1. Chapter 13: Processing Medication Orders and Prescriptions

2. 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

3. Upon Receipt 2 steps review order for clarity & completeness prioritize the order

4. 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

5. 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

6. Order Start Times STAT – immediately- an urgent need “Now” or “ASAP” “start today” or “start this morning” Has 1 st 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

7. 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

8. Patient Profile Patient name Identification numbers Date of birth/age Sex Height and weight Lab values Admitting/2 nd diagnoses Room & bed number Names of admitting & consulting physicians Allergies Medication history Special considerations Clinical comments- therapeutic monitoring, counseling notes

9. 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)

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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)

18. Special Instructions Pharmacy instructions notes between pharmacist/technician clinical notes Nursing instructions storage information administration instructions physician-specified parameters displayed on MAR & medication label

19. 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

20. 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

21. Special Considerations “Charge-Only” & “No-Charge” Entries Pharmacist protocols Diagnostic preparation orders Computer physician order entry Automated dispensing technology Centralized dispensing automation Decentralized automation

22. 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

23. 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

24. 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)

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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”)

33. 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