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CHRISTUS HOSPITAL
ADMINISTRATIVE POLICY
TITLE: PHARMACEUTICALS: DISTRIBUTION AND DISPENSING
Date Adopted: 3/67
Date Revised: 10/06,4/07,6/07,8/07,11/08
7/11,12/11
Supersedes:
Date Reviewed: 4/07,6/07,8/07,11/08
7/11,12/11,8/12
______________________________________________________________________________
AFFECTED DEPARTMENTS: All

PURPOSE: To provide safe and effective medication therapy for the patients in this hospital.

POLICY: The pharmacist in charge, with the cooperation and input from the medical staff and
representatives from other departments when necessary, has established the following written
standards and procedures for intra hospital drug distribution.

PROCEDURE:
I.
Drug preparation and dispensing are performed by a licensed pharmacist, or a designee who is under the direct supervision of the pharmacist. A. Medications will not be dispensed, removed from stock or a dispensing cabinet without an order by a licensed practitioner. Orders are faxed, scanned or delivered to the pharmacy by dumbwaiter or nursing personnel. The order is reviewed by the pharmacist before the medication is dispensed or removed from a dispensing cabinet or stock, with the exception of instances as described under the stat or emergency policy under B. below or section X of this policy. B. If an order is received for a stat or emergency item, and a pharmacist is not immediately available, the technician may have another technician check his/her work and send the medication to the nurse. The pharmacist will review the order as soon as possible. This policy is only to be utilized when the patient’s life or wellbeing would be compromised by any delay, and only when the item is released in an original container or a prepackaged container which was checked by a pharmacist. The use of floor stock is allowed mostly through dispensing cabinets. The unit dose distribution system permits identification of the drug up to the point of administration, and is preferable to stock bottles or supplies on the nursing unit. Most drugs such as controlled substances and commonly used medications can be controlled as floor stock through use of automated dispensing cabinets or CDARS/Stock sheets or another document with similar requirements will be used to insure accountability. To add or delete items from stock in a medication area or in an ADM, the supervisor must submit a memorandum or e-mail with the items requested added or deleted. Concentrated potassium chloride, potassium phosphate and hypertonic saline will not be kept as floor stock anywhere in the system. The director of pharmacy will approve or disapprove items according to patient needs and ability to TITLE: PHARMACEUTICALS: DISTRIBUTION AND DISPENSING
Date Adopted: 03/67
Date Revised: 05/06,10/06,4/07,6/07,8/07
8/08,11/08,7/11,12/11
Supersedes:
Reviewed:
11/08,7/11,12/11,8/12
control the item (see policy on floor stock). Medications dispensed directly to patients will be kept in medication cassettes/bins that are either in the medication room. Cassettes/bins will be labeled with the patient name, and room number. Written policies and procedures necessary for patient safety and for control, accountability, and intradepartmental distribution of drugs are reviewed periodically, revised as needed and are enforced. Certain medications i.e. titrate drips, concentrations of some antibiotic IV piggy backs, irrigating solutions will be standardized when possible for use in the hospital All drugs are labeled in accordance with existing regulations, as well as good judgment concerning precautions/warnings. This label will include the name (generic if possible) strength, concentration, dosage form, amount/quantity, (liquid, suspension, tablet) lot number and expiration date (expiration time if less than 24 hours). If the medication is for an individual patient it will have the patient name, location and instructions or directions for use. Cautionary and/or any applicable accessory instructions will be added if necessary. This information will be the standard for labels. Discontinued medication is returned to the pharmacy. The nurse or other individual responsible for the patient at the time a discontinuation order is written is responsible for seeing that the medication, IV, or otherwise, is returned to the pharmacy for proper disposal and credit. This prompt return is also in the interest of patient safety, to avoid inadvertent administration of a discontinued medication by someone unaware of the new order to stop or change the order. A. Any medication discontinued or when patient is discharged will be credited in the automated dispensing cabinet it was withdrawn from; any remaining medications should be placed in a ziplock bag, clear plastic bag, or brown paper bag with a patient identification sticker affixed to that bag with a “C” written on that sticker and returned to pharmacy. B. All medications/containers shall be placed in a ziplock or brown bag (except for IV piggy backs) and returned to the pharmacy via dumbwaiter/tube system. C. Medications returned to pharmacy for credit will be credited to the patient through Outdated drugs, items with worn, illegible, or missing labels, are returned to the pharmacy as soon as discovered, to prevent errors, and to allow for proper disposition. In the event of a drug recall, affected items will be retrieved from patients in the hospital immediately. If recall instructions require contacting physicians and/or patients at home, prescription addresses and phone numbers will be used to contact the necessary individuals. The results of such action will be appropriately documented on back of the TITLE: PHARMACEUTICALS: DISTRIBUTION AND DISPENSING
Date Adopted: 03/67
Date Revised: 05/06,10/06,4/07,6/07,8/07
8/08,11/08,7/11,12/11
Supersedes:
Reviewed:
11/08,7/11,12/11,8/12
recall notice (or additional data sheets will be attached) and filed with that notice. Medical professionals will be contacted according to the Drug Recall Policy. If a physician writes an order for a medication to be relabeled for home use, a pharmacist will create an ambulatory care prescription, and will label the remainder of the medication in the container prescription and not charge the patient if the medication was started prior to discharge. Appropriate drug information for the patient will be sent with the relabeled container. Description of Inpatient Medication order processing: (Routing of a Physician’s Medication order through the pharmacy) A. Medication order writing guidelines: 1. A staff physician or practitioner working under the guidance of that physician will be responsible for writing medication orders. There will be a documented diagnosis, condition or indication for use of each medication ordered. The patient’s response to the medication will be monitored according to the clinical needs of the patient. This will include the patient’s own perception about side effects and when appropriate, the patient’s perceived efficacy of the medication. 2. Orders are written legibly. The prescriber will print if necessary. 3. Any medications that are on the look alike, sound alike list will be handled with extra precautions recommended for each drug listed. The list will be reviewed at least annually based on ISMP and current variance report data. Medications on this list should be ordered by generic name. 4. Orders are not to be written over a previous order. The old order will be cancelled and a new order written on another line. 5. Indefinite hold orders are not allowed. If an order is written to place a medication on “hold” there must be time frames, conditions or parameters which clearly indicate when to resume the medication order. If time frames, conditions and parameters are not known the medication must be discontinued and a new order written when it is time to be restarted. Pharmacists will not utilize the deactivate function to place orders on hold. The pharmacist will discontinue any “hold” order that does not specify when to resume the medication (indefinite “hold” order). A clarify/verify order will be entered requesting time frames, conditions or parameters be added to the order making it clear when to resume the medication (see XI. B. 2 this policy for clarify/verify process). 6. There will be no blanket “resume” or “reinstate” medication orders. Each medication should be resumed individually 7. Orders to taper medication doses will be written specifically for each dose and schedule as it descends to the next until the medication is discontinued. 8. There will be no standing orders used in the hospital. Preprinted order sets may be used. These orders will be initiated by a physician order. 9. Orders written to titrate medications will be administered according TITLE: PHARMACEUTICALS: DISTRIBUTION AND DISPENSING
Date Adopted: 03/67
Date Revised: 05/06,10/06,4/07,6/07,8/07
8/08,11/08,7/11,12/11
Supersedes:
Reviewed:
11/08,7/11,12/11,8/12
to the physician order in each case. Practitioners will write titrate orders in a manner that increases or decreases the dose to achieve the desired response or patient status. 10. Orders written for compounds not available on the market will be prepared for dispensing if the ingredients are USP or NF grade chemicals, or FDA approved ingredients, and are ordered in acceptable concentrations for the type of patient and condition for which the compound is to be used. Pharmacists are to use professional judgment on all orders for compounds. If there is any question about the safety or effectiveness of the product, the physician will be contacted. 11. The hospital official abbreviations will be used when writing medication orders. 12. The metric system will be used for weights, volumes and units. For numbers less than one a preceding 0 will be used before the decimal. For numbers more than one, a following decimal and 0 will not be used. 13. The following essentials will be included in medication orders: a. Name of patient b. Room number and/or patient number c. Name of drug (generic or trade) d. Strength, dose or concentration of drug. There will be no requirement for medication orders to be weight based for dosing, however pharmacists will calculate doses that are ordered by weight or square meters. The dose of a drug with a narrow therapeutic index (high risk/high alert) ordered by patient weight, will be calculated by a pharmacist prior to order entry. Neonatal and pediatric drugs ordered by patient weight will be calculated by pharmacists prior to order entry. Chemotherapy ordered by body surface area or patient weight will be calculated by two pharmacists prior to order entry. f. Frequency of administration g. Indication if a prn order and generic name if required on look/alike sound B. Order arrives in pharmacy by one of 6 methods: CPOM (computerized physician order management) dumbwaiter, fax equipment, scan equipment, delivered via courier, or delivered to Pharmacy by nursing personnel. If the faxed copy is not legible, the pharmacist must ask the nurse to send a direct copy of the physician’s order. If the order copy is not legible, the physician must be contacted for clarification. 1. When essential elements are left out of medication orders, the order is not legible, or the order is pending lab results or a consulting physician’s approval, the pharmacist will contact the nurse and ask that the order be clarified or follow up orders be scanned to pharmacy when lab results or a physician’s approval is received. The nurse will call the physician as soon as possible (depending on the urgency of the order). The clarification will be added to the order or the order will be rewritten and faxed/scanned to pharmacy. 2. Pending clarification of the order, a “clarify/verify” transaction will be TITLE: PHARMACEUTICALS: DISTRIBUTION AND DISPENSING
Date Adopted: 03/67
Date Revised: 05/06,10/06,4/07,6/07,8/07
8/08,11/08,7/11,12/11
Supersedes:
Reviewed:
11/08,7/11,12/11,8/12
a. The pharmacist will enter an order for a formulary item called “clarify/ verify”. The start time will be an appropriate time in the future. b. This will cause the “clarify/verify” item to be timed in the nurse scan system, or medication administration record where the order cannot be forgotten. c. The pharmacist will enter a note on the medication description line and in the label comments box during computer order entry briefly stating what is needed for the order to be complete. d. When the physician makes the correction, the order is received, and the issue is clarified, the pharmacist making the entry will discontinue the corresponding “clarify/verify” order. e. When orders for “stat” items are called for or a nurse requests a “stat” item at a pharmacy or satellite window, the medication may be dispensed prior to order review, however, a “clarify/verify” transaction will be carried out to ensure follow up with a written order. f. Any order in a satellite pharmacy that is pending prior to the closing of the satellite will be resolved prior to the closing of the satellite. Pending orders will not be left for central pharmacy to resolve. g. Pending orders in central pharmacy will be resolved prior to that pharmacist leaving. In the event the order cannot be resolved prior to the end of the shift, a report of the pending order will be passed on to a pharmacist on the next shift. The order will be left, with appropriate notes on actions needed, in the pyxis connect queue for the oncoming pharmacist. Information on all pending orders will be obtained and orders completed as soon as possible. 3. Two patient specific identifiers must be used as the first step in the order entry process. In the computer system, the patient number and name will both be used to assure orders are being entered on the correct patient. If the patient number is not available, the date of birth should be used. 4. If a 'prn' order is written without a time and it is for a dangerous drug (one that may cause harm to the patient if given too soon after the previous dose, i.e. vasotec injection, inderal injection, apresoline injection, metoprolol injection, trandate injection, clonidine, and others, do the following: a. Pharmacist- Call the nurse and ask him/her to contact the physician for a time b. Pharmacist- Dispense one dose until the frequency time is obtained by the nurse (enter initial order as a "one time"). c. The nurse will contact the physician, fill in the missing information for the order on the communication form, apply a patient label to the form, fax it back to pharmacy. The nurse will attach the original communication form to the physician's order in the chart. d. Pharmacist- Enter the order with the time frequency included, attach the communication form to the copy of the physician's order and file. TITLE: PHARMACEUTICALS: DISTRIBUTION AND DISPENSING
Date Adopted: 03/67
Date Revised: 05/06,10/06,4/07,6/07,8/07
8/08,11/08,7/11,12/11
Supersedes:
Reviewed:
11/08,7/11,12/11,8/12
a. If a pharmacist feels that a drug order may cause harm to a patient if followed, the patient’s chart, nurses and other pharmacists may be consulted for their opinions. If the pharmacist is not comfortable with the consults, the physician writing the order should be contacted by the nurse. If the nurse is not comfortable discussing the issue with the Physician, the pharmacist must contact the physician to resolve the matter. b. After contacting the physician, the pharmacist is still not comfortable with the order and the physician will not change it, the following individuals will be contacted: (2.)The Director of Pharmacy or his/her designee (3.)The administrator on call c. If the physician still insists on having the medication order carried out, he/she will assume full responsibility for the administration of the drug and the pharmacist will complete a variance report with the details. 6. When writing orders and labeling medications, the metric system will be used. The use of leading decimal points will be avoided. 7. When physicians or practitioners enter orders using computerized provider order management (CPOM), the provider will enter the order and review the order for appropriateness against the e-MAR or MAR. The order entered will then be routed to pharmacy as unverified and will then be reviewed against the pharmacy patient profile by a pharmacist (see E. below). If the order is appropriate for the patient, with correct pneumonic for dose ordered, correct package size for billing, the pharmacist will verify the CPOM entry. C. The orders are prioritized by the pharmacist with IV orders receiving prompt attention. Orders, messages for redispensing PRN items, or refill orders are all placed in an area where they can be easily located if questions arise prior to dispensing. Stats are processed first, nows and IV admixtures are second priority, others are processed in order of receipt. Stats should be available for administration within 15 minutes of when the order was scanned or faxed to pharmacy or sooner if stored on the nursing unit in ADM’s. Nows should be available within one hour. All other medications within four hours (depending on when the dose may be due). D. Pharmacists may document interventions through the computer system. Interventions types may include: 1. therapeutic drug monitoring 2. drug information 3. antibiotic therapy follow up 4. dose/route/frequency adjustments 5. potential adverse drug reaction, contraindication review 7. potential drug interaction review 8. therapeutic duplication 9. Interventions may be communicated to physicians via communication cards or verbally as needed. The communication card will not become part of the patient record. TITLE: PHARMACEUTICALS: DISTRIBUTION AND DISPENSING
Date Adopted: 03/67
Date Revised: 05/06,10/06,4/07,6/07,8/07
8/08,11/08,7/11,12/11
Supersedes:
Reviewed:
11/08,7/11,12/11,8/12
E. The computer system provides a patient profile that includes the patient name, age, sex, allergies, sensitivities, height and weight, diagnosis, pregnancy and lactation status, lab results, and medications. Prior to order verification, the pharmacist is to review the profile for allergies, food, drug or lab interactions, appropriateness of the medication (variation from approved indications), dosing, frequency, route of administration, therapeutic duplication, other contraindications and potential sensitivities. If there are problems the physician will be contacted and a record made in the profile of the physician's response. F. A sufficient quantity of medications is sent to meet patient needs as determined by the computer system during order entry or by the order entry pharmacist. Items ordered “PRN” are sent in an appropriate quantity (indicated by pharmacist order entry). Intravenous solutions, if medication stability is sufficient, are sent to last through 1600 (or assigned time) the next day. The technician and pharmacist checking the final product will initial the label for accountability and follow-up. If the medication is being dispensed to a pediatric or neonatal patient two pharmacists will check the drug and initial the label. The computer label will provide the patient name and room number, and directions for use. Auxiliary labels and cautionary statements will be provided as needed. IV and TPN label information is specified in the pharmacy TPN policy and IV admixture policy. 1. When a patient is admitted with home medications to be taken while in the hospital, an order must be written for the medications to be entered 2. These orders will be subject to the same rules spelled out in this policy. 3. If the medication is not stocked by the pharmacy and a physician orders a patient’s own home medications be administered the physician must write “may continue own home med” in the order. These medications will be entered as a “med demand” (MEDD) order type which will create a scheduled dose on the medication administration record. The name of the medication will be in the medication description line. Add “home med” to the end of the medication name and strength. Under “label comments” enter “patient may take own home med”. H. A file is started for each patient receiving TPN Therapy. The original order and subsequent orders to change TPN’s are filled together. The pharmacist entering the original order and each subsequent change is responsible for maintaining the file. Calculations are to be written on each order. The calculations and order entry are to be verified as correct by the pharmacist prior to admixture of the solution. A final check made by the pharmacist assures that the correct ingredients were added. The pharmacist and technician signs the label to be affixed to the bag to verify accuracy of mixing. I. For “Routine Orders”, only the items underlined, checked, or by some means flagged for pharmacy by the nurse, will be acted upon in general, (referring to PRN orders). A non-PRN order need not be flagged, since its presence on the routine order sheet implies it is to be processed. Also, if an order only contains one item and it is TITLE: PHARMACEUTICALS: DISTRIBUTION AND DISPENSING
Date Adopted: 03/67
Date Revised: 05/06,10/06,4/07,6/07,8/07
8/08,11/08,7/11,12/11
Supersedes:
Reviewed:
11/08,7/11,12/11,8/12
apparent to the pharmacist that it is indeed needed, the order will be filled, underlined or not. PRN’s are entered into the patient’s profile and are not sent until requested. J. An order is needed to change oral medications to IV or injectable, rectal, and sublingual or vice versa. The nurse may not make these types of changes without an official physician’s order. K. Medications are delivered to nursing units/medication areas via several 1. Dumbwaiter or tube system (depending on which the dispensing area has) except for controlled substances, chemo, or home medications. No TPN Solutions, solutions over 1000ml in volume, or any containers that may leak will be sent via tube. When sending glass in the tube, containers must be padded to avoid breakage. 2. Couriers may be used when the above methods of delivery are down, or L. Refills, or “Re-supply” orders for medications are issued in a number of ways depending on the nature of the item: 1. Standard Meds: 24 hour supply delivered each morning between 0700 and (the original number 2 and 3 deleted “prn and bulk replace dose”) 2. IV Solutions: A list of IV Therapy shown to still be active is run early in the morning. The pharmacist will edit the list and request labels for the next 24 hour period. IV’s will be prepared for the next 24 hours (if stability permits) and delivered to the refrigerator or med area on the nursing unit. M. A pharmacy technician will refill meds for in patient nursing areas of the hospital daily. A pharmacist will check meds for each nursing area daily to determine accuracy. N. Orders for items to be left at bedside, or to go home with the patient, are labeled for outpatient use prior to being sent to the patient. The labeling will be the same as required for any outpatient prescription As stated in the process above, the pharmacist will review physicians orders prior to dispensing medications, with the exception of situations where time does not permit or when a licensed independent practitioner (LIP), with appropriate clinical privileges, controls prescription ordering, preparation and administration of the medication. These instances may be for first doses, emergent or urgent situations (as defined by the LIP) or instances where waiting on a pharmacist review may be detrimental to patient care. In these situations, the prescriber/orderer must remain in the area where the medication is being ordered, dispensed and administered, and will provide input if questions arise. XI. After hours procurement in dispensing areas that close. A. Automated dispensing cabinets will provide the great majority of B. If a dispensing area is closed and medications are needed: TITLE: PHARMACEUTICALS: DISTRIBUTION AND DISPENSING
Date Adopted: 03/67
Date Revised: 05/06,10/06,4/07,6/07,8/07
8/08,11/08,7/11,12/11
Supersedes:
Reviewed:
11/08,7/11,12/11,8/12
1. Non-pharmacy personnel will not have access to controlled substances Those must be obtained from another automated dispensing cabinet. 2. No after hours access to a pharmacy by non-pharmacy personnel is permitted. 3. A night locker ADM unit will be utilized for access by authorized nursing associates to obtain additional medications that are not readily available in other pyxis units on each campus (see list of override medications and authorization charts in the administrative policy: “Use of Automated Dispensing Cabinets”). 4. The pharmacist on call should be contacted for urgent medications that are not available in ADM on a unit or the night locker ADM. An urgent medication is defined by the medical and dental staff as a drug immediately necessary for therapeutic management of a condition where a delay in this therapy may cause significant clinical decline or otherwise unacceptable outcomes in the patient. Non-urgent medication orders will be held until the pharmacy reopens. An order is required for any medication taken from an ADM or night locker ADM. If it is an urgent situation, after hours, authorized nurses will be able to over ride the ADM or night locker ADM and obtain the urgent medication. A secondary verification by another individual will be required to prevent medication retrieval errors. The pharmacist is to review all such orders for appropriateness, the next morning, as soon as the dispensing area opens. 5. If the nurse has a question about the order it may be faxed to a dispensing area that is opened 24 hours for pharmacist review. The nurse may call the opened dispensing area and discuss the order with the pharmacist. 6. A pharmacist on call will report to the closed dispensing area if a TPN, or unusual XII. Furlough medications: If a patient is granted permission by his physician to leave the hospital for a period of time, but not be discharged from the hospital, a supply of meds may be filled as an outpatient prescription at the Hospital Pharmacy. Only active orders will be dispensed. Each medication issued in this fashion will be considered a separate prescription, and will be labeled in accordance with the provisions of all outpatient prescriptions. In any event, the supply of meds issued is not to exceed the expected time of the furlough. XIII. Controlled substances, floor stock, and outpatient order processing are addressed, in detail, in separate policies or sections of this policy. XIV. Daily MAR corrections and allergy reports are to be filed with accompanying orders in a plastic box in the new order processing area. After 7 days they are placed in a file cabinet for 30 days. They are then discarded. XV. Prescribing practitioners may, within their discretion at the time of prescribing, approve or disapprove the dispensing of a nonproprietary drug or the dispensing of a different proprietary brand to their patients by the pharmacist. The physician may TITLE: PHARMACEUTICALS: DISTRIBUTION AND DISPENSING
Date Adopted: 03/67
Date Revised: 05/06,10/06,4/07,6/07,8/07
8/08,11/08,7/11,12/11
Supersedes:
Reviewed:
11/08,7/11,12/11,8/12
communicate this option to the pharmacist by writing the words “Brand Medically Necessary” and the name of the drug requested. XVI. Medications are prepared under proper conditions: A. Work Counters are free of equipment, supplies and other items unrelated to preparing a given medication. B. Work surfaces are clean. C. IV hoods are periodically inspected for operational effectiveness. D. Aseptic technique is used in IV compounding (See IV policy) E. IV preparation areas are separate from other areas (see IV policy). F. Cytotoxic meds are prepared using protective clothing and under appropriate chemo hoods (see IV policy and Chemo policy).

APPROVAL:
Regional Director of Pharmacy
Signature: _______________________
Medical Staff
Signature:
Executive Leadership:
Signature:

Distribution Date:

Source: http://www.christushospital.org/workfiles/MedicationOrdering.pdf