Medication Orders and Prescriptions

Inpatient Pharmacies

• Receiving Medication Orders – hand-delivered

– mechanical method

– fax transmission or pneumatic tube

• Computer physician order entry, or CPOE – orders verified by pharmacisst

• Telephone orders – by prescriber or an intermediary

– legal restrictions

Upon Receipt

• 2 steps

– review order for clarity & completeness

– prioritize the order

Ideal Medication Order

• Patient name

• Hospital identification #

• Room/bed location

• Generic drug name

• Brand drug name*

• Route of administration

• Dosage form

• Dose/strength

• Frequency & duration

• Rate & time

• Indication

• Other instructions

• Prescriber’s signature

• Printed name if needed

• Credentials

• Pager number

• Date & time of order

Prioritization

• PATIENT DISCOMFORT – initial treatment of pain, fever, or nausea & vomiting

are generally high priority

• Urgent orders are filled first

• Evaluate by analyzing: – route

– time of administration

– type of drug

– intended use of drug

– patient-specific circumstances

Order Start Times

• STAT – immediately- an urgent need

• “Now” or “ASAP”

• “start today” or “start this morning”

• Has 1st dose of medication been given? (ER)

• Standard amount of time to process & deliver order – typical turnaround times in hospital

• 15 minutes for STAT order

• 1 hour for a routine order

• Technicians use critical thinking skills to prioritize orders

Processing Medication Orders

• Identify patient

• Compare order with patient’s existing medication

• Order entry steps – choose correct medication from database

– identifying administration schedule

– enter any special instructions

• Medication must be selected, prepared or compounded, checked, dispensed for use

Patient Profile

• Patient name

• Identification numbers

• Date of birth/age

• Sex

• Height and weight

• Lab values

• Admitting/2nd diagnoses

• Room & bed number

• Names of admitting & consulting physicians

• Allergies

• Medication history

• Special considerations

• Clinical comments-therapeutic monitoring, counseling notes

Selecting Drug Product

• Drug may be ordered by generic or brand name

• Abbreviations often used

• Lists of abbreviations that cannot be used

• Look-alike & sound-alike drug strategies

– store in separate locations

– additional labeling

– tall man letters (example: buPROPion – busPIRone)

Drug Selection

• Mnemonic is code, associated with medication

• Ampicillin 250 mg

– mnemonic, or drug code, “amp250,”

– choices:

• amp250c ampicillin 250 mg capsule

• amp250s ampicillin 250 mg/5 mL oral suspension

• amp250i ampicillin 250 mg injection

Order Processing

• Labels generated upon order entry

– IV label format different from unit dose tablet

• Form of medication

– pediatric

– meds through tubes (nasogastric tubes or gastric tubes)

• Formulary considerations

Order Processing

• Pharmacist input

– consult pharmacist if any warnings appear

• Computer warnings:

– interactions

– duplications

– allergies

– dosage range

– diluent choices

• may be standardized as defaults in computer system

• Final step-pharmacist verification of all orders

Medication Administration Times

• Administration time impacts:

– drug efficacy

– diagnostic laboratory testing

– Pharmacokinetic studies using administration time in relation to lab test time to determine drug dose recommendation

• Full stomach or empty stomach

• Standard medication administration times

Standard Administration Times

• daily = 0900 (9 a.m.),

• bid = 0900 and 1700 (5 p.m.)

• q8h=every 8 hours = 0600 (6 a.m.), 1400 (2 p.m.), and 2200 (10 p.m.)

• Warfarin – 1700 to allow time to review lab results

• Standardized schedules of drug administration

– based on therapeutic issues, nursing, pharmacy

MAR

• Medication administration record

• Part of patient’s medical record

• Nurse documents when medication administered

• Standardized times appear as default entries on MAR

• Default times may differ on some specialized units

– “daily” may default to 0900

– physical rehabilitation unit

• might require daily administration to occur at 0800

Scheduling Considerations

• Must be aware of exceptions

• Pharmacists must consider other medications

– ciprofloxacin & calcium carbonate must be spaced

– day or days of the week

– important to coordinate with patient’s home schedule

– every-other-day orders

• avoid advising caregiver to give medication on odd days or even days, because depending on number of days in month, “every other day” will change with respect to odd/even

Information System

• Physicians’ orders are input into patient profile in pharmacy information system

• Information used to generate:

– MARs

– medication profiles

– fill lists (for pharmacy use)

– labels for medications to be issued to patient care areas

• MARs may be either paper or electronic (eMAR)

Special Instructions

• Pharmacy instructions

– notes between pharmacist/technician

– clinical notes

• Nursing instructions

– storage information

– administration instructions

– physician-specified parameters

– displayed on MAR & medication label

Sample Inpatient Order Entry

• Enter patient’s name/account number-verify pt

• Compare order to patient profile in detail

• Enter drug

• Verify dose

• Enter administration schedule

• Enter any comments in clinical comments field

• Verify prescriber name

• Fill & label medication

Filling, Labeling, Checking

• Send enough doses to last to next scheduled delivery

– 24-hour cart fill system common

• Review label carefully

– against order

– against product

• Medication order is filled

• Pharmacist checks-legally required in most cases

• Technology-order images archived

Special Considerations • “Charge-Only” & “No-Charge” Entries

• Pharmacist protocols

• Diagnostic preparation orders

• Computer physician order entry

• Automated dispensing technology

• Centralized dispensing automation

• Decentralized automation

Outpatient Pharmacies

• Receiving Prescriptions

– presented in person

– telephoned in from prescriber’s office

– facsimile

– electronic transmission

• Refill requests

– internet

– phone

• manual-uses person

• automated system

Payer Information

• Establish:

– primary payer for prescription

– patient’s portion of reimbursement (copayment)

– drug formulary

• Electronic claims adjudication

• Prescription may be held until information gathered

Clarity & Completeness

• Patient name

• Patient home address

• Date written

• Drug info

– name

– strength

– dose

• Directions

– route

• Frequency & duration

• Quantity to be dispensed

• Number of refills

• Substitution (DAW)

• Signature/credentials

• DEA # if required

• Prescriber’s info

– name, address, phone

– indication (not required, but recommended)

Dispense as Written (DAW)

• DAW= brand name drug written must be dispensed

• Some states require phrase “Do Not Substitute” (DNS)

• Must consider state law & pharmacy policy

– Preprinted areas-prescriber signs to designate “DAW” or “generic substitution acceptable” ok in some states

DAW codes 0 = No product selection indicated

1 = Substitution not allowed by provider

2 = Substitution allowed- patient requested product

3 = Substitution allowed- pharmacist selected product

4 = Substitution allowed- generic drug not in stock

5 = Substitution allowed- brand drug dispensed as generic

6 = Override

7 = Substitution not allowed- brand drug mandated by law

8 = Substitution allowed- generic drug not available in marketplace

9 = Other

Forgeries

• Screen prescriptions for controlled substances

• May be fairly easy to identify

– erasure or overwriting of strength or dispensing quantity of drug (changing 3 to 8)

• More subtle

– theft of preprinted prescription pads

– legitimate-looking prescriptions

– telephoned in to pharmacy

Other Considerations

• Legibility problems & interpreting abbreviations

• Patient notification if

– contacting prescriber

– medication is not in stock

• Prioritization

– order in which presented to pharmacy

– common-sense judgment

Patient Profile • Patient’s name/identification number

• Date of birth/age

• Home address/telephone numbers

• Allergies

• Principal diagnoses

• Primary healthcare providers

• Third-party payer(s)/other billing information

• Over-the-counter medication/herbal supplements

• Prescription & refill history

• Patient preferences

Prescription Entry

• Appropriate drug product selection

– mnemonic

– alphabetical listing

– National Drug Code (NDC) number

• Directions for use

• Fill quantity

• Initials of pharmacist checking prescription

• Number of refills authorized

Primary Prescription Label (information may vary by state)

• Patient’s name

• Date the prescription is being filled (or refilled)

• Prescriber’s name

• Sequential prescription number

• Name/strength/manufacture

• Quantity dispensed

• Directions for use

• Number of refills remaining/associated refill period

• Expiration date

• Physical description of med if required by state law

Instructions for Use

• Administration directions (“Take,” “Insert,” “Apply”)

• Number of units constituting one dose/dosage form

• Route of administration

• Frequency

• Duration if applicable (“for 10 days,” “until finished”)

• Indication if applicable (ex: “for pain” or “for blood pressure”)

Outpatient Prescription Process

• Enter patient’s medical record number or name

• Enter or verify existing third-party billing information.

• Compare order to patient profile in detail

• Enter drug

• Enter label direction mnemonic

• Enter comments

• Enter prescriber’s name

• Enter amount to dispense/refill information

• Fill & label the prescription