Hospital pharmacy part 2 part 2 Flashcards
There shouldn’t be a period following mg or ml because that could be misinterpreted as well
How do we write our medication dose…the CPOEs can have doses ready to go and prepopulate so the physician doesn’t need to type them or enter them but if they do need to free hand a medication sig we need to be paying attention intended meetings and making sure we are formatting the doses correctly so there always needs to be a zero before a decimal point so that we know its 0.5mg and not just 5mg but on the other hand we don’t want a trailing decimal point we write 1.0mg and mean 1mg and it can be easily mistaken as 10 mg for that reason we avoid trailing zeros but we always need a zero before the decimal point and there should always be a space between whatever dose that we are using and our mg or mL following it so that they are not blurred together and misinterpreted
PRN medications can be used in the outpatient setting but at that point its up to the patient to take the medication as needed for whatever indication that the provider is prescribing it for but on the inpatient setting these prn medication orders are followed by nursing so its nursing administering the medication to the patient as needed per the indication so PRN or as needed medication orders requires specific indications for administration and these indications should not overlap with another PRN medication with the same indication so we have some example of PRN or as needed medication
Give pt according to pt’s level of pain
Hospital Formulary it doesn’t dictate what a physician can order when a patient is discharged from the hospital it dictates what a physician can order within the hospital so any of the medications that are coming from the hospital pharmacy are dictated by hospital formulary so this hospital formulary is a list of the medication that the hospital has available
P and T committee meet regularly throughout the year sometimes once a month and then decide if medication should be added or removed from the formulary so medication is no longer available it might be removed from the formulary and if a new medication becomes available that may be a cheaper alternative or has better evidence behind it for its indication they would review those medications and see if its appropriate to add to the hospital formulary is continuously changing but generally has a set list of medications that are available so even if a medication is in the hospital formulary it doesn’t mean hospital pharmacy always has it in stock
Our hospital pharmacies do the best that they can and we do have every medication in our pharmacy in stock but if something is not there it also means that pharmacy has the availability to order that medication because it is on there formulary so it might be ordered and come in the next day and it could be started while the patient is still admitted might be a slight delay and its not readily available. If a medication is not on formulary so if a physician wants a particular medication ordered for there patient what does that look like
If pt comes in on an inhaler that the hospital doesn’t have because the hospital can’t have every medication under the sun we have therapeutic interchange so this is a list of P and T approved substitutions so it allows a pharmacist to automatically interchange the medication without contacting the provider so if the provider orders all the pt’s home medications right from there medication list but they are on an inhaler that the hospital doesn’t have…the pharmacist can automatically use this list of approved medications and go okay the patient was on a Flovent inhaler okay we don’t carry Flovent but this P and T list of approved substitutions says we can use Symbicort instead for this patient so it will have Flovent dose and an interchange to what dose the Symbicort at instead while the patient is in the hospital and the pharmacist can update this order automatically without needing to ask the provider for approval this commonly happens with inhalers because we cant always carry every inhaler specifically at Umass memorial this can be seen with proton pump inhibitors because we don’t carry every medication in the class we only carry 2 of them and then it also happens with OTC allergy medications because there are so many on the market nowadays but we only a couple of them on are hospital formulary and in hand on house
A patient that comes in on a home PPI that the hospital doesn’t carry because the hospital only carries pantoprazole so looking at this table take a minute to think about what the therapeutic interchange would be if the patient came in on omeprazole 40mg by mouth daily and the provider ordered this patients home medication and they ordered omeprazole 40mg by mouth daily….What are we going to interchange this to in the hospital that only carries pantoprazole and PPIs? Omeprazole 40mg PO daily and the automatic interchange that the pharmacist can do is pantoprazole 40mg by mouth daily
If pt came in with omeprazole 80mg PO daily and because its not an option on our P and T approved therapeutic interchange given example this means that the pharmacist cannot automatically interchange this medication and this dose of omeprazole for another strength of pantoprazole because its not on this therapeutic interchange policy
However what could be done is the pharmacist could make a recommendation to the provider using their clinical judgment so between omeprazole and pantoprazole so omeprazole 20mg by mouth daily is equivalent to pantoprazole 20mg po daily and it keeps going up by that stepwise so using our clinical judgment and checking our resources the clinical pharmacist could go okay we don’t have a therapeutic automatic interchange that I can do for you but I can recommend omeprazole 80 mg by mouth daily would be equivalent to pantoprazole 80 mg by mouth daily and if provider took that recommendation they could switch the patient from the omeprazole dose that they were on at home to the pantoprazole that is provided by the hospital pharmacy
If the medication is not on this policy the pharmacist CANNOT automatically interchange it you would need the providers _________ and a new ________ if its not part of this interchange policy
approval
a new order
Restricted medications are approved to be on the hospital formulary but they are restricted to certain pt population so this might be a cost saving measure or because not all providers are able to order this medication and it might be restricted to only ordering via a certain subset of providers and this is based on what the P and T committee approved appropriate for a particular medication so one of the medications that is frequently restricted are certain IV antibiotics and this is from an antimicrobial stewardship perspective as well as a cost perspective so example that we have as a restricted medication at my clinical practice site is meropenem (IV antibiotic) falls into the carbapenem class and this IV antibiotic requires prior ID approval to be used inpatient or in the hospital or if its order on off hours…pharmacist can put it through until can see pt the next day and this only to continue on this restricted antibiotic it requires ID approval so pharmacy would need to document that they received approval due to infectious diseases and this medication can be continued and for how long and this is a broad spectrum antibiotic that the hospital does not want any provider just ordering for any patient they want to make sure that its appropriate for that patient
Restricted medication:Cost saving measure to making sure our meds are being used appropriately
What if we dont have a medication that a patient really needs but its not on hospital formulary.. there’s no appropriate formulary alternative and this patient needs to continue this medication while in the hospital and this is what is called a nonformulary approval process for a nonformulary medication both provider and verifying pharmacist goes through approval process where pharmacist has to escalate it for approval by pharmacy management to continue this nonformulary medication in house
The hospital doesn’t carry non-formulary medications that is not being used in their hospital and there is two ways this can be mitigated and the hospital can use a patient’s own medication and use that in house verify label it and make sure it is what it says it is and give the nurse barcode scanning to be able to scan that patients own medication to be used in house or both of these processes need pharmacy management approval and the hospital can then purchase that nonformulary medication to give that patient while they are there to continue that patients home medication and this is what is being done more and more nowadays because there’s issues where being able to verify a home medication or medication that was not dispensed to a hospital pharmacy is what it says it is and especially on the formulation and making sure its not expired so for that reason the hospital going towards ordering these nonformulary medications on a case by case basis when they are needed
