https://medica-musc.researchcommons.org/musc-ptupdate/1022/thumbnail.jp

Berensen, Nannette M.

Bush, Paul W.

Davis, Kelli L.

MacFall, Holly M.

Medical University of South Carolina

Moorman, Krystal L.

English

MEDICA@MUSC (Medical University of South Carolina)

Medical University of South Carolina MEDICA Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals 5-1-2006 Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals Medical University of South Carolina Paul W. Bush Medical University of South Carolina Nannette M. Berensen Medical University of South Carolina Kelli L. Davis Medical University of South Carolina Holly M. MacFall Medical University of South Carolina See next page for additional authors Follow this and additional works at: https://medica-musc.researchcommons.org/musc-ptupdate Recommended Citation Medical University of South Carolina; Bush, Paul W.; Berensen, Nannette M.; Davis, Kelli L.; MacFall, Holly M.; and Moorman, Krystal L., "Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals" (2006). Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals. 23. https://medica-musc.researchcommons.org/musc-ptupdate/23 This Newsletter is brought to you for free and open access by MEDICA. It has been accepted for inclusion in Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals by an authorized administrator of MEDICA. For more information, please contact medica@musc.edu. Authors Medical University of South Carolina, Paul W. Bush, Nannette M. Berensen, Kelli L. Davis, Holly M. MacFall, and Krystal L. Moorman This newsletter is available at MEDICA: https://medica-musc.researchcommons.org/musc-ptupdate/23       Pharmacy & Therapeutics   Update       Drug Information        for Health Care Professionals                                    May 2006   MUSC MEDICAL UNIVERSITY  OF SOUTH CAROLINA   Drug Information Center Medical University of South Carolina Department of Pharmacy Services Charleston, South Carolina     Editorial Staff  Paul W. Bush, PharmD, FASHP Director, Department of Pharmacy Services  Nannette M. Berensen, PharmD, BCPS Manager, Drug Information Center Editor  Kelli Davis, PharmD Drug Information Specialist Associate Editor  Holly M. MacFall, PharmD, BCPS Drug Information Specialist Associate Editor Newsletter Layout  Krystal Moorman, PharmD Drug Information Practice Resident Assistant Editor   In This Issue   • Medication Error Prevention Strategies in the Pediatric Population   • Did You Know…  • Prescribing Restricted Formulary Medications: How You Can Help Us Help You  • Dexmedetomidine Guidelines for Use  • Formulary Update Medication Error Prevention Strategies  in the Pediatric Population By Elisabeth Mouw, PharmD Pharmacy Practice Resident Pediatric patients often require medication therapy during their childhood and require special consideration because they are at an increased risk for medication-related errors.1-8  Young children have less developed communica-tion skills compared with adults, which impedes feedback to health care professionals about potential adverse effects or mis-takes in medication administra-tion.5 In addition, children are less likely to ask health care pro-fessionals about their care.4   Pediatric patients may be up to      3 times more likely than adult patients to experience a medica-tion error.2  Pediatric patients are most likely to experience medi-cation errors due to health care professionals being unfamiliar with pediatric dosage forms and weight-based dosing.2,4  The medication use cycle in-cludes prescribing, transcription, preparation, dispensing, admini-stration, and monitoring.2  The most commonly reported errors are the administration of an in-correct dose or incorrect fre-quency, the administration of an inappropriate medication for the condition being treated, the pre-scribing of the wrong route of ad-ministration for a medication, and failure to perform follow-up monitoring for adverse reactions and drug interactions.2  The lack of information regarding pediatric doses and dosage forms may also increase the risk of errors.2   Some strategies to help reduce medication errors include stan-dardizing order forms with weight-based dosing and allergy information as required compo-nents of the order.  Standardizing weight measurements (ie, only expressing body weight in kilo-grams) across the organization decreases confusion regarding weight-based dosing.2  MUSC or-der forms may be accessed at www.musc.edu/cce/ORDFRMS/.  In addition, by encouraging em-ployees to report errors, more de-tailed information can be obtained regarding pediatric medication errors, and better policies can be Pharmacy & Therapeutics Update   Page 2 developed and implemented.2,4,7 Medication errors occurring at MUSC should be reported on the Patient Safety Net (PSN) Website which can be accessed using the UHC PSN icon located on every LYNX workstation.  Prescribers should be encouraged to write legibly using unambigu-ous language.2,4  Orders for pedi-atric patients should be written based on weight, and prescribers should ensure that the prescribed dose does not exceed the usual adult dosage.2  In addition, pre-scribers should ensure that they are using the patient’s current weight when writing orders.2  Be-cause medication errors are most likely to occur when orders are written for intravenous fluids, or-ders should be written to include dose and volume, as well as quan-tifying additives per liter, and also including the rate at which the so-lution is to be administered.2  All instructions should be written out to eliminate confusion and vague instructions.  Institutions should establish prohibited abbreviations, and all orders that are written us-ing these abbreviations should be clarified.2  Prescribers should avoid the use of terminal and lead-ing zeroes.2  For example, orders for 5 milligrams of a medication should be written as 5 milligrams as opposed to 5.0 milligrams.2  The use of terminal zeros may lead to a pharmacist misinterpret-ing the order as 50 milligrams, resulting in a 10-fold overdose.2  The names of medications should be spelled out and not abbrevi-ated, and generic names should be used in place of brand names.2  Physicians should also be required to print their name along with a signature and contact number.2 The MUSC policy regarding medication orders may be ac-cessed at www.musc.edu/medcenter/policy/Med/C78.pdf, and the policy regarding prohib-ited abbreviations may be ac-cessed at www.musc.edu/medcenter/policy/Med/C21.pdf.  Pharmacists working in chil-dren’s hospitals should ensure that all medication orders are written according to organiza-tional guidelines.2,4  Pharmacists can work with prescribers to help ensure that all medications ordered are in an easy-to-administer dosage form and that there are no cross-sensitivities with allergies or interactions with pre-existing medications.2   In addition, all orders requiring calculations should be rechecked for accuracy, and all confusing orders should be clarified.2  Studies have shown that errors are less likely to occur when a clinical pharmacist is present on rounds or is involved in dosing medications.2,7  Pharmacists can also be involved with medication histories and discharge counsel-ing to help ensure that parents are familiar with pediatric medi-cation administration.2,4,8    Nurses are usually the last step in the medication use cycle be-fore the medication reaches the patient.  The nursing staff should be encouraged to recheck all pre-vious calculations and verify all medication orders before admin-istering medications to the pa-tient.2  In addition, nurses should frequently consult with parents to ensure that all questions are answered regarding medication therapy.2,4 Technology can play a significant role in decreasing medication er-rors. Some examples include com-puterized prescriber order entry, computerized medication admini-stration records, automated phar-macy systems, bar-coding, “smart” intravenous devices, and computerized discharge prescrip-tions and instructions.5  Through instituting policies and procedures, integrating technology appropriately into the organiza-tion, and continued training, medi-cation errors in pediatric patients can be reduced.  Did You Know... Acute phosphate nephropathy as-sociated with the use of oral so-dium phosphates (OSP) (eg, Fleet®  Phospho-soda®) for bowel cleansing has been reported by the Food and Drug Administration.  Individuals at increased risk of acute phosphate nephropathy in-clude those of advanced age, those with kidney disease or decreased intravascular volume, and those using medications that affect renal perfusion or function.  Use of OSP in patients with kidney disease, impaired renal function or perfu-sion, dehydration, or uncorrected electrolyte abnormalities should be avoided. Also, the recom-mended doses of OSP should not be exceeded, and the concomitant use of laxatives containing sodium phosphate should be avoided. Pa-tients should be adequately hy-drated during bowel cleansing, and baseline and post-procedural laboratory values should be evalu-ated in patients at risk for serious adverse events. Page 3 Pharmacy  & Therapeutics Update The  Pharmacy   and  Therapeutics  Committee recently approved the following actions that became ef-fective May 15, 2006: Formulary Update Additions: Acamprosate (Campral®) 333-mg enteric-coated tablets   Additions with Restriction: Suboxone® 2/0.5- and 8/2-mg sublingual tablets   Palifermin (Kepivance™) 6.25-mg vials   Deletions: Urokinase (Abbokinase®) 9000- and 250,000-IU injections   Streptokinase (Streptase®) 250,000-, 750,000-, and 1,500,000-IU injections   Lipisorb® nutritional supplement 8-oz cans   Vasocon-A® 0.5-oz ophthalmic drops   Accuzyme®  Spray 33-mL bottles   Line Extentions: Risperidone (Risperdal® M-Tab®) 3- and 4-mg orally disintegrat-ing tablets   Accuzyme® Ointment 6- and 30-g tubes   Temporary Product  Replacement: Perflutren lipid microspheres (Definity®)  2-mL vial   Change in Restriction: Dexmedetomidine (Precedex®)  2-mL vials [100 micrograms/mL] Dexmedetomidine (Precedex®),  is a relatively selective alpha2 agonist with sedative properties. This medication is significantly more costly than similar alterna-tives (eg, propofol, midazolam).   An interdisciplinary group was convened to develop guidelines for appropriate use of dexmede-tomidine. The group was led by Holly MacFall, PharmD, and consisted of Alice Boylan, MD; Julio Chalela, MD; Jack Crum-bley, MD; and Susan Harvey, MD. Frank Mielck, MD; Joel Cochran, MD; Fred Tecklen-burg, MD; and Sally Webb, MD, were also consulted during the development of the guidelines. The guidelines are printed on page 4 and are posted online at w w w m u s c . e d u /pharmacyservices/medusepol/DexmedetomidineGL.pdf. Dexmedetomidine The Pharmacy and Therapeutics Committee recently approved standardized scripting for physi-cians to use when writing orders for restricted formulary medica-tions.  By using standardized wording, physicians will improve the efficiency with which a phar-macist can process an order for a restricted medication.  Scripting of orders for restricted formulary medications will also assist the pharmacist processing the order to determine whether the intent of the restriction is met.  An addi-tional benefit is that fewer tele-phone calls will be made by phar-macists to physicians for order clarification. The following exam-ples illustrate the use of scripting orders for restricted formulary medications.  Approved scripting appears in boldface.  An internal medicine physician (Dr. Barton) wants to prescribe linezolid for a patient on 8 West. The formulary restriction on line-zolid specifies that when it is used outside of an intensive care unit, a consult must be obtained from an attending or fellow on the infec-tious diseases service.  The order that Dr. Barton writes is as fol-lows: linezolid 600 mg, IV, Q12H, verbal approval obtained from Dr. Cantey on ID Consult Service concerning formulary restriction.    A pediatrician (Dr. Noyes) wants to prescribe meropenem for a pe-diatric patient who weighs 22 kilograms.  The formulary restrict- Prescribing  Restricted   Formulary Medications:  How You Can Help Us   Help You ion on meropenem specifies that this agent may be used in pa-tients with cystic fibrosis.  The order that Dr. Noyes writes is as follows:  meropenem 440 mg, IV, Q8H (60 mg/kg/day), pa-tient has cystic fibrosis con-cerning formulary restriction.  Physicians who prescribe re-stricted formulary medications are asked to use the approved scripting.  The Medical Center Formulary System Policy C-82 has been revised to reflect this practice. Formulary restrictions are noted in the electronic for-mulary, and an alphabetic listing is available at www.musc.edu/pharmacyservices/DI/restricts.pdf. Pharmacy & Therapeutics Update   Page 2  e 4 MUSC Dexmedetomidine (Precedex®) Guidelines for Use  Prescribing is restricted to physicians with deep sedation privileges or attending-level physicians and fellows practicing in a critical care setting or anesthesiology.   Dexmedetomidine may be used for the following indications in adult patients, for no greater than 24 hours.1  Generally initiate a loading dose of 1 microgram/kg over 10 to 30 minutes (consider longer load [ie, 30 min-utes] for patients ≥ 65 years of age).  A loading dose should be followed by a maintenance infusion of 0.2 to 0.7 micrograms/kg/hr.  Dose reductions should be considered in patients with renal or hepatic impairment.  ‡Sedation of initially intubated and/or mechanically ventilated adult patients in the ED, OR, or ICU with an absolute or relative contraindication to propofol, benzodiazepines, and/or opioids (eg, hypersensitivity, hypertriglyceridemia) 1  ‡Awake craniotomy in adult patients 2-8  ‡Extubation of ICU and post-operative adult inpatients in an ICU or PACU when unable to wean using propofol, benzodiazepines, or opioids or when they are contraindicated  9-19  ₤Sedation prior to ECT in adult patients with a history of postictal agitation 20  ‡Intubated and nonintubated adult neurology patients, in an ICU, requiring sedation and fre-quent neuroassessment when other short-acting titratable sedatives are contraindicated or inef-fective 8, 13, 21-25     ‡Awake fiberoptic intubation 26-29 or ₤bronchoscopy in adult patients with difficult airways whose comorbidities may increase risk for developing hypoxemia and/or hypercapnia during intubation and/or patients in which hypoxemia and/or hypercapnia could significantly increase morbidity or mortality (eg, head trauma, history of sleep apnea, morbid obesity)  ‡Bariatric surgery in adult patients (immediate postoperative period only) 30-37  ‡Sedation or agitation in pediatric patients in an ED, OR, PACU, ICU, or radiology with an abso-lute or relative contraindication to propofol, benzodiazepines, chloral hydrate, and/or ketamine (eg, hypersensitivity, sedation failure, respiratory depression, paradoxic agitation) provided ap-propriate monitoring is in place 38-40  ‡Literature to support dexmedetomidine use ₤Lack of literature to support dexmedetomidine use   Level of sedation using SAS Blood pressure every 5 minutes for first 30 minutes, then every 15 minutes Heart rate Continuous oximetry Telemetry Renal function Restrictions Dosing Guidelines and Indications Monitoring Parameters References available upon request 

Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals, May 2006

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Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals

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