Inpatient Pharmacy Practice 2008

Inpatient Pharmacy Practice 2008 - Processing a...

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Unformatted text preview: Processing a Prescription: Inpatient/Institutional Damary C. Torres, Pharm.D., BCOP Associate Clinical Professor castanhd@stjohns.edu 7189902485 Required Reading Chapter 127 Hospital Pharmacy Practice in Remington's Objectives Review sections of a medical chart Review hospital abbreviations How to write an medication order Describe the process of communicating the medication order between the prescriber and pharmacists How are medication orders verified How is a prescription filled To review different technologies to assist with medication distribution Medication reconciliation What's different in community vs. hospital pharmacy practice? What's the same? Types of Hospitals / Inpatient Institutions Hospitals LongTerm Health Care Facility Resident Treatment Facility General Special hospice Rehabilitation Psychiatric What do Pharmacists do in a Hospital? Receive and evaluate medication orders Prepare and distribute drugs Provide drug information Coordinate Investigational Drug Service Staff Poison Control Center Provide clinical services in patient units Fill/check code boxes, floor stock, carts Serve on committees Administration in the department Hospital Pharmacy Hospital Pharmacy Patient Medical Chart Administrative Records Admission Notes Continuation Notes Doctors Orders Procedures Records Tests Diagnostic Reports Old MAR sheets Discharge Summary Name, age, medical record number on every page/screen MAR medication administration record Patient Medication Administration Record (MAR) Meds administered with time, dose and initials Flowsheets Vital Sign In's and Outs Fluids Blood glucose Allergies Weight Abbreviations Used in a Hospital cc milliliter NG nasogastric tube IV intravenous IVF IV fluids TPN total parenteral nutrition MICU medical intensive are unit CCU cardiac intensive care unit DNR/DNI do not resuscitate / do not intubate npo nothing by mouth s/p status post r/o rule out VSS vital signs stable BS blood sugar, breath sounds or bowel sounds Abbreviations Progress Note H&P History and Physical CC chief complaint "I can't breathe" HPI history of present illness Ms. X is a 64 yo WF (year old white female) who presents with SOB (shortness of breath) and DOE (dyspnea on exertion) for the past 3 days PMHx past medical history asthma, HTN (hypertension), migraines PSHx past surgical history none SHx social history smoked for 30 yrs, quit 5 yrs ago, social EtOH, no IVDA, lives with husband FHx family history M heart disease, F A&W (alive & well) Meds PTA medications prior to admission ROS review of systems no N/V/D (nausea, vomiting or diarrhea, no HA (headache) PE physical exam 140/85 72 20 98.7 (BP, pulse, RR respiratory rate, temperature) Gen: General illappearing WF HEENT: Head, eyes, ears, nose and throat PERRLA (pupils equally round and reactive to light), EOMI (extraocular movements intact) Pulm: pulmonary wheezing CV: cardiovascular RRR (regular rate and rhythm), S1, S2 (these are normal heart sounds) Abd: abdomen soft, NT (nontender), ND (nondistended), BS (bowel sounds) present, pain in LUQ (left upper quadrant) Ext: extremities edema bilaterally in LE (lower extremities) Neuro: neurological A&O x 3 (alert and oriented to person, place and time, CN IIXII (cranial nerves) intact SOAP subjective/objective/assessment/plan Abbreviations Progress Note Labs in the Hospital Electrolytes: Na, K, Cl, CO2, Mg, PO4, Ca Hematology: CBC, WBC, RBC, Hgb, Hct, Plat / INR, aPTT Liver Function Tests: AST, ALT, Alk Phos, LDH, GGT/ Alb, T. prot / T. bili, D. bili / INR, aPTT Renal Function Tests: SrCr, BUN, electrolytes, UA Cardiac Tests: CK, CKMB, troponin, T. chol, LDL, HDL Infection: C&S Drug levels Homework look up all these abbreviations Labs in the Hospital Electrolytes: Na Cl BUN Hematology: Hgb . K CO2 Cr Glu WBC Hct Plat The Joint Commission Mission: "To continuously improve the quality and safety of care provided to the public, the Joint Commission is: Committed to continually enhance the value of its accreditation and certification programs. Committed to developing, utilizing, and maintaining valid and reliable performance measures. Committed to ensure that the accreditation process is publicly accountable. Committed to making patient safety an imperative in all accredited organizations. Committed to addressing pressing public policy issues that impact the quality and safety of health care" Maintains standards of healthcare "Checksup" on facility Publishes yearly "patient safety goals" Used to be called JCAHO Joint Commission on Accreditation of Healthcare Organizations Hospital Pharmacies: Centralized versus Decentralized Centralized One pharmacy that serves the entire hospital Satellite Decentralized Satellite Central Satellite One central pharmacy and Many "satellite" pharmacies Satellite Satellite Located near patient units Pharmacy and Therapeutics Committee Chaired by a physician Multidisciplinary Cochair or secretary is usually the pharmacy director Pharmacists Physicians/Prescribers Nurses Social workers Administration Laboratory Quality Improvement Other pertinent Duties departments To make important decisions/changes for the hospital formularies, policies and procedures What is a formulary anyway? List of drugs available in the hospital What drives formulary decisions? Need, safety, cost, individuality and others Inpatient Medication Orders Written by prescriber Sent by nurse Filled by pharmacist Floor Stock meds and crash carts (code boxes) are replenished by Pharmacy Medication Order Writing Inpatient Medication Orders Date and Time are critical Name, MRN, Location Name of medication Stat vs. Routine Dosage Generic vs. brand Frequency Indication Start and Stop Dates Route of administration Signature of prescriber Approved abbreviations only Cosigned in some cases Joint Commission DO NOT USE List Do not use... U IU QD, Q.D., qd, q.d., QOD, Q.O.D, qod, q.o.d, Trailing 0 (1.0 mg), lack of leading 0 (.1mg) MS, MSO4, MgSO4 so use: unit International unit Daily or every other day 1 mg or 0.1 mg Morphine sulfate or magnesium sulfate Joint Commission Proposed DO NOT USE List Do not use... > Or < Drug name abbreviations Apothecary units (drams) @ cc g so use: Greater than or less than drug name written out Metric units at ml or milliliter mcg or microgram Writing Inpatient Medication Orders: Look Alike/Sound Alike Ephedrine and epinephrine Hydromorphone and morphine injection Taxol and taxotere Amaryl and reminyl Celebrex, celexa and cerebyx Clonidine and clonazepam Serzone and seroquel **Typically hospital create their own list of look alike/sound alike drugs How Do Orders Get to Pharmacy? Baskets Telephone Fax Scanning procedures Computerized Physician Order Entry Filling Medication Orders Medication order sent to pharmacy Pharmacist reviews order Pharmacist approves order Medication is filled by technician/intern/pharmacist/robot Checked by a pharmacist Only unit doses are sent at a time Distributed to respective patient unit When the Order Gets to Pharmacy Pharmacist enters into computer Order is entered in patients profile Unless facility has physician order entry, then R.Ph. will only verify Profile is usually acute (for this visit) Profile will typically consist of PO and IV meds Profile is checked for potential problems Verifying Medication Order Age Allergies Dose Route of administration Comorbidities Drug interactions Intubated? Renal function Liver function Organ function in general Other lab values Interactions between administration methods Indication listed Abbreviations On formulary, no restrictions or shortage Therapeutic duplication Duration of therapy PO vs. IV When the Order Gets to Pharmacy: Problems with Orders PRESCRIBER MUST BE CONTACTED Pharmacist must take a telephone order from prescriber if not prohibited Write on inpatient order sheet, enter, fill and be sure to send order to the floor Documentation is key Pharmacist Interventions Appropriate medication prescribed Appropriate dose of medication Formulary medications Appropriate route of medication Appropriate monitoring of medication Age, weight, renal and hepatic function Medication reconciliation Laboratory results, radiology, signs, symptoms ER interviews Discharge counseling Filling IV Orders Regular IV orders Chemotherapy Horizontal air flow hoods Preparation and spills are not dangerous Drugs that cause: genotoxicity, carcinogenicity, teratogenicity or fertility impairment or serious organ or other toxic manifestation Use protective gear Use vertical air flow hoods Spills require special handling Resources: http://www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html ASHP guidelines on handling hazardous drugs. Am J Health Syst Pharm 2006;63:117293. Filling IV Orders Administration of Medication Nursing responsibility Becomes important to the pharmacist when we are monitoring levels of specific medications Medication Distribution Medication Carts Pharmacy tube system Medication Distribution Pyxis machine Pharmacy Robots New Technology Bar Coding Verifying correct medication to correct patient Patient Self-Administration of Medications Patients bringing in their own meds In longterm care faculties patients may take meds on their own (if ok'ed by MD) Pharmacy MUST identify Nurses administer Drug Information Will be asked many questions on administration Questions may be more emergent than in outpatient pharmacy Assess resources that facility has already Learn how to use them! Medication Reconciliation Process of identifying the most accurate list of all medications a patient is taking Use this list to provide correct medications for patients anywhere within the health care system Involves comparing the patient's current list of medications against the physician's admission, transfer, and/or discharge orders Experience has shown that poor communication of medical information at transition points is responsible for as many as 50 percent of all medication errors and up to 20 percent of adverse drug events in the hospital Includes name, dosage, frequency, and route What's different in community vs. hospital pharmacy practice? What's the same? ...
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