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VOLUME 18 NO.3 MARCH 2003
PRESCRIBING, DISPENSING AND ADMINISTERING FORMULARY COMBINATION MEDICATIONS
The number of drugs available in fixed combination has increased over the past few years. In an effort to maintain continuity of care in a timely manner, the Pharmacy, Therapeutics and Nutrition Committee recommended and the Medical Board approved the following policy and procedure:
Policy:
When a combination medication is prescribed, and only the individual agents of that combination are available in the hospital formulary, the pharmacist shall dispense and nurse shall administer the individual agents that make up the combination product.
Procedure:
a) Physician/Prescriber: (Drug Ordering)
1) The physician/prescriber writes a medication order for a combination product with the knowledge that the individual agents in the combination will be dispensed separately.
2) All non-formulary medication orders for combination products shall be handled as a pharmacist intervention.
b) Pharmacist: (Drug Dispensing)
1) The pharmacist will enter the individual drugs on the patient profile and dispense them.
2) In addition, an auxiliary label will be affixed to the initially dispensed drugs to alert the medical and nursing staff.
c) Nurse: (Drug Administration)
The nurse will compare the auxiliary label with the individual drug labels and make the necessary notation on the medication administration record.
MORE ABOUT DANGEROUS ABBREVIATIONS FROM THE INSTITUTE FOR SAFE MEDICATION PRACTICES:
v Confusing the @ sign for a number:
Problem: A pharmacy label for an octreotide infusion stated to run the solution "@5ML/H," but the rate was misread as 25ml when the typewritten @A symbol was mistaken as the number "2."
Recommendation: Don't use the @ symbol when prescribing medications. Maintain a space before and after abbreviations to avoid misinterpretation.
v Concentration expressed as dilution or percentage:
Problem: The concentrations of most medications are stated in mg or mcg per ml, but a few drugs (e.g., epinephrine, lidocaine) have concentrations expressed as a dilution ratio or percentage. These expressions are error-prone. Studies show that knowledge about converting ratio/percentage concentrations to mg/mcg doses is inadequate, even among physicians. Errors have been reported due to confusion between concentrations (e.g., 1:10,000 and 1:1,000)
Recommendation: Do not expect staff to be familiar with converting percent/ratio expressions to mg or mcg/ml doses. Store a single concentration for these products whenever possible. Create a dose conversion chart reflecting concentrations that are available in your facility and post them on code carts and in other areas where emergency medications may be prepared. Review the dose chart for emergency drugs during annual CPR certification.
v Use of volume alone to express liquid doses:
Problem: Only the volume was specified for the dose of oxycodone solution. With both a 1mg/ml and a 20mg/ml concentration available, the patient accidentally was given the higher concentration, resulting in an overdose.
Recommendation: Always prescribe liquid medications by metric weight. If prescribed by volume, clarify the concentration. Computerized prescriber order entry, pre-printed order forms and protocols can prompt physicians to properly express doses. Where possible, stock just one concentration of oxycodone.
v Drug names that end in "L":
Problem: Misreading of the terminal "L" in orders for both TEGRETOL (carbamazepine) and AMARYL (glimepiride) resulted in dosing errors "Tegretol300mg" was misinterpreted as 1300mg, and "Amaryl2mg" as 12mg.
Recommendation: Ensure proper spacing between the drug and dose on handwritten orders, printed materials, computer screens, pharmacy labels, etc.
v Methotrexate injection given by the oral route:
Problem: Inaccurate information from a patient's family prompted a nurse practitioner to order "methotrexate injection 80cc every Sunday." But the patient had been taking 0.8ml of the injectable solution orally once weekly (less costly than tablets), and hand been using an insulin syringe to measure the dose (80 units = 0.8ml) The nurse was told that the patient was taking 80 "cc", not 80 units, each week.
Recommendation: Avoid writing or accepting orders without a route of administration, or with a volumetric dose only. Verify information provided by patients/family, especially if the medication history seems unusual or unexpected. Carefully balance affordability with risk and safety and identify potential problems before prescribing medication in an unconventional way.
Source: ISMP Medication Safety Alert, January 9, 2003 issue