Studied by 25 people
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?
streamlined documentation
has time stamps of when sent and received
decreased risk of loss of prescription or diversion
decreased interpretation error
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?
omission of essential information
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
pharmacokinetic properties in infants and children are NOT The same as adults
CANNOT just cut the dose in half, etc.
look for dosing recommendations
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
