MEDICATION USE EFFECTIVE DATE: 06/2003 REVISED: 2/2005, 04/2008, 06/2014

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1 TITLE / DESCRIPTION: SAFETY PROCEDURES FOR MEDICATION USE DEPARTMENT: Pharmacy PERSONNEL: All Pharmacy Personnel EFFECTIVE DATE: 06/2003 REVISED: 2/2005, 04/2008, 06/2014 Leadership and Culture A culture of safety is clearly framed in the organizational leadership as a state of mind. Patient safety is a core value in the organization. Patient safety is everyone s responsibility. Capital planning with safety as a criterion. (AllScripts, Omnicell) Facility construction with safety as a criterion. Materials procurement with safety as a criterion. (Unit dose medication with safety as reviewed for sound alike, look alike issues Legal, quality, pharmacy, nursing and risk management departments approach safety issues in a coordinated fashion. Non-punitive approach to reporting, analyzing and evaluating errors and problems. Safety is monitored regularly by senior leadership. Access to Information Physician orders faxed to pharmacy or entered into HIS ( Sunrise Medication Manager). Orders are profiled to ADM, Hand delivery of patient orders is not routine but could be a mechanism to deliver information to pharmacy when no other mechanism were available. Phone orders may be obtained from a physician to a pharmacist during the clarification of physician orders. Standardized and simple communication is preferred (minimizing verbal orders and the use of abbreviations) Appropriate current reference materials on hand, Lexicomp, AHFS, PDR, etc. Drug Selection and Procurement The Pharmacy and Therapeutics Committee focuses on the safe use of drugs within the hospital and considers problems such as drug interactions, medication errors, safety

2 concerns such as sound alike, look alike medications, protocol treatment, formulary deletions/additions, and therapeutic interchanges. It is a dynamic effort to keep formulary products available with many back orders and shortages. Daily communication to pharmacy personnel concerning shortages and appropriate substitutions is often required such that knowledgeable advice can be given to health care professionals. Direct manufacture ordering process is in place when the wholesaler supply is limited. Increased use of internet sites such as ASHP and AmerisourceBergen for shortage information. There is awareness to ordering products that have clear labeling. Technology New opportunities to reduce errors, track effectiveness and focus on organization high-yield are reviewed to improve safety. Computerized Pharmacy System Automatic drug-drug interaction alerts Automatic allergy checking Automatic duplicate alerts Automatic stop alerts Automatic alerts for clinical laboratory values, e.g., creatinine clearance Computer generated/daily MARs Clinical interventions logged daily into Sunrise Medication Manager ADM Profile/Med Station Pharmacy reviews med orders prior to med administration with profiling, Report capabilities on discrepancies, users and activities at the station. Prescribing and Ordering The pharmacy information system has forcing functions requiring the entry of pertinent clinical information prior to orders being dispensed, such as height, weight, allergy and triggers to alerts like, sound-alike, look-alike or duplicates. A clinical laboratory interface allows pharmacy to review pertinent clinical data related to safety in prescribing medications as an independent check. Order sets are in place for many physician procedures, which have been reviewed for best practice safety initiatives as related to not abbreviating medication names, indicating the purpose of the med, using metric nomenclature, not using leading or trailing zeros and brand and generic listing.

3 An institution specific formulary is in place which reduces variation in prescribing, utilizing automatic substitution by classes and, reducing the risk of sound-alike, look-alike medications. The clinical pharmacist is key to error surveillance by. providing clinical consults on TPN, amino glycoside and vancomycin dosing and any other drug information or medication management issues. Standardized protocols are designed to reduce variation, reduce omission, and provide quality. Chemotherapy orders are tripled checked as to regimen, dose, labs. Verbal orders/phone orders should be used only in an emergency situation when the physician is unable to transcribe the orders himself. Implemented pharmacy read-back procedure when verbal/phone orders are received from a physician during a clarification of a medication order. Pharmacists clarify all unusual or ambiguous orders demonstrating one of the roles played in the culture of safety Physicians writing habits which are illegible or use unapproved or unacceptable abbreviations will have their orders clarified when necessary. Unapproved abbreviation list is available on each nursing unit. Dispensing The accurate delivery process rests with the pharmacist and the processes that support the pharmacist. Pharmacy leadership must actively promote an open learning environment to encourage the identification of errors to continuously implement system improvements. Workload is reviewed to view orders processed per pharmacist worked hour, technician worked hour, order turnaround time, and medication errors reported. Sound-alike, look-alike drug names are marked as such on the med bins alerting the staff to take a second look at the med being selected. Standardized dosing and protocols are in place. Current reference material is in the pharmacy and on the nursing units. As a quarterly liaison, pharmacists visit all areas where medications are stored for out-of-date checks, refrigerator checks, etc. Unit dose is implemented and IV solutions are purchased premade when possible. Overrides are tracked and evaluated. Liquid medications are dispensed in unit of use form whenever possible. Lidded matrix drawers are always used for narcotic control and for high risk, high alert meds when possible. High alert meds of different strengths can be separated by drawers. Centralized IV admixture compounding. After order is profiled by a pharmacist, the unit dose item is released from the ADM. Override medications are specific to floors and monitored for appropriateness to override For Urgent/Emergent needs.

4 Administering There is greater risk for harm occurring at this step. Medication process must assure the Five Rights. Processes to assist the nurse are: Standardized blood sugar check times to administer sliding scale insulin. Standardized time to administer daily coumadin. Standardized time to administer daily digoxin. Phone/verbal orders are read back to the physician and co-signed by a physician as soon as possible. A triple check process is in place for chemotherapy administration. Documentation to the E-MAR is done immediately upon administration of a medication to a patient. Only one patient s medication is removed for administration at a time unless they can be secured in a patient s individual cassette. Special warnings or stickers are placed on many drugs, i.e., chemotherapy, must be filtered, shake well, do not handle if pregnant, etc. Monitoring Basic monitoring of the effects of a medication and any adverse reaction is a fundamental recommendation of every safety program. Certain medications have a narrow therapeutic window, clear and measurable toxicities, or a high frequency of significant complications and form the framework for focus as HIGH RISK/HIGH ALERT MEDICATIONS. Pharmacists monitor pertinent abnormal lab values daily. Pharmacists provide aminoglycoside and vancomycin monitoring, TPN monitoring, digibind usage and any other monitoring related to a specific patient need. Pharmacy/Nursing Educators meets regularly. Non punitive medication error reporting. Critical lab values monitored are: Serum creatinine Serum drug levels Coagulation studies C. Difficile toxin assay Microbiology culture data to appropriate antibiotic Trigger medications are identified at order entry and reviewed for Possible ADR. Some examples are: Naloxone (Narcan) Antihistamines Vitamin K Flumanzenil (Romazicon) Oral or pre-packaged IV glucose Glucagon Epinephrine Topical calamine Phentolamine

5 Glucocorticoids Protamine Digoxin-immune FAB (Digibind) Hyaluronidase Sodium polystyernesulfonate (Kayexalate) Anti-emetics Anti-diarrheals System Performance Clinical pharmacy specialists participate in interdisciplinary team meetings on the nursing floor/unit. The P&T committee meets routinely to review trended medication error data Data from quality observations are reviewed for process changes in the pharmacy relating to ADM drug locations, sound-alike, look-alike changes that need to be evaluated, ordering issues, timeliness of order issues, etc. Home medications identified and permanently maintained in Prescription Writer during the medication reconciliation process. Special Medications The pharmacy participates in the dispensing of investigational drugs. One pharmacist is designated the INVESTIGATIONAL pharmacist who is responsible for receiving the drug, closing out the study, setting up the documentation and reviewing the dispensing guidelines, preparing for proper storage by temperature and location, and in-servicing the staff on the study to assure proper documentation is maintained. Investigational medications are stored separately from other medications. The patient consent form is signed prior to an investigational drug being administered. Nursing personnel and patients are in-serviced on the drug and therapy prior to administering the medication. Investigational drugs are clearly labeled INVESTIGATIONAL and the medication is handed to the nurse for administration. If a patient comes in to the hospital on a protocol treatment that has not been approved, the physician will be instructed to contact the IRB