ProcessingMedication Ordersand Prescriptions

Inpatient PharmaciesReceiving Medication Orders

hand-deliveredmechanical methodfax transmission or pneumatic tube

Computer physician order entry, or CPOEorders verified by pharmacist

Telephone orders by prescriber or an intermediarylegal restrictions

Upon Receipt 2 steps

review order for clarity & completenessprioritize the order

Ideal Medication OrderPatient nameHospital identification

#Room/bed locationGeneric drug nameBrand drug name* Route of administration Dosage formDose/strengthFrequency & duration

Rate & timeIndicationOther instructions Prescriber’s signature Printed name if

needed Credentials Pager number Date & time of order

PrioritizationPATIENT DISCOMFORT

initial treatment of pain, fever, or nausea & vomiting are generally high priority

Urgent orders are filled firstEvaluate by analyzing:

routetime of administrationtype of drugintended use of drugpatient-specific circumstances

Order Start Times STAT – immediately- an urgent need“Now” or “ASAP”“start today” or “start this morning”Has 1st dose of medication been given? (ER)Standard amount of time to process & deliver

ordertypical turnaround times in hospital

15 minutes for STAT order 1 hour for a routine order

Technicians use critical thinking skills to prioritize orders

Processing Medication OrdersIdentify patientCompare order with patient’s existing

medicationOrder entry steps

choose correct medication from databaseidentifying administration scheduleenter any special instructions

Medication must be selected, prepared or compounded, checked, dispensed for use

Patient ProfilePatient nameIdentification

numbersDate of birth/ageSexHeight and weightLab valuesAdmitting/2nd

diagnoses Room & bed number

Names of admitting & consulting physicians

AllergiesMedication history Special

considerationsClinical comments-

therapeutic monitoring, counseling notes

Selecting Drug Product Drug may be ordered by generic or brand

nameAbbreviations often usedLists of abbreviations that cannot be usedLook-alike & sound-alike drug strategies

store in separate locations additional labeling tall man letters (example: buPROPion –

busPIRone)

Drug SelectionMnemonic is code, associated with

medicationAmpicillin 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

Order ProcessingLabels generated upon order entry

IV label format different from unit dose tabletForm of medication

pediatricmeds through tubes (nasogastric tubes or

gastric tubes)Formulary considerations

Order ProcessingPharmacist input

consult pharmacist if any warnings appear Computer warnings:

interactionsduplicationsallergiesdosage rangediluent choices

may be standardized as defaults in computer systemFinal step-pharmacist verification of all orders

Medication Administration Times Administration time impacts:

drug efficacydiagnostic laboratory testingPharmacokinetic studies using administration

time in relation to lab test time to determine drug dose recommendation

Full stomach or empty stomach Standard medication administration times

Standard Administration Timesdaily = 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

resultsStandardized schedules of drug

administrationbased on therapeutic issues, nursing, pharmacy

MARMedication administration record Part of patient’s medical recordNurse documents when medication administered Standardized times appear as default entries on

MAR Default times may differ on some specialized units

“daily” may default to 0900physical rehabilitation unit

might require daily administration to occur at 0800

Scheduling ConsiderationsMust be aware of exceptionsPharmacists must consider other medications

ciprofloxacin & calcium carbonate must be spacedday or days of the weekimportant 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

Information SystemPhysicians’ orders are input into patient

profile in pharmacy information systemInformation used to generate:

MARsmedication profiles fill lists (for pharmacy use)labels for medications to be issued to patient

care areas MARs may be either paper or electronic

(eMAR)

Special Instructions Pharmacy instructions

notes between pharmacist/technicianclinical notes

Nursing instructionsstorage informationadministration instructionsphysician-specified parametersdisplayed on MAR & medication label

Sample Inpatient Order Entry Enter patient’s name/account number-verify pt Compare order to patient profile in detail Enter drugVerify doseEnter administration scheduleEnter any comments in clinical comments fieldVerify prescriber nameFill & label medication

Filling, Labeling, CheckingSend enough doses to last to next scheduled

delivery24-hour cart fill system common

Review label carefully against orderagainst product

Medication order is filled Pharmacist checks-legally required in most

casesTechnology-order images archived

Special Considerations “Charge-Only” & “No-Charge” EntriesPharmacist protocols Diagnostic preparation ordersComputer physician order entryAutomated dispensing technologyCentralized dispensing automationDecentralized automation

Outpatient PharmaciesReceiving Prescriptions

presented in persontelephoned in from prescriber’s officefacsimile electronic transmission

Refill requestsinternetphone

manual-uses person automated system

Payer Information Establish:

primary payer for prescriptionpatient’s portion of reimbursement

(copayment)drug formulary

Electronic claims adjudicationPrescription may be held until information

gathered

Clarity & Completeness Patient name Patient home address Date written Drug info

namestrengthdose

Directionsroute

Frequency & duration

Quantity to be dispensed

Number of refills Substitution (DAW) Signature/credentialsDEA # if required Prescriber’s info

name, address, phone indication (not

required, but recommended)

Dispense as Written (DAW)DAW= brand name drug written must be

dispensedSome 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

DAW codes0 = No product selection indicated1 = Substitution not allowed by provider2 = Substitution allowed- patient requested product3 = Substitution allowed- pharmacist selected product4 = Substitution allowed- generic drug not in stock5 = Substitution allowed- brand drug dispensed as generic6 = Override7 = Substitution not allowed- brand drug mandated by law8 = Substitution allowed- generic drug not available in

marketplace9 = Other

ForgeriesScreen prescriptions for controlled

substancesMay be fairly easy to identify

erasure or overwriting of strength or dispensing quantity of drug (changing 3 to 8)

More subtletheft of preprinted prescription padslegitimate-looking prescriptionstelephoned in to pharmacy

Other ConsiderationsLegibility problems & interpreting

abbreviationsPatient notification if

contacting prescriber medication is not in stock

Prioritizationorder in which presented to pharmacycommon-sense judgment

Patient Profile Patient’s name/identification numberDate of birth/ageHome address/telephone numbers AllergiesPrincipal diagnosesPrimary healthcare providersThird-party payer(s)/other billing informationOver-the-counter medication/herbal supplements Prescription & refill history Patient preferences

Prescription Entry Appropriate drug product selection

mnemonic alphabetical listingNational Drug Code (NDC) number

Directions for useFill quantityInitials of pharmacist checking prescriptionNumber of refills authorized

Primary Prescription Label (information may vary by state)Patient’s nameDate the prescription is being filled (or refilled)Prescriber’s nameSequential prescription numberName/strength/manufactureQuantity dispensedDirections for useNumber of refills remaining/associated refill period Expiration date Physical description of med if required by state law

Instructions for Use Administration directions (“Take,” “Insert,”

“Apply”)Number of units constituting one dose/dosage

formRoute of administrationFrequency Duration if applicable (“for 10 days,” “until

finished”)Indication if applicable (ex: “for pain” or “for

blood pressure”)

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 detailEnter drug Enter label direction mnemonic Enter comments Enter prescriber’s nameEnter amount to dispense/refill informationFill & label the prescription