Inpatients:

• All medications and fluids are to be ordered in the EMR, with some exceptions:

Non-oral chemotherapy (paper form)

MET call/Code Blue (paper form: retrospectively add to EMR)

Discharge prescriptions:

• Complete Discharge Medication Reconciliation to generate prescription Ensures correct medication list appears on discharge summary

• Prescribe all items the patient is to continue taking after discharge except if: No changes to regular medicines (other than short term additions, e.g. antibiotics, analgesia

etc.) AND patient does not require a complete medication list o Prescribe only new short-term medicines and document on discharge summary:

“Continue regular medicines as before”

Outpatients:

• MerlinMAP (electronic prescribing program unique to Monash Health)

Complete short eLearning module on Pharmacy intranet site prior to first use

Monash Health intranet site → Clinical Portal → Pharmacy

Prescribing at Monash Health

Antimicrobial Traffic Lights:

Antimicrobials are classified into three categories (traffic lights):

Approval:

Infectious Diseases (ID) approval is required for all RED antimicrobials

and ORANGE antimicrobials if the indication is not pre-approved. The

first dose may be given without approval to ensure treatment is not

delayed. Subsequent doses will not be supplied or administered

without ID approval.

Obtain ID approval by calling the ID approval hotline on ext 3725 (ESBL)

or via switch for adults and pager #100 for paediatrics.

Documentation of antimicrobial indication:

Indication is a mandatory field for all antimicrobials when placing the order in the EMR. Ensure the most

appropriate indication is selected from the drop-down field.

Further information:

Refer to the Antimicrobial Traffic Lights Prescriber Tools on Prompt for further information. Specific information is

also available on Prompt for surgical antibiotic prophylaxis, vancomycin, aminoglycosides and many more.

Adult Vancomycin and Gentamicin initial dosing calculators are also available via the clinical portal and the AMS

intranet page to guide dosing.

Antimicrobial Stewardship (AMS)

Error Recommended action

Incorrect medication dose or frequency Use available order sentences & amend as necessary (instead of selecting medicine and needing to complete each field)

Medicines inadvertently not restarted Chart medicine and suspend. Medicine will appear greyed out on the Medication Administration Record (MAR) as a prompt to review and recommence/cease as appropriate.

VTE risk not assessed Complete VTE care pathway and order enoxaparin if recommended. Avoid ordering enoxaparin as VTE prophylaxis outside of the pathway.

Warfarin/insulin ordered as ‘free text’ Use order sets for warfarin and supplemental insulin

Dual route instructions omitted or incorrect Each route to have individual order with reference in special instructions to other route orders. For example oral and IV ondansetron orders.

Incomplete ADR and allergy details Document medicine unless medication class reaction is confirmed. For example amoxicillin rather than penicillins. Document clinical decision to prescribe despite known ADR/allergy.

IV sequencing not used or inaccurate Use IV sequencing for IV bags to be administered in a specific order (bag 1 followed by bag 2)

Discharge prescription errors Click ‘pill container’ to continue medication at home and include on the PBS discharge prescription

Review Medication Administration Record (MAR) or MAR Summary regularly and always during rounds.

Refer to EMR Quick Reference Guides (QRGs): www.emr.monashhealth.org

Add a shortcut to your mobile phone and access the QRGs via the Resources heading.

EMR: Common medication errors to avoid

Clinical pharmacists are linked to treating teams across all sites. We

are medicines experts and here to assist with all medication

management issues.

Pharmacists complete Patient’s Home Medications and Medication

Management Plans in the EMR

o Reconciliation against medicines prescribed

o Identification and communication to medical staff about

any issues. Refer to the Pharmacy Clinical Intervention

Form in the EMR.

Review and supply of all medicines during the patient admission

Partnered Pharmacist Medication Charting in General Medicine

teams at Clayton, Dandenong and Casey

o Pharmacist orders inpatient medications in the EMR

following documented conversation with medical officer

Discharge prescriptions

o Dispensing of medicines required by patient

o Generation of medicines list

o Medication counselling

Medication formulary

o Medicines not available on the Monash Health Formulary require Single Patient Use Request Form

Useful medicine resources:

Monash Health Prompt: procedures, clinical guidelines and extensive medication profiles to guide prescribing and

administration of medicines.

Pharmacy and library intranet sites have links to AMH, MIMS, Therapeutic Guidelines and PBS website.

Pharmacy services and useful resources