prescribing & ordering medications asynchronous

Pharmacology Lecture 1

prescription

implies care is provided in the outpatient setting

medication order

implies care is provided in the inpatient setting

what are essential methods of communication between the prescriber and healthcare team?

prescriptions and medication orders

what are used as documentation resources for hospitals, offices, and pharmacies?

prescriptions and medication orders

prescriptions and/or orders can be written for

medications

labs

diagnostic procedures

medical equipment

glasses/contacts

what are the communication methods for prescribing?

written

verbal/phone

electronic

fax

written

on a prescription pad, given to a patient

what is a con of written prescriptions?

patient can lose the script

verbal/phone

transcribed by pharmacy staff immediately

electronic

automatically sent to the pharmacy through a computer system

this is the most common!

fax

sent directly to pharmacy from prescribing office

what are the elements of a prescription?

prescriber info

date of prescription

patient info

drug name, strength, formulation

quantity to dispense

directions for use

refills authorized

prescriber authorization

prescriber state or dea license

what do you need to include on a prescription if a generic substitution is NOT permissible?

“Brand Medically Necessary”

prescriber information

full name, license classification, address, phone number

what is a license classification?

PA, NP, MD, DO, etc.

date of prescription

when the script is written

this will dictate the expiration of the script

patient information

full name, DOB, address

drug name, strength, formulation

brand name or generic

concentration, mg, etc.

capsule, tablet, liquid, etc.

quantity to dispense

number of pills

amount of mL

etc

directions for use

the “sig”

PO, IM, IV, SUBQ, etc.

refills authorized

how many times the pt can get the medications again

prescriber authorization

signature

if written- needs to be a signature

if electronic- will automatically generate

prescriber’s state license number and/or NPI

DEA number IS required if medication is a controlled substance

what are the advantages to electronic prescribing?

1. streamlined documentation

2. has time stamps of when sent and received

3. decreased risk of loss of prescription or diversion

4. decreased interpretation error

   1. poor handwriting

what are the elements of a medical order?

date/time of order

name and strength of medication

dose

route

frequency

ordering prescriber’s name

what is assumed in a medication order?

therapy will be continued throughout hospital admission, unless otherwise noted with a stop date

how is a medication order made?

through a patient’s medical record during hospital admission

it is right in their chart/profile

a medication order is more ______ because ______

abbreviated; it is within a hospital system

what are the components of a medication regimen?

name of medication

strength/concentration

formulation

dose

route of administration

frequency

indication

example of a medication regimen

Amoxicillin 250 mg/5 mL suspension

Take 5 mL by mouth every 8 hours for 5 days

when do you need to include indication in a medication regimen?

should ALWAYS be included for “as needed” medications

so patients know when to take medications

what are the two common errors in writing a prescription?

1. omission of essential information

2. poorly written prescription

omission of essential information

missing a required element

• not enough information to identify correct patient or prescriber

• missing dosing regimen components

  • especially formulation

• missing quantity dispensed or refills authorized

• missing prescriber signature on written/faxed prescriptions

poorly written prescriptions

• confusing or unclear instructions

  • “take as directed” or “as needed” without indication

• illegible components of written prescription

BID

twice daily

TID

three times daily

QID

four times daily

Q_H

every _ hours

AC

before meals

HS

at bedtime

ODT

orally disintegrating tablet

PRN

when needed

GTT

drops

SUBQ

subcutaneous

IM

intramuscular

IV

intravenous

PO

by mouth

SL

sublingual

peds patients are ______ just a smaller version of adults

NOT

not a 1:1 ratio

considerations for peds

1. pharmacokinetic properties in infants and children are NOT The same as adults

   1. CANNOT just cut the dose in half, etc.

2. look for dosing recommendations

   1. often weight based

pediatric patient is defined as

12 and under

OR

17 and under

what are dosing recommendations for peds patients based on?

weight

considerations for pregnant patients

need to consider effect on pregnant pt AND the fetus

why do you need to consider the fetus when prescribing medications to pregnant patients?

bc the medication can cross the placenta

what must you ensure for all medications for pregnant patients?

teratogenic possibilities

what are teratogenic possibilities?

Teratogens are substances that cause congenital disorders in a developing embryo or fetus

what do teratogenic possibilities vary based on?

• physicochemical properties of drug

• rate/amount of drug crossing placenta

• duration of exposure to drug

• stage of fetal development at time of drug exposure

where to look for information on medication safety for pregnant & breastfeeding pts

• drug packet insert

• prescribing information

  • section 8

• NIH drugs & lactation database

  • LactMed

prescribing information (section 8)

8.1 pregnancy

8.2 lactation

8.3 females and males of reproductive potential

geriatric patients are defined as

65 +

considerations for geriatric patients

• physiological changes

• pill burden on patients

what are some physiologic changes in geriatrics?

• reduced body mass

  • increased body fat

• decrease in hepatic blood flow

  • decreases metabolism

• decrease in kidney function

  • decreases elimination

these can cause drug toxicity

pill burden

• regimen complexity or forgetfulness

  • as cognitive decline increases

• additive costs of medications

  • especially for patients with many comorbidities

safety considerations in geriatrics

• adverse drug reactions

  • 2 x more likely than younger population

Due to:

• many medications without cross referencing for interactions

• non-adherence

• increased self-medication

• reliance on caregivers

non-adherence

forgetting doses

forgetting medication instructions

self-medication

use of OTC and/or herbal products

resources for prescribing in geriatrics

• drug package insert

• prescribing information (section 8.5)

• american geriatrics society beers criteria

American Geriatrics Society Beers Criteria

published list of potentially inappropriate medications in older adults

listed drugs are not contraindicated BUT risk/benefit should be assessed

considerations for renal impairment

• decrease elimination rate of medication

  • increase risk of toxicity

• reduction of dose or frequency

• dose adjustments based on CrCl or eGFR

CrCl

creatinine clearance

CrCl and eGFR

measurements of kidney function

considerations for hepatic impairments

• decrease metabolism of some medications

  • can increase or decrease efficacy/risk of toxicity

• some medications need to be AVOIDED

• dose adjustments based on Child-Pugh Score

Child-Pugh Score

estimation of severity of liver damage

prescribing guidlines in PA

• expiration of prescriptions

• refills

when do non-controlled medication prescriptions expire?

1 year from date of being written

when do controlled medication prescriptions expire?

6 months from date of being written

how often can a non-controlled medication prescription be refilled?

there is NO limit

as long as script is within expiration date

can schedule II medications be refilled?

NO

can schedule III-V medications be refilled?

YES

up to 5 times until expiration date

controlled substances

drugs that have the potential for abuse, misuse, dependence

schedule I

NO acceptable medical use

cannot be prescribed legally

schedule I example

heroin, marijuana, THC, peyote

schedule II

high abuse potential that can lead to dependence

schedule II example

amphetamines, fentanyl, oxycodone, morphine

schedule III

moderate risk of abuse potential

schedule III example

testosterone, buprenorphine

schedule V

least abuse potential and contained limited quantities of controlled substance

schedule V example

pregabalin, acetaminophen with codeine

PDMP

prescription drug monitoring programs

what are PDMPs?

statewide online platform to help prevent and identify potential misuse of controlled substances

what do state PDMPs contain?

• what controlled substance medication are filled by a patient

• what prescriptions are filled

• how prescriptions are paid for

• what prescribers are writing controlled substance medications for the pt

• what pharmacies are dispensing controlled substance medications for the pt

when does a prescriber need to check the PDMP?

• a pt is prescribed a controlled substance by the provider for the 1st time

• at least once during time of pt admission BEFORE discharge, if prescribed controlled substance in inpatient

• anytime pt is on opioid or benzodiazepine

• if prescriber believes pt is misusing or diverting drugs

when does a pharmacist need to check the PDMP?

• must check before dispensing an opioid or benzodiazepine

  • is new to the pharmacy

  • chooses to pay cash for controlled substance

  • requests an early refill

  • has multiple prescriptions at more than one pharmacy

pharmacist’s role in inpatient

verify selection of therapy and dosing based on

-comorbidities

-concurrent meds

-labs

pharmacist’s role in outpatient

-identify drug interactions

-potential prescription errors

-assist with medication coverage or prior authorization

-EDUCATION

implementation challenges

lots of things can be a barrier

follow-up with pt to see how medication use is going, barriers to adherence, and any questions

interprofessional collaboration

allows for team-based approach

in-depth pt education

ISMP

Institute for Safe Medication Practices

where to report medication errors

ISMP or FDA MedWatch

MedWatch is used to report

unexpected side effects

adverse effects

product quality problems

preventable product use/medication errors

therapeutic failures