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