2. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved Math for the Pharmacy Technician: Concepts and Calculations Chapter 4: Drug Orders Egler Booth

3. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-2 Drug Orders

4. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-3 Learning Objectives  Summarize the Rights of Medication Administration.  Interpret a written drug order.  Identify on the information on a medication order needed to dispense medications. When you have successfully completed Chapter 4, you will have mastered skills to be able to:

5. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-4 Learning Objectives (con’t)  Locate on medication administration records or medication cards the information needed to administer medication.  Recognize incomplete drug orders.  Select appropriate action for confusing, incomplete, or illegible drug orders.

6. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-5 Learning Objectives (con’t)  Identify and verify DEA numbers.  Recognize classifications of controlled substances.  Recognize prescription errors and forged or altered prescriptions.  Interpret and use pharmaceutical and medical abbreviations and terminology.

7. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-6 Introduction  In order to correctly calculate a medication dose, you must be able to read and understand the drug order.  This chapter will discuss: Drug orders Patient’s rights Medication administration systems Your responsibilities

8. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-7 The Rights of Medication Administration 1. Right patient 2. Right drug 3. Right dose 4. Right route 5. Right time 6. Right technique 7. Right documentation To prevent errors, check the rights!

9. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-8 Right Patient You are responsible if an error occurs.  Name on original order must be exactly the same as the name on the Medication Administration Record (MAR), medication card, or prescription.  Verify the full name.  Ask “What is your name?”  Check the bed number and tag.  Read the patient’s identification bracelet.

10. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-9 Right Drug  Only give drugs that you have prepared yourself.  Or that are clearly and completely labeled.  Check the expiration date.  If the patient questions a medication, then recheck it.  A patient always has the right to refuse a medication.  Dispose of medicine according to facility guidelines.

11. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-10 Right Drug (con’t)  Always check medication three times: 1. when you take it off the shelf. 2. when you prepare it. 3.when you replace it on the shelf.  Check it three times even if it is prepackaged, labeled, and ready to be administered.

12. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-11 Right Dose Later you will learn how to convert from the dosages ordered by the doctor to the desired dose.  Use extreme caution when calculating dosages.  Pay special attention to decimal points.

13. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-12 Right Route  A drug intended for one route is often not safe if administered via another route.  Some medications are produced in different versions for different routes.  For example: suppositories, oral tablets, or injections  Be especially careful between ophthalmic and otic routes.

14. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-13 Right Time  Some medications must be given at a specific time.  Some medications are given before or after food, depending on food- drug interactions.  Other medicines can be spaced over waking hours.

15. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-14 Right Technique  Medications must be given correctly according to the order. For example: Buccal -- between cheek and gum Sublingual -- under the tongue  If unsure, check references materials. Examples: Physicians’ Desk Reference (PDR) Facts and Comparisons Remington: The Science and Practice of Pharmacy

16. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-15 Right Documentation  Be sure that the right documentation is completed. For example, inpatient facilities administer medication to the patient. The health professional who administered the medication must, immediately after the patient takes the medication, sign the medication administration record (MAR)

17. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-16 Physician’s Orders and Prescriptions Abbreviations used when writing orders:  general abbreviations  form of medication  route  frequency  You will be expected to have these memorized.  See the next slides for a review of Table 4-2

18. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-17 Table 4-2 Abbreviations Commonly Used in Drug Orders

19. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-18 Table 4-2 Abbreviations Commonly Used in Drug Orders (con’t)

20. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-19 Table 4-2 Abbreviations Commonly Used in Drug Orders (con’t)

21. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-20 Table 4-2 Abbreviations Commonly Used in Drug Orders (con’t)

22. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-21 Abbreviations Joint Commission on Accreditation of Healthcare Organization (JCAHO) has established a list of “Do Not Use” and “Undesirable” abbreviations. See Tables 4-3 and 4-4 on the following slides. Be certain to check abbreviations carefully when reading drug orders.

23. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-22 Table 4-3 “Do Not Use” Abbreviations

24. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-23 Table 4-4 “Undesirable” Abbreviations

25. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-24 Table 4-4 “Undesirable” Abbreviations (con’t)

26. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-25 General Abbreviations a, a BP c, c NKA NPO p, p s blood pressure with no known allergies nothing by mouth after without before

27. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-26 Forms of Medication cap, caps elix gtt, gtts LA supp tr, tinct, tinc. ung, oint capsule elixir drop, drops long acting suppository tincture ointment

28. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-27 Route IM, I.M. od, O.D., OD os, O.S., OS ou, O.U., OU po, p.o., PO, P.O. Sub-Q or subq intramuscular right eye left eye both eyes by mouth; orally subcutaneous, beneath the skin

29. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-28 Frequency a.c., ac, AC, ac b.i.d., bid, BID h, hr n, noc, noct p.c., pc, PC, pc p.r.n., prn, PRN before meals twice a day hour night after meals when necessary, when required

30. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-29 Frequency (con’t) q.___ hrs, q ___h qhs, q.h.s. q.i.d., qid, QID stat t.i.d., tid, TID every ___ hours every night, bedtime 4 times a day immediately 3 times a day Note: Do not use QD or QOD instead write “Daily” or Every other day”

31. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-30 Outpatient Settings  Physicians’ orders are given as prescriptions that are filled at a pharmacy or through the mail.  Prescriptions include all the elements of a physician’s order as well as the physician’s name and prescriber number.

32. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-31 Physician’s Drug Order  Full name of the patient  Full name of the drug  The dose  The route  The time  The frequency  Signature of prescribing physician  The date  PRN order must include the reason

33. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-32 Physician’s Drug Order (con’t)  Outpatient Settings -- written as prescriptions  Inpatient Settings -- written on physicians’ order forms

34. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-33 Prescription Form I. Heal, MD Best Medical Clinic 123-456-7890 Name Anna Versary Date April 19, 2012 Address________________________________ Rx: Lopressor 50 mg QUANTITY: # 90 SIG: i tab po tid Refills: 5 AH1234567 I. Heal, MD Prescriber ID #

35. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-34 Controlled Substances  A controlled substance is a drug that has the potential for addiction, abuse, or chemical dependency, also referred to as a narcotic.  There are five categories of controlled substances listed by schedule.

36. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-35 Controlled Substances (con’t)  Schedule I-Drugs have a high level for potential abuse and are unacceptable for medical use in the United States. These drugs are not to be prescribed. For example: marijuana, heroin.

37. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-36 Controlled Substances (con’t)  Schedule II-Drugs have a high level for potential abuse and dependency. Drug orders must be on a written or typed hard copy order and have DEA number and prescriber signature. Referred to as narcotics. Quantities are limited and NO REFILLS are allowed. For example: opium, morphine, oxycodone.

38. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-37 Controlled Substances (con’t)  Schedule III-Drugs have less potential for abuse than Schedule I and II drugs, but still have a moderate potential for dependency. Drug orders may be ordered by phone or in writing and may have five refills in a six- month period. For example: butalbital, hydrocodone/codeine.

39. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-38 Controlled Substances (con’t)  Schedule IV-Drugs have a low level for potential abuse, and limited potential for dependency. Drug orders may be ordered by phone or in writing and may have five refills in a six-month period. For example: alprazolam (Xanax®), diazepam (Valium®), zolpidem (Restoril®).

40. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-39 Controlled Substances (con’t)  Schedule V-Drugs have a low level for potential abuse, and limited potential for dependency. Drug orders may be ordered by phone or in writing and may have five refills in a six-month period. For example: diphenoxylate (Lomotil®), pregabalin (Lyrica®)

41. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-40 DEA Numbers  The Drug Enforcement Administration (DEA) of the Justice Department passed the Controlled Substances Act in 1970. It regulates the distribution of controlled substances.  Federal law mandates that any prescriber that writes a medication order for a controlled substance must be registered with the DEA and are given a DEA number that must be listed on the controlled substance orders.

42. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-41 DEA Numbers (con’t)  A DEA number always consists of two letters followed by seven numbers. The second letter is the initial of the prescriber’s last name.  An example of a DEA number is AH1234567.

43. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-42 Formula to Verify DEA Numbers  To ensure that a DEA number is authentic, the following formula is used for verification. Using the example DEA number of AH1234567.  Add the first, third, and fifth digits together;  Next add the second, fourth, and sixth digits together and multiply the sum by 2.

44. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-43 Formula to Verify DEA Numbers (con’t)  Then add the two answers together.  The last number in your answer of the formula must be the same as the last number of the DEA number for it to be authentic.

45. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-44 Formula to Verify DEA Numbers (con’t) Using the formula verify the example DEA number AH1234567.  Step 1. Add the first, third, and fifth numbers. 1 + 3 + 5 = 9  Step 2. Add second, fourth, and sixth numbers and multiply by 2. 2 + 4 + 6 = 12 x 2 = 24

46. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-45 Formula to Verify DEA Numbers (con’t)  Step 3. Add the two answers together. 9 + 24 = 33  If the answer in Step 3 of the formula ends in the same number as the last number of the DEA numbers, it may be an authentic number.  In working the formula we see that the example DEA AH1234567 is not an authentic number; if it were, it would have ended with the number 3.

47. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-46 Detecting Errors and Forged or Altered Prescriptions  As a pharmacy technician you need to know federal and state restrictions for all schedules of controlled substances.  You must verify the date, DEA number, and prescriber’s signature on all controlled substance drug orders.

48. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-47 Detecting Errors and Forged or Altered Prescriptions (con’t)  On Schedule II drug orders, verify the allowable quantity limits and that there are NO refills written.  Inspect the hard copy for paper type and the order for consistent handwriting style.  If a prescription looks altered or forged in any way, follow your facility’s protocol.

49. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-48 Inpatient Setting  For inpatient settings, drug orders are usually written on physicians’ order forms, with space for multiple orders.  Orders may also be entered into a computer. The patient’s name and the physician’s signature appear once on the form.

50. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-49 Inpatient Setting (con’t) Under Medication Orders, the physician writes the components of each medication requested in the following sequence:  name of drug  dose route  frequency  any additional instructions.

51. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-50 Physician’s Order Forms: Medication Orders Prescription Order Forms

52. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-51 CAUTION!  Never guess what the prescriber meant!  If the order is not legible, always contact the prescribing physician to clarify the order.

53. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-52 Verbal Physician’s Orders  If the physician is unable to write or personally sign an order, verbal orders may be used.  These are governed by state laws as to which personnel may accept verbal orders.  You must be legally permitted to accept a telephone order.

54. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-53 Verbal Physician’s Orders (con’t)  Write the order carefully and legibly as you receive it, not after the call.  Identify it as a verbal order.  Read the order back to the physician.

55. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-54 CAUTION!  Always be certain that you are dispensing the correct medication.  Many drugs have names that are similar. DarvonDiovan

56. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-55 Medication Administration Systems  Most facilities have a standard schedule for administering medication.  Person who verifies the transcription ensures that the times listed are appropriate for the medications.  Times may need to be adjusted according to mealtimes or conflicting medication schedules.

57. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-56 Sample Times for Medication Administration Frequency OrderedTimes to Administer qd0800 bid0800 – 2000 tid0800 – 1400 – 2000 qid0800 – 1200 – 1600 – 2000 q 12 hrs0800 – 2000 q 8 hrs2400 – 0800 – 1600 q 6 hrs2400 – 0600 – 1200 – 1800 Every night at bedtime2000

58. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-57 Medication Administration Records (MAR)  Legal documents  Handwritten or computerized printouts  Contains same information as a physician’s order form  Specify the actual times to administer the medication  Provide a place to document each medication administration  By law, after you give a medication you must immediately document it

59. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-58 Medication Administration Records (con’t) An MAR must include the following information:  Name of medication, dose, route, frequency  Times that accurately reflect the frequency specified  Name and identification number of patient  Date of order  End date of narcotics and antibiotics  Special instructions, diagnosis, weight, etc.

60. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-59 Review and Practice Is the following MAR complete? If not, what is missing?

61. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-60 Review and Practice  Answer: In the previous MAR the order is written correctly and all information is complete.

62. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-61 Is the following MAR complete? If not, what is missing? Review and Practice

63. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-62 Review and Practice  Answer: In the previous MAR: Order A is correct. Order B dose not include the strength of the medication. Order C contains an error in the times listed. Order D does not include a route.

64. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-63 Medication Reference Materials  You must be familiar with drug information sources  Resources Physicians’ Desk Reference (PDR) United States Pharmacopeia National Formulary Drug handbooks Internet sites Software programs used with personal digital assistant (PDA)

65. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-64 Review and Practice  Which of the Rights of medication administration is not listed? right patient right drug right dose right time right technique right documentation Answer: right route

66. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-65 Review and Practice What do the following abbreviations mean? pc os qd supp BP after meals left eye every day suppository blood pressure

67. McGraw-Hill ©2010 by the McGraw-Hill Companies, Inc All Rights Reserved 4-66 Drug Orders THE END You must be 100 percent accurate in interpreting medication orders. I. Heal, MD Best Medical Clinic 123-456-7890 Name Anna Versary Date April 19, 2012 Address________________________________ Rx: Lopressor 50 mg QUANTITY: # 90 SIG: i tab po tid Refills: 5 AH1234567 I. Heal, MD Prescriber ID #