator


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April 19, 2013


DRUG SHORTAGE

Potassium Phosphate Injection

A nationwide shortage of parenteral potassium phosphate has resulted in near depletion ofthe SFMC Pharmacy inventory. Supplementing parenteral nutrition formulas will continuewhile remaining supplies last.

Unfortunately, there is no accurate prediction as to when more of this product will becomeavailable.

No new orders for this product will be processed until new supplies are available.

Alternatives to IV potassium phosphate include using an oral preparation or giving IV sodiumphosphate. Listed below are the constituents of available oral phosphate containing products:

Oral Phosphorus Replacement Preparations

Product Potassium(meq) Sodium(meq) Phosphorus(mM)K Phos Neutral

(tablet)

1.1 13 8

Neutra-Phos(powder)

7.13 7.13 8

¨Tablets should be taken with full glass of water. Powder should be dissolved in 75ml of water.

IV sodium phosphate provides 3 mmoles of phosphate and 4 meq of sodium per ml.




Ed Rainville, Pharm MS, Pharmacy Clinical Manager

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May 2013


PEN Lab Upgrade:

Due to a PEN Lab System upgrade all TPN and enteral feeding orders will need to be entered into EPIC no later than

Noon on Monday, May 6th. Normal operation will resume at 8AM Tuesday May 7th.


Ioflupane I 123 (DaTScan®) – a radiopharmaceutical indicated for striatal dopamine transporter visualizationused in the evaluation of suspected Parkinson’s disease.Influenza quadravalent vaccine (Fluarix®) – contains coverage for two influenza type A and type B viruses,which will be indicated for high-risk patients.

Formulary Denials:

· Adalimumab (Humira®) – Indicated for Crohn’s Disease. Anticipated low use and availability ofinfliximab (Remicade®).

· Eclulizumab (Soliris®) – Indicated for hemolytic uremic syndrome, which is a rare diagnosis and thedrug is not emergent.

Formulary Deletion:

Asparaginase (Elspar®) is no longer manufactured. Pegasparaginase (Oncaspar®) is still available and onthe Formulary.

Coming Soon: Standardized Subcutaneous Enoxaparin and Heparin Times:

To reduce waking patients for dose administration and to assure post-operative anticoagulation isadministered when required, subcutaneous enoxaparin and heparin will have a default frequency of BID at0600 and 1800 if ordered twice daily.

Discharge Assistance for Warfarin Dosing:

When utilizing the Pharmacy Warfarin Dosing Service either refer to the daily warfarin progress note or contact thepharmacist for discharge dosing recommendations.

Disposal of Un-needed Home Medications:

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For Peoria County Residents ONLY, the following places will accept unneeded medications.

BARTONVILLE POLICE DEPARTMENT

918 South Adams Street, Bartonville

CHILLICOTHE POLICE DEPARTMENT

823 North 2nd Street, Chillicothe

PEORIA HEIGHTS POLICE DEPARTMENT

1311 East Sciota Avenue, Peoria Heights

PEORIA POLICE DEPARTMENT

600 Southwest Adams Street, Peoria

PEORIA COUNTY COURTHOUSE

324 Main Street, Peoria

PEORIA COUNTY JAIL

301 North Maxwell Road, Peoria


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June 2013


eparin Vial Label Change:

To help reduce heparin dosing errors from mis-read drug labels, newer heparin products will be starting toappear that indicate the amount of heparin per total volume, followed by units per ml in smaller print. Seebelow for an example.

OLD LABEL NEW LABEL

Prophylaxis Required for PEG Tube Placement:

A single, pre-procedure antibiotic dose (usually cefazolin 1gm IV) is required prior to PEG tube placementper SCIP measures.

NEW: Sound Alike / Look Alike Drugs (SALAD):

HYDROmorphone MorPHINEHydrOXYzine HydrALAzine

HumuLIN HumaLOG

Heparin 1,0000 unit/ml Heparin 10,000 unit/mlHEParin HESpanSulfaSALAzine SulfaDIAzineClobazam Clonazepam Carbatrol ® Tegretol XR® Isosorbide MONOnitrate Isosorbide DInitrateVinCRIStine VinBLAStineValGANCIclovir (ValCYTE) ValACYclovir (ValTREX)

Formulary Addition:

Levonorgestrel (Plan B One Step®) will replace ethinyl estradiol/norgestrel (Ovral®) in the Sexual Assaultprotocol, which is consistent with Catholic Directives and State regulations.

Temporary Suspension of Leflunomide (Arava®) During Hospitalization:

Chronic treatment of rheumatoid arthritis with leflunomide will be temporarily suspended duringhospitalization due to potential side effects, cost and long half-life of the drug.

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Ertapenem (Invanz®) 5 min IV Push:

Starting Monday, June 24th, ertapenem 1gm will be given over 5 minutes after diluting with 10ml normalsaline. This procedure will reduce nursing time and cost of therapy.


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June 11, 2013


Update on Availability of Select Drug Shortage Products

Calcium Chlolride Injection

Calcium Gluconate Injection

Dextrose Injection

Mannitol Injection


The Pharmacy has received shipments of the products listed above that have been out of stock or in criticallylow supply. The Pharmacy currently has sufficient supplies to meet the needs of our patients.

We appreciate your understanding and cooperation during this difficult time of drug shortages.





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July 2013


Antibiotic Surgical Prophylaxis Changes:

New 2013 clinical practice guidelines for antimicrobial prophylaxis in surgery, Am J Health-Syst Pharm. 2013;70:195-283, recommend that all patients requiring the use of cefazolin for preop/postop antibiotic prophylaxis shouldbe dosed with cefazolin 2g unless the patient is 120kg or greater and then the dose should be cefazolin 3g. OSF haschanged surgical order sets to align with these guideline recommendations. Cefazolin 1g doses will still be availablefor non-surgical, mild infections such as UTIs or cellulitis. Also, as a part of the same guidelines, clindamycin dosinghas increased from 600 mg to 900 mg. These changes have been made to all OSF Surgical ordersets.

Order Set Updates:

In addition to the above antibiotic changes to surgical orders the follow orderset changes were approved by P&T:

v ED Sepsis Orders – streamline antibiotic prescribing for more efficient use

v Heparin Order Sets – updated and revised to prevent order errors


Ivermectin (Stromectol®), an anthelminthic, and Similac Liquid Protein Fortifier® were added to the OSF Formulary.

FDA approved non-US manufactured Glucophos® and Peds Trace Elements were temporarily added to Formulary dueto drug shortage supply issues.

Changes Addressing Anticoagulation Coming:

The following were P&T approved for implementation:

v Epic documentation of double-checked heparin doses

v Requesting heparin PTT s called to bedside nurse

v Epic Report showing timeline of anticoagulants and associated labs

Magnesium Infusion Warning from FDA:The FDA is advising against using magnesium sulfate injection for more than 5 to 7 days to stop pre-term labor.Administration longer than this time may lead to low calcium levels and bone problems in the fetus. In addition, theteratogenic effects section of the package labeling is being changed from Category A (well-controlled studies havefailed to demonstrate a risk to the fetus) to Category D (positive evidence of human fetal harm.).

Calcium Chloride Infusions Standardized:High dose calcium chloride infusions will now be standardized to 5gm in 100ml NS and ordered as mg/hr,instead of mls/hr.

Procedural Sedation Policies Updated:

Procedural Sedation policy and Drug Matrix were updated regarding propofol administration bynon-anesthesiologists in non-intubated adults.

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July 12, 2013


DRUG SHORTAGE


A nationwide shortage of parenteral potassium phosphate has resulted in near depletion ofthe SFMC Pharmacy inventory. Supplementing parenteral nutrition formulas will continuewhile remaining supplies last.

Unfortunately, there is no accurate prediction as to when more of this product will becomeavailable.

No new orders for this product will be processed until new supplies are available.

Alternatives to IV potassium phosphate include using an oral preparation or giving IV sodiumphosphate. Listed below are the constituents of available oral phosphate containing products:

Oral Phosphorus Replacement Preparations

Product Potassium(meq) Sodium(meq) Phosphorus(mM)K Phos Neutral

(tablet)

1.1 13 8

Neutra-Phos(powder)

7.13 7.13 8

¨Tablets should be taken with full glass of water. Powder should be dissolved in 75ml of water.

IV sodium phosphate provides 3 mmoles of phosphate and 4 meq of sodium per ml.


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Ed Rainville, Pharm MS, Pharmacy Clinical Manager


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August 2013


*Note: Items approved by the System P&T Committee may not be fully implemented when published in the PharmaGram

Formulary Actions:

Deletions:

Dronedarone (Multaq®): due to low use and Black Box warnings.

Rosuvastatin (Crestor®): not covered by many health-care insurances. Autosubstitution to atorvastatin (Lipitor®)approved.

Codeine with acetaminophen liquids: due to high acetaminophen concentration

Promethazine (Phenergan®) injection: due to recovery after drug shortage.

Additions:

Epoprostenol (Veletri®): used intravenously for pulmonary hypertension. Flolan® will remain on Formulary.

Tolvaptan (Samsca®): for refractory heart failure and restricted to Cardiology and Nephrology. Prescribing by ordersetonly (see below)

Nifedipine (Adalat®, Procardia®) regular-release: approved indications altered to exclude hypertension, angina andmyocardial infarction.

Therapeutic Substitutions Approved:

Rosuvastatin (Crestor®) substitution to atorvastatin (Lipitor®)Nebivolol (Bystolic®) substitution to bisoprolol (Zebeta®)Codeine with acetaminophen substitution to hydrocodone with acetaminophen oral solution.Doses of pre-operative antibiotics in adults may be adjusted in accordance with Antimicrobial Clinical PracticeGuidelines.

Order-Set Changes Approved*:

new Impella® Post-Insertion Orders for use as left ventricular assist device.new Tolvaptan (Samsca®) Orders for refractory heart failure.GI PEG Preop Orderset revised to be compliant with Antimicrobial Practice GuidelinesNeuro CVA Thrombolytic Administration orders revised to consolidate contraindications to a single question.

Patient Controlled Analgesia (PCA) Dosing Limit:

The PCA 4-hour dose administration instructions for the fentanyl, morphine and HYDROmorphone will now bestandardized to read ‘75% of continuous plus on-demand doses (PCA dose). Adjust 4 hour dose limit with dose orinterval changes.’

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Non-Formulary Exception Code Expanded:The exception code choices when ordering a non-formulary drug have expanded to include hospice patientswho are in Richard L.Owens Hospice Home.


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August 20, 2013


CRITICAL DRUG SHORTAGE - Calcium Chloride Injection

Autosubstitution Authorized

Once again, a nationwide shortage of calcium chloride injection has resulted in severedepletion of the SFMC Pharmacy inventory. The Pharmacy will maintain calcium chlorideinjection on Blue Alert Cart.

As with the previous shortage, the Pharmacy will substitute calcium gluconate injection forcalcium chloride orders in a 3:1 dose conversion.

(Ex. 3 Grams of Calcium Gluconate will be used for each 1 Gram of Calcium Chloride).

This substitution will expire when there adequate supplies are available.


James Graumlich, MD, Drug Analysis Work Group Chairman


Ed Rainville, Pharm MS, Clinical Pharmacy Manager


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September 2013



Discharge Medication Reconciliation by Pharmacists:

Prior to discharge all in-patients must have their medication orders reviewed by a pharmacist prior todischarge. Orders may be placed in Epic by nursing by entering Pharmacy Discharge Med Review in theordering section. During startup of this service there were about 700 moderate or severe defects detected in1800 discharge orders reviewed.

Therapeutic Substitution: Acyclovir Cream (Zovirax®) to Docosanol Cream (Abreva®) :

Acyclovir cream (Zovirax®), which is commonly used to treat herpes labialis and stomatitis, will now besubstituted to docosanol (Abreva®). Both products have shown equal effectiveness, while the acyclovircream costs over $500 per 30 gram tube compared with $15 for 2gm tube of docosanol.

Pharmacy Kinetic Dosing Protocol:

The aminoglycoside and vancomycin pharmacy dosing protocols have been revised and includes informationon dosing patients receiving dialysis.

Warfarin Orderset for New Admissions:

Patients who are ordered to continue on warfarin upon hospital admission, may have a Warfarin Ordersetplaced into Epic by the pharmacist if not already completed by the admitting physician.

Argatroban Pharmacy Dosing Protocol Revised:

The Argatroban Dosing Protocol has been revised to include a recommendation to use the HepaticImpairment dosing nomogram for obese patients. Actual body weight is used, however the starting dose islowered to avoid over anticoagulation.

Pediatric Heparin Orderset Revised:

An order for heparin boluses has been added to the Pediatric Heparin Orderset

Acetaminophen Dose Rounding in Epic:

For pediatric patients there will soon be more incremental dose choices for acetaminophen to provide moreaccurate dosing.

FDA Warning: Fluoroquinolone-Associated Nerve Damage:

The FDA recently released a MedWatch notice describing the association between fluoroquinolones (ex.Levofloxacin (Levaquin®) and peripheral neuropathy. Patients should be instructed to contact their

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healthcare provider if they develop neurologic symptoms.


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October 2013



IV Immune Globulin Dosing Change for Adults:

Based on the tissue distribution characteristics of IV immune globulin (Privigen®), the dosing for adults will not bebased the patient’s body weight but will change to being based on a dosing weight calculated from the patient’s idealand actual body weights.

Changing from IV Esomeprazole (Nexium®) to Pantoprazole (Protonix®):

OSF will be changing the intravenous proton pump inhibitor from esomeprazole to pantoprazole. Both drugs use thesame doses and can be administered as an IV bolus or infusion.

Discharge Prescribing Pearls:

Use discrete fields when possible and use free text for prescribing tapers, warfarin with rotating doses, etc.

Do not use ‘Mark All Resume’ medication button. This usually results in errors.

Watch for dose errors based on resuming home doses that were changed during the hospitalization

Coordination of care between services – need consensus regarding discharge medication orders

Common medications prone to error are anticoagulants (dose), insulin (dose/type), and antibiotics(duration/quantity)

Policy, Guideline and Protocol Changes:

Hospital Drug Formulary Policy revised to allow pre-approved dose substitutionMedication Administration Policy updated.High Risk/High Alert Medications Policy revised to include a table with drugs requiring double checksGuidelines for administering Epoprostenol (Flolan®) nebulization revisedCHOI protocol for central catheter (CVC) heparin flush changes from 200 units to 20 units.

Orderset Changes:

Adult Diabetic Ketoacidosis ordersets standardized to one with revisionsPneumococcal and Influenza ordersets revised with an algorithm for selecting appropriate vaccines.

NEW: Treatment Guidelines for Bleeding Associated with Oral Anticoagulants;

Guidelines for treatment of bleeding associated with rivaroxaban (Xarelto®), Apixaban (Eliquis®) anddabigatran (Pradaxa®) are posted online under Guide to Medication Use for SFMC Clinicians and on theEmergency Department portal.

Formulary Addition:

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Apixaban (Eliquis®), a new oral anticoagulant, has been added to the Formulary. An orderset will be requiredto assure correct dosing.


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October 22, 2013


Update on Availability of Select Drug Shortage Products

Calcium Chlolride Injection

Calcium Gluconate Injection

The Pharmacy has received shipments of the products listed above that have been out of stock or in criticallylow supply. The Pharmacy currently has sufficient supplies to meet the needs of our patients.

We appreciate your understanding and cooperation during this difficult time of drug shortages.





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November 2013



Formulary Changes:

Addition: Linagliptin (Trajenta®) – for treatment of type 2 diabetes

Deletion: Sitagliptin (Januvia®) – Linagliptin will be available for substitution.

Deletion: Alvimopan (Entereg®) – No significant benefit identified.

Denied addition: Trospium (Sanctura XR®) – for overactive bladder; will be substituted to solfenacin (Vesicare®).

Neuroaxial Anticoagulation Guidelines Updated:

The Neuroaxial Anticoagulation Guidelines have been updated to include the newer oral anticoagulants. TheseGuidelines are available online on the SFMC website and by typing into the Search function box: Epidurals andAnticoagulants.

Algorithm for Cephalosporin/ Carbapenem Orders on Patients with a Penicillin Allergy Revised:

An algorithm that assists in making a more appropriate decision with administering a cephalosporin or carbapenem toa patient with a recorded penicillin allergy has been revised. The algorithm now has information to differentiatebetween types of skin reactions associated with the previous reaction. The algorithm is available online on the SFMCwebsite and by typing into the Search function box: Medication Use Guidelines.

Orderset Changes:

Pediatric Neuromuscular Blockade Orderset will include allowance for individual doses and revised monitoringparameters.

Factor VII (eptacog alpha) Orderset will include non-FDA approved dosing information and will become the only way toorder Factor VII.

Vitamin K Orderset will be removed due to lack of use. Vitamin K or phytonadione will still be available as an individualdrug order.

B‐lactamase positive H. influenza Reporting Change:

Microbiology reports on B‐lactamase positive H. influenza will be clarified as to which antibiotics could beused.

Pediatric Dose Alert for Acetaminophen to be Revised:

The maximum dose alert for one-time acetaminophen doses will be increased to 25 mg/kg/dose for pediatricpatients only. This dose is frequently used for pain associated with circumcisions.

IV Potassium Phosphate Protocol Revised:

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The dilution and maximum concentrations of IV potassium phosphate contained in the protocol for adults willbe revised to eliminate confusion with previous recommendations. This protocol is posted on the SFMCwebsite under Guide to Medication Use for SFMC Clinicians.


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December 2013



New: Adult PostSplenectomy Orderset:

An Adult Post Splenectomy orderset was approved and will contain thenecessary vaccinations and the repeat dose schedule.

Revised: AlcoholWithdrawal Orderset –‘Banana Bag’

The 3-day stop date for the intravenous multivitamin solution, also referred toas a ‘Banana Bag,’ will be changed to a single, one-liter IV solution on theAlcohol Withdrawal orderset.

Revised: PotassiumReplacement Orderset:

The option of administering potassium chloride for a serum potassium of 3.6to 4 mmol/L, which is within the normal range, will be removed.

Protocol Changes:

The addition of sodium bicarbonate to a 1000ml Dextrose intravenoussolution for the prevention of contrast-induced nephropathy will be limited topatients with glomerular filtration rates (GFRs) of less than or equal to 40ml/min. Hydration with Normal Saline for patients with a GFR greater than 40ml/min is suggested.Intravenous to oral medication pharmacy protocol has been revised to limitthe need to contact providers as part of the assessment.

Formulary Denial:Clevidipine(Cleviprex®):

Clevidipine, a calcium channel blocker with arterial vasodilating activity, wasdenied addition to the Formulary, due to lack of additional benefit overcurrently available Formulary drugs, higher cost and a potential look-alikesafety risk.

Revised: TransdermalPatch Policy:

Transdermal patch policy changes will include a reminder to check patientsfor transdermal patches, instructions on disposal, and the use of a‘Transdermal Patch Ordered’ sticker on a wrist band will be re-emphasized tostaff.

Access of IntravenousPotassium ChlorideRiders through Pyxis®:

Most intravenous potassium chloride orders are for adjustments in low serumlevels and not for emergency electrolyte replacement. Based on this, it wasdecided to remove IV potassium chloride from the override drug list forautomated drug dispensing machines.

Labeling Change forLiquid Medications:

Labeling of liquid medications which are packaged by the Pharmacy will bechanged to make the total dose content and the concentration clearer:

CURRENT LABEL:Phenobarbital10 mg/mL 5 mL UDC

NEW LABEL:Phenobarbital ORAL50 mg/ 5mL

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SHAKE WELL (10mg/mL)SHAKE WELL


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january 2013 - osf · pdf filejanuary 2013 educational memo ... sodium bicarbonate injection...

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