Introduction to Prescription Drug Orders Colleen Dula, PharmD, BCACP Director, Professional Practice Laboratory Clinical Assistant Professor The Ohio State University College of Pharmacy

Objectives Review medication classifications Discuss legal requirements of outpatient prescription orders Identify tips to avoid medication errors

Legal Controls Over the Counter (OTC) Drugs Drugs deemed safe enough for self-treatment of simple conditions Behind the Counter (BTC) Drugs Restricted over the counter drugs based on potential for misuse or harm Maintains reasonable access for patients to self-treat Patients must request from and consult with the pharmacist Prescription or Legend Drugs Drugs useful after expert diagnosis of licensed practitioner Federal Law Prohibits Dispensing without a Prescription Controlled Substances Have potential for abuse or psychological or physical dependence Comprehensive Drug Abuse Prevention & Control Act of 1970 established 5 schedules based on potential for abuse & medical use

Medication Schedules Schedule I (May not be prescribed) Schedule II Heroin, Methamphetamine, LSD Schedule II Methadone, Oxycodone, Oxycodone combinations (e.g. Percocet®), Morphine, Fentanyl, Hydrocodone combinations (e.g. Vicodin®) Methylphenidate, Dextroamphetamine Schedule III Codeine combinations (e.g. Tylenol #3®) Testosterone Schedule IV Benzodiazepines Zolpidem (Ambien®), Eszopiclone (Lunesta®) Tramadol (Ultram®) Schedule V Codeine containing cough syrup (available BTC) Diphenoxylate products (e.g. Lomotil®)

What is the Prescription?

Ohio Administrative Code 4729-5-21 The Prescription An order, by a licensed practitioner, for a medication. “A prescription, to be valid, must be issued for a legitimate medical purpose by an individual prescriber acting in the usual course of his/her professional practice.” Methods of transmitting or receiving prescription drug orders include: Signed hard copy prescription Oral prescription given by prescriber or the prescriber’s agent Facsimile of a signed prescription Prescription sent using a board approved electronic prescription transmission system Ohio Administrative Code 4729-5-21

Who can prescribe in Ohio?

Ohio Administrative Code 4729-5-15 Prescriber Doctor of medicine (MD) Doctor of osteopathic medicine (DO) Doctor of podiatry (DPM) Doctor of veterinary medicine (DVM) Dentist (DDS) Optometrist (OD) “Therapeutic pharmaceutical agents certificate” Advanced practice nurse (restrictions) CNS (Clinical nurse specialist) CNM (Certified nurse midwife) CNP (Certified nurse practitioner) Physician Assistant (restrictions) Ohio Administrative Code 4729-5-15

Ohio Administrative Code 4729-5-15 Prescriber “Those persons pursuing an approved internship, residency, or fellowship program in this state are authorized to write prescriptions only when acting within their scope of employment in the hospital(s) or institution(s) Ohio Administrative Code 4729-5-15

Outpatient Prescription Orders Prescriptions are the primary method of physician-to-pharmacist communication Can be useless if incomplete, confusing, or not filled by the patient Results of miscommunication: Delay of care Undesired outcome (preventable ADEs) Insurance reimbursement problems

By law, what must each prescription contain? Ohio Administrative Code 4729-5-30

Outpatient Prescription Order The Ohio State University Physicians Group 123 Main St. Columbus, OH 43210 614-555-5555 Patient’s Name: Joe Smith__________ Address: 456 Buckeye Lane Date: 9/29/2014 Rx: Percocet 5/325mg # 30 (thirty) Sig: i po q 6 hr prn pain   Refills: 0 Mary Jones M.D. Mary Jones M.D. AJ1234563   For Instructional Purposes Only Patient’s full name Address & phone # of prescriber Patient’s address Date issued Drug name & strength Quantity to dispense* Directions for use Address often added by pharmacist (check records/profile, ask patient, or prescriber) – If contained on backtag label that is sufficient Must contain date issued, if prescriber does not want patient to fill until certain date they can write that in the directions, they cannot post date a prescription. For example prescriber should write the date issued plus do not fill until… For controlled substances quantity must be numerical and alphabetical For hand written order prescriber must manually sign Rx DEA required for controlled substances (often preprinted) Refill PRN not valid Other useful information that should be provided or included but not required by law age/date of birth and weight (especially for pediatric patients) Prescriber signature Preprinted full name & professional title of prescriber Refills authorized If nothing specified, 0 refills allowed for that prescription unless you call the physician "Refill P.R.N." is NOT valid Ohio Administrative Code 4729-5-30 Prescriber DEA # Required for controlled substances

What else should be included?

Prescription Orders Additional items that should be included on prescription orders but NOT required by law Patient date of birth Patient weight (especially in pediatrics) Route of administration Dosage form Purpose of medication (i.e. indication)

Prescription Orders – Other Requirements DAW (dispense as written) must be handwritten (in Ohio) Section (A)(1) ORC 4729.3 Only 3 orders per prescription Can not include controlled substances Each controlled substance must be written on its own prescription

Tamper-Resistant Prescriptions in Ohio Claim to be eligible for reimbursement through ODJFS, a written format must be on a tamper resistant form Ohio Department of Job and Family Services Consumers enrolled in the Ohio Medicaid or Disability Medical Assistance programs Must contain all three features Feature to prevent unauthorized copying Feature to prevent erasure or modification of information Feature to prevent the use of counterfeit prescription forms Ohio Administrative Code 5101:3-9-06

Controlled Substances Requirements Only 1 order per prescription Prescriber DEA number must be on each controlled substance prescription Quantity must be written numerically and alphabetically Refill regulations CII – no refills, multiple scripts for up to 90 day supply, “do not fill until” CIII-IV – max 5 refills, must be within 6 months from date written CV – max refills 1 year CII’s must be handwritten or electronically printed and manually signed (No telephone orders*) Controlled Substances Act (CSA), ORC 3719.05

D.E.A. Number Assigned to individual prescriber for controlled substances Unique letter and number combination 2 letters followed by 7 numbers Can be checked for legitimacy Interns, residents, and fellows are assigned individual number to use as a hypenated suffix with the hospital D.E.A. number DEA number must be written on each prescription for a controlled substance. DEA can be determined if it is real or not by a mathematical formula.

Tips for Electronic Prescribing All fields must be completed to have legal prescription Carefully select drug, dose, frequency, etc. Proofread, proofread, proofread E-prescribing will send script to selected pharmacy Always ask patient what pharmacy they go to Any changes after prescription is sent require a new prescription and/or a call to the pharmacy Printed electronic prescriptions must be manually signed Ask questions! While there are advantages to e-prescribing including decision support features there are also pitfalls and areas prone to error so don’t be afraid to ask questions.

Electronic Prescribing

Pharmacist’s Role Pharmacists can do on his/her own: Generic substitution Reduce quantity dispensed Add patient address Compound

Pharmacist’s Role Pharmacists cannot do without calling: Add or subtract refills Add quantity Change drug Including formulary substitutions Change strength Change formulation Add physician’s D.E.A. number

Medication Errors Definition - "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use." National Coordinating Council for Medication Error Reporting and Prevention www.nccmerp.org

Medication Errors - IOM Estimated 1.5 million preventable ADEs/year Cost in ambulatory care setting in Medicare patient estimated at almost $900 million in 2000 Preventing Medication Errors: Quality Chasm Series - IOM 2006

Tips to Avoid Errors Write legibly Include all required elements on orders/prescriptions Avoid Abbreviations Drug Names Sig codes Medical Terminology Avoid trailing zeros 1.0mg, use leading zeros 0.1mg Use metric system (e.g. mL vs. tsp) Specify strength rather than unit 250mg vs. 1 tablet Specify dosage form Be aware of sound alike/look alike medications

Error Prone Abbreviations http://ismp.org/Tools/errorproneabbreviations.pdf

Summary Support interdisciplinary practice Educate patients on medications Encourage use of one pharmacy Encourage patients to talk to pharmacists Promote medication lists for patients

Acknowledgements Stu Beatty, Pharm.D., BCPS Anna Haas-Gehres, Pharm.D. Cari Brackett, Pharm.D., BCPS

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