JULY 1999 We would like to devote this Special Pharmacy Key to welcoming you to the University of Kansas Medical Center. We would like to discuss the services provided by the Department of Pharmacy, institutional policies concerning drug use in the hospital and suggested guidelines for prescription writing. The goal of this publication is to foster an understanding of pharmacy services and medication use policies so that safe, efficient and rational drug use or therapy may continue in this institution. PHARMACY SERVICES AT THE UNIVERSITY OF KANSAS MEDICAL CENTER The Department of Pharmacy provides comprehensive, 24-hour service to patients, physicians and staff as an integral part of the teaching, research and patient care programs at The University of Kansas Medical Center. CLINICAL PHARMACY SERVICES Pharmacy Services for inpatients are provided by decentralized Clinical Pharmacists. The clinical pharmacist responsible for the medical service and/or nursing unit caring for your patients is a good person to know. This pharmacist is an excellent resource and your best liaison with the central Department of Pharmacy when drug-related questions or problems and any special requests arise. The Clinical Pharmacist is responsible for review of the patient medication regimen. Pharmacists screen for potential problems with medication orders: dosing, drug allergies, drug interactions, intravenous incompatibility and more. Physicians are informed of potential problems and possible drug therapy modification. Pharmacists are actively involved in monitoring antibiotic therapy and provide pharmacokinetic dosing for selected antimicrobials. Patient education during the hospital stay and/or upon discharge is provided by Clinical Pharmacists. A Self-Medication Educational Program for patients and medication calendars are available for patients with multiple medications and compliance problems. Pharmacy notes located in the patient chart may and/or the electronic medical record, contain information regarding patient education, compliance assessment, pharmacokinetic dosing or other information related to patient drug therapy decisions. Nursing units at KUMC are divided among seven pharmacy teams. Coverage during evening and weekend shifts varies slightly. Clinical Pharmacists carry pagers for accessibility and nursing unit staff or central pharmacy can provide the pager number for designated pharmacists. Clinical Pharmacists: Pager DAY (0800-1500)   Team 1 (PED,56MB,56E) 7972 Team 2(45,BBC,15,15E) 7958 Team 4 (41,43) 7908 Team 5 (42, 42MT) 7956 Team 6 (44ICU, 46) 7970 Team 7 ((SIC, 51) 7964 EVENING (1500-2300)   Team 1E (PED,55,15C,56E,54,56) 7972 Team 2E (BBC, 43, 45) 7908 Team 5E (41,42,42MT) 7956 Team 6E (44’s, 46, 15,15E) 7970 Team 7E (SIC,51) 7964 Central (27,30F) Ext.2321 2300-0800 Ext. 2321     THE FORMULARY SYSTEM The Formulary System is the accepted method approved by the Medical Staff whereby physicians select medications to be available for KUMC patients. The Pharmacy and Therapeutics Committee evaluates, appraises and selects from the numerous medical agents commercially available and makes recommendations to the Executive Committee of the Medical Staff indicating medications which are the preferred medications for patient care at KUMC. These recommendations require approval by the Executive Committee of the Medical Staff prior to formulary inclusion. The evaluation of drugs for admission into the Formulary System is comprehensive and considers efficacy, safety, and economic issues, all aimed at promoting rational, cost-effective drug therapy. It also includes comparisons of therapeutic alternatives to minimize therapeutic duplication in the formulary. The KUMC Formulary is the published list of approved medications considered most useful in providing care for the vast majority of patients, both inpatient and outpatient, in the KUMC Health System. KUMC prescribers are expected to prescribe these approved formulary medications. If medically necessary, non-formulary medications can be obtained upon request for specific patients during their hospital stay. When a non-formulary medication is requested for a specific patient, the pharmacist will inform the prescribing physician of therapeutically equivalent formulary alternatives. If a formulary medication is not identified and the non-formulary request is approved, the Pharmacy will obtain a sufficient supply of the non-formulary drug for that patient’s hospital stay. A time delay may occur if the drug must be ordered from outside sources. REQUEST FOR NON-FORMULARY DRUGS When a non-formulary drug is requested, the pharmacist will inform the prescribing physician of formulary alternatives, which are therapeutically equivalent, and of their proper dosage. If an acceptable formulary medication is not identified, the Pharmacy will obtain a small supply of the drug for that an particular patient. The entire quantity ordered and any delivery fee incurred will be billed to the patient. A time delay of 24-48 hours should be anticipated since the drugs must be ordered from outside source. The non-formulary drug may be sent home with the patient as a dismissal medication, if written for, but will be limited to only the remaining supply. It is recommended that another prescription be sent with the patient for any additional quantity necessary. If a physician intends to prescribe a non-formulary drug on a regular basis, it is recommended that a request for evaluation for Formulary admission be submitted. FORMULARY ADDITIONS AND DELETIONS Requests for additions to or deletions from the KUMC Formulary should be submitted to the Director of Pharmacy on the Application for Formulary Admission Form to facilitate consideration by the Pharmacy and Therapeutics Committee. Such requests must be approved by the Chairman of the Department desiring the drug. Applications must be complete and must include sufficient supportive data to enable the committee to make a sound decision. Application forms are available from the Department of Pharmacy or on the KUMC Pulse at the following url: http://www2.kumc.edu/pharmacy/formrequest.html. All drugs are admitted on a nonproprietary name (generic) basis. No drug of unknown or secret composition will be admitted. DRUG DISTRIBUTION Unit floor stock is available from Pyxis units on all patient care units and many diagnostic units. This automation allows a health care professional with a password to access medications that are on a patient profile and medications that are considered "PRN" for an individual unit. Passwords are electronic signatures for which the health care professional is held ultimately accountable. The medications available in each Pyxis unit are chosen by each nursing unit and its pharmacist. The availability of each medication is based upon safety, usage and stability. Prescribed medications that are not available in Pyxis units are delivered to patient care areas by the Department of Pharmacy in individual packages which identify each dose (unit dose packaging). These doses are placed in a secure cassette drawer labeled for each patient on the nursing units PATIENT’S OWN MEDICATION FROM HOME The hospital encourages the use of medications supplied by the hospital at all times. Patients may use their own medications only under specific limited circumstances. This limitation is based on patient safety with product integrity and potential self-administration of incorrect dosages being issues of concern. In addition, the risk of medication error is increased by the use of medications outside of the normal medication use system. Handling of patient’s own medications is very time consuming. Order clarification, medication identification, documentation, special storage procedures and administration of these medications outside of the normal system consume valuable hospital resources. Appropriate Use of Patients Own Medication Patients may use medication from their own supply only if: The medication is not on the hospital formulary and a reasonable therapeutic substitution is not available. Rarely, a formulary medication may be used from the patient’s personal supply when the physician, pharmacist, and patient deem the use medically necessary to meet a specific health care need. The medication is an investigational or study medication provided under protocol as part of the patient’s participation in an investigational study. Medications that are not provided by the study shall be obtained through the pharmacy. The medication is contained in an original prescription container that identifies the name, strength, dose, route, and directions for use of the medication. Study medications may contain information as allowed by the study protocol and must be labeled with the patient name. Physician Orders for Patient’s Own Medications For medications meeting the requirements above, written orders allowing a patient to use medications from their own supply must include the following: Name, dose, route, and directions for each medication. A statement that the "patient may use their own supply" while in the hospital. Must specifically state "at bedside" if the medication is to be kept in the patient’s room. Orders for the patient to use personal supplies of a formulary medication must include the medically necessary reason. Identification of Patient’s Own Medication The clinical pharmacist will identify each medication used from the patient’s own supply and document this in the patient’s medical record. The clinical pharmacist will: Verify the name, dose, route, and directions for use of each medication. Assess the patient’s understanding of how to take the medication correctly. Clarify with the physician any differences between the written order and communication with the patient. 4. Storage of Patient’s Own Medications All medications not meeting the above requirements for appropriate use of patient’s own medication should be returned home with a friend or family member. Medications patients will be taking from their own supply must be securely stored. The nurse will collect any medications, which are kept in the hospital, for secure storage until discharge. The medication Pyxisâ unit on most units includes a section for secure storage of patient’s own medications. Administration of Patient’s Own Medications A nurse must observe patients taking medications from their personal supply to assure that the appropriate medication and dose are taken at the appropriate time. Documentation on the medication administration record (MAR) must indicate the medication, dose, and time given.  INTRAVENOUS ADMIXTURE SERVICE The Department of Pharmacy prepares all intravenous drug admixtures. The policy ensures that all solutions are prepared under aseptic conditions and are screened for drug interactions and incompatibilities. Standard infusion concentrations have been established for several intravenous drugs. Medication orders for these drugs should be written in the concentrations listed below. Dopamine 400mg/250 mL Dopamine 800mg/250 mL Dobutamine 1gm/250 mL Heparin 20,000 Units/D5W500 mL Morphine (PCA) 1mg/mL Nitroglycerin 50mg/D5W 250mL Potassium Chloride (bolus) 10mEq/50mL diluent Except for reasons of stability, compatibility, and/or volume problems, the standard diluent used in intravenous "piggyback" orders is D5W 50ml. TOTAL PARENTERAL NUTRITION The standard hang time for all adult and pediatric TPN solutions is 20:00. Neonatal TPNs are hung between 1500 - 1700 All TPN orders for adults and pediatric patients are due in Pharmacy by 14:00. This includes new and changed orders. Changes in neonatal orders are due in the Pharmacy by 1300 For adult and pediatric patients, the pharmacy will compound the 24 hr supply of TPN for a patient based on the orders in the Pharmacy at 14:00 and these solutions will be delivered to the nursing unit by 19:30. Neonatal TPNs will be delivered by 1500. When a new TPN order is received after 14:00 for an adult or pediatric TPN, the pharmacist will contact the prescribing physician to determine when the order will need to be processed and if it can be scheduled for delivery the next day at 20:00. MEDICATION ORDER TURN AROUND TIME To prioritize the processing of new medication orders and to establish an appropriate turnaround time for these orders.The following turnaround times have been established: STAT: Stat orders are defined as emergency medications (medications that are needed only in life threatening situations) and so written by the prescribing physician. The physician should call a STAT order to the attention of the nurse so it can be taken off the chart immediately. Pharmacy can fill these orders in five(5) minutes if the order is called down and someone from the unit picks up the order. ASAP/NOW: ASAP or NOW orders will be written as such by the prescribing physician. These orders will be delivered to the nursing unit within 30 minutes from the time pharmacy receives the written order. Exception: Chemotherapy will be delivered within 2 hours from the time pharmacy receives the written order. ROUTINE ORDERS: Routine orders are all orders not written as STAT, ASAP or NOW. Routine orders will be delivered within two (2) hours from the time pharmacy receives them. SCHEDULED TIMES FOR MEDICATIONS Standard schedules for medication orders have been established when a specific schedule is not indicated on the medication order or pharmacy requisition. PROCEDURE: It is the responsibility of the physician, nurse and/or clinical pharmacist to indicate the appropriate time schedule for the drug on the order or pharmacy requisition. If a time schedule is not indicated on the order, the following schedules will be used: QD 0900 QHS 2100 BID 09-21 TID 09-15-21 TIDac 07-11-17 TIDpc 09-13-18 WITH MEALS 08-12-17 QID 09-13-17-21 Q12H 09-21 Q24 09 Q8H 09-17-01 Q6H 09-15-21-03* Q6H 12-18-00-06* Q4H 09-13-17-21-01-05 *These schedules are to be determined by when the order is received in the pharmacy and what the turn around time for the order needs to be. Special Schedules: Unit specific schedules will be limited to the following: 37 TID 09-13-21 27 BID 08-20   TID 08-12-20   QID 08-12-16-20   HS 20 46 Q6H 05-11-17-23   Q8H 06-14-22 QID verses Q6H schedules are not interchangeable and will be interpreted strictly as indicated above unless the clinical pharmacist suggests a different time schedule is more appropriate and indicates that schedule on the pharmacy requisition. If the prescribing physician does not want the standard time schedule he/she must indicate on the drug order the exact times the doses are to be administered. OUTPATIENT PRESCRIPTIONS Prescriptions filled in the KUMC Pharmacy must be written only on a KUMC prescription blank by the KUMC Medical Staff and the patient must be a patient of the Medical Center. Prescriptions for KUMC employees must also comply with these requirements. The Outpatient Pharmacy may fill a prescription from an outside physician only if for an employee or a dependent of an employee. Schedule II prescriptions must be written on green blanks. All other prescriptions, including Schedule III, IV and V are to be written on KUMC buff colored prescription blanks labeled "Not Valid for Schedule II Prescriptions". Prescriptions written by medical students must be countersigned by a staff physician. The outpatient pharmacy is open 8:00am – 7:00pm Monday through Friday and 9:00am – 3:00pm Saturday and Sunday and Holidays. REFILLS: Prescriptions may not be refilled unless the physician specifies the number of refills to be permitted in the lower left hand corner of the prescription blank, where the following is printed: "Refill ______ times". Prescriptions written at the Medical Center may be refilled in the Outpatient Pharmacy for not longer than one year for non-controlled drugs and 6 months or 5 refills for schedule III, IV and V Controlled Substances per Kansas State Law. Schedule II medications are not refillable and require a new written prescription for each dispensing. DIRECTIONS: Prescriptions written for outpatients must include adequate directions for the patient. The use of "Take as Directed" does not provide these patients with adequate directions on the prescription label to insure proper dosage. All prescriptions filled by the Pharmacy will be labeled with the name and strength of the medication. DISMISSAL PRESCRIPTIONS: Prescriptions for dismissal medications the patient wants filled at the KUMC Outpatient Pharmacy should be written on the Take Home Medication Form. The order form should be faxed to the Outpatient Pharmacy. The pink copy of the form will stay in the patient’s chart and the white copy is exchanged for the medications at the pharmacy. The Pharmacy cannot release the medications without the form. DISMISSAL PRESCRIPTIONS SHOULD BE WRITTEN 24 HOURS PRIOR TO DISCHARGE. The early writing of the dismissal prescriptions facilitates patient medication counseling by the Clinical Pharmacist. This also eliminates the patient having to wait for their prescriptions upon discharge. TELEPHONE PRESCRIPTIONS ORDERS: The Department of Pharmacy will accept phone-in prescriptions for KU patients and employees where federal and state law allows. The pharmacy cannot accept telephone orders for Schedule II drugs due to the Drug Enforcement Administration regulations restricting such activity. Phone-in prescriptions will not be accepted for routine dismissal prescriptions. CONTROLLED SUBSTANCES: All prescriptions written for controlled Substances (Schedule II – Schedule V) MUST be written by a physician possessing a Drug Enforcement Administration (DEA) registration number. All new staff must sign a signature card to be maintained in the outpatient pharmacy. All prescriptions written for Controlled Substances must bear the name and address of the patient, the current date and the DEA number. Refills on the Schedule II prescriptions are not permitted. INVESTIGATIONAL DRUGS The Investigational Drug Service at the University of Kansas offers a range of research activities to ensure the safe delivery of quality health care for patients participating in an investigational drug trial. Through supporting the Department of Pharmacy’s mission, this service assures appropriate procurement, storage, handling, drug accountability, and information access about the investigational agents utilized. The Investigational Drug Service also supports and complies with hospital policy, JCAHO, state and federal standards. The goal of this service is to assist and support investigators in meeting their obligations in conducting clinical drug research at the University of Kansas while promoting safe and rational therapy for the patient. The investigational drug service supports and promotes an interdisciplinary approach to patient care by offering its services to physicians, nurses, pharmacists and other health care providers at the University of Kansas Medical Center. The design of the study and the objectives of the investigator determine services needed by Investigational Drug Services. A fee for Investigational Drug Services will be based upon the level of involvement the service has within the clinical trial. The Investigational Drug Service can be reached at 588-2314 or e-mail address invrph@kumc. There is also a pharmacist on call 24 hours a day. EMERGENCY DRUGS AND CODE BLUE RESPONSE Each nursing unit or patient care area maintains a standardized Emergency Box containing emergency medications. The Emergency Box is on an exchange basis with the pharmacy. Once the tamper proof lock is broken, the Emergency Box should be returned to the pharmacy for the exchange of a complete Emergency Box. The complete contents of this standardized box are listed in the KUMC Formulary. There is a number of Code Blue carts located throughout the Medical Center. These carts also contain a standardized drug box with emergency drugs for use in resuscitation of patients. A pharmacist will respond to all Code Blue calls with a secondary drug box of medication to supplement the Code Blue cart medications. DRUG INFORMATION SERVICES The Department of Pharmacy offers an organized Drug Information Service to promote rational drug therapy by improving availability and use of drug information to physicians, nurses, pharmacist’s, dentists, dieticians and other health practitioners. The Drug Information Service maintains special journals, texts and reference sources designed to answer questions about the identification, availability, pharmacology, pharmaceutics, toxicology, stability, adverse effects, drug interactions, bio-availability and pharmacokinetics of various medications. The Drug Information Service is available to health practitioners from 0800 – 0600 Monday through Friday. Questions concerning drugs or drug therapy on an Inpatient Service should be directed to the Clinical Pharmacist by paging the pharmacist. If the Clinical Pharmacist is not available, or the request does not originate on the Inpatient Service, the request may be referred to the Drug Information Service by calling extension 2328. Other services provided by the Drug Information Service include publication of pharmacy newsletters for physicians, nurses and other health care personnel, evaluations of drug studies for the Pharmacy and Therapeutics Committee and coordination of the Adverse Drug Reaction Reporting Program. Drug Audit criteria that has been used in Patient Care Audits is available from the Drug Information Service as a source of rational prescribing information. The reference book, Drug Information – American Hospital Formulary Service is available on all nursing units to aid in answering less complex questions. The Micromedex7 Drug Information System is also available for use via the hospital computer system. Drug utilization reviews are routinely conducted by the pharmacy with P & T Committee approval. Generally, a particular drug, therapeutic class, or specific use will be targeted. For example, a recent drug utilization review focused on CDC Recommendations for the appropriate Use and Monitoring of Vancomycin. POISON CONTROL CENTER The Department of Pharmacy is also the site for the Mid-America Poison Center. The poison control center, established in July 1982, answers over 30,000 calls a year from health care professionals and lay public throughout the State of Kansas. Questions range from children accidentally ingesting a household product to suicides and environmental hazard The Poisindex and Identidex computerized date systems are among the many toxicology references utilized. The poison center is staffed by pharmacists specially trained in toxicology and also certified as Poison Information Specialists by the American Association of Poison Control Centers. In addition, various consultants are available in the following areas: medical, toxicological botany, herpetology, mushroom poisoning and industrial exposure. Information is available 24 hours a day, 365 days a year by dialing extension 6633. ADVERSE DRUG REACTON REPORTING To insure continued patient drug therapy safety and to fulfill the role of a major medical center in the promotion of good health care, all Adverse Drug Reactions (ADR) must be reported. The Pharmacy and Therapeutics Committee has defined an adverse drug reaction as any untoward reaction which is associated with drug therapy and meets any of the following criteria: Requires treatment with prescription medications Results in or prolongs patient hospitalization Results in permanent or temporary disability Results in patient death Requires reporting to the Food and Drug Administration These reports may include reactions already listed in the package insert. A causal relationship DOES NOT have to be established between the drug and the reaction, it may only be suspected. If the patient is on multiple drug therapy, the most likely agent or agents should be listed. Any physician, nurse, pharmacist or other health care professional identifying a POSSIBLE adverse drug reaction can file a report. An ADR report may be filed by telephone or by completing a form. 1) Phone – Call ext. 2328 and provide data regarding the reaction. A form will be completed by a Drug Information Pharmacist. 2) Form – Forms are kept on all nursing units and in recovery rooms. The time to complete a form is minimal. The patient’s addressograph, the name of the reporter and the name of the institution reporting the ADR is held confidential and protected from public disclosure. Completed forms should be given to the Pharmacy Department by placing them in the Pharmacist’s order bin on the nursing unit. Reporters can designate that the reaction should be reported to the FDA by checking the appropriate box. The more detailed FDA reporting form will then be completed by the Pharmacy Department.Any questions concerning ADVERSE DRUG REACTION reporting should be referred to the Drug Information Center (extension 2328)All adverse reactions reported are reviewed by the Pharmacy and Therapeutics Committee. AMERICAN SOCIETY OF INTERNAL MEDICINE PRESCRIPTION WRITING GUIDELINES The following guidelines are provided by the American Society of Internal Medicine and the American Pharmaceutical Association to guide prescribers in writing prescription orders. The name and strength of the drug dispensed will be recorded on the prescription label by the pharmacist unless otherwise ordered by the physician. Whenever possible, specific times of the day for drug administration should be indicated e.g. "Take one tablet at 8:00am, 12 Noon, and 8:00pm" is preferable to "Take one tablet three times daily". The use of potentially confusing abbreviations is discouraged (e.g., qid, qod, qd) Vague instructions which are confusing to the patient should be avoided (e.g., "Take as necessary" or "Take as directed"). The indication, symptom or intended effect for which the drug is being used should be included in the instructions whenever possible (e.g., "Take one teaspoonful at 9:00am, 1:00pm, 5:0pm and 9:00pm for cough"). Metric system measurements (mg, ml, etc.) should be used instead of outdated apothecary system measurements (grs,oz,etc.). A prescription should specify whether or not it is refillable. If so, the number of refills authorized should be indicated. Statements such as "Refill PRN" or "Refill ad lib" are discouraged. (State regulations limit the validity of any prescription to one year from the date of issuance). A separate prescription blank should be used for each drug prescribed. When hospital prescription blanks are used, the prescriber should print, as well as sign, his or her name, phone number and DEA registration number on the prescription blank. QUICK REFERENCE PHARMACY TELEPHONE NUMBERS Extension PHARMACY ADMINISTRATIVE OFFICES 2330 INPATIENT PHARMACY – 24 Hr. Service 2321 OUTPATIENT PHARMACY 2361 OUTPATIENT FAX LINE 2385 DRUG INFORMATION 2328 DRUG INFORMATION FAX 2350 MID-AMERICA POISON CONTROL CENTER 6633

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