Attachment 8 - 119-02 MEDICATION USE POLICIES AND PROCEDURES.pdf

1. PURPOSE: To state policies and procedures governing control and utilization of drugs and medications for both hospitalized and ambulatory patients.

2. POLICY:

a. Only those medications, diagnostic agents, and medical and prosthetic supplies which have been approved by the Pharmacy Benefits Management Services or Medication Use Committee will be stocked routinely by Pharmacy Service. All medications, biologicals, etc., will meet applicable national standards of quality and have contents accurately labeled. All drugs are to be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation and security. The medical center formulary will include the national formulary and be continuously revised to reflect the current clinical judgment of the professional staff.

b. All medications for patients leaving the medical center (i.e., authorized absence, discharge, etc.) must be ordered in an approved manner (i.e., electronically through VistA/CPRS or other approved prescription form when electronic order entry is not available) and will be dispensed by Pharmacy Service in properly labeled containers.

c. Prescribers are expected to enter outpatient medication orders electronically into VistA utilizing Computerized Patient Record System (CPRS). Medication orders should include the patient's name, last four digits of social security number (or equivalent approved patient identifier), name of drug, dosage form, strength, quantity, complete directions for use, refills if indicated, and the prescriber's signature.

d. Written prescriptions, under the contingency plan, should include the patient status (SC, OPT-NSC, etc.) unless it is submitted by an authorized non-VA presciber (i.e. Care in the Community Provider).

(1) Prescriptions may be written for up to a 90-day supply of medication for eligible patients.

(2) No prescription over twelve months old can be refilled.

(3) Pharmacy Service cannot fill medication orders or prescriptions with "as directed" as the only directions. Prescriptions should follow the national formulary guidelines or local criteria for use.

(4) Based on the patient's eligibility status, the following list states the maximum time limit that medications may be filled per prescription. Once this maximum quantity has been

POLICY MEMORANDUM

VA Medical Center 1030 Jefferson Avenue Memphis, TN 38104

Number: 119-02

Dated: April 14, 2019

Expires: April 13, 2022

Title: MEDICATION USE POLICIES AND PROCEDURES

36C24920R0114 - Attachment 8 utilized, new prescriptions must be written or the old prescriptions must be renewed if the patient is to continue receiving medications.

PATIENT'S STATUS

MAXIMUM QUANTITY OF

MEDICATION THAT CAN BE

PROVIDED PER PRESCRIPTION

AUTH. ABS. -96 Hrs 4 days AUTH. ABS. +96 Hrs 14 days INPATIENT 30 days CNH (Community Nursing Home) 3 days OPT-AC (Ambulatory Care) 365 days

OPT-NSC-D (< 50% SC, A&S, HB,

Mexican Border, WWI, former POW's)

365 days

OPT-SC (Service Connected) 365 days OPT-NSC (Non-Service Connected) 365 days OPT-DHP (Day Hospital Program) 365 days OWCP 365 days HBPC (Hospital Based Primary Care) 365 days OTHER FEDERAL 30 days EMP (Employee) 3 days (except antibiotics)

IRREGULAR RELEASE (AMA,

AWOL, etc.)

Prescriptions are not normally provided, but may be dispensed at the discretion of the provider.

Incarcerated Patients Medications may not be furnished to a Veteran serving sentence in a penal institution.

CHAMP-VA Medications can be dispensed when a patient receives care directly from a VHA facility.

Non VA Care

When a patient is approved for specific care by a non-VA provider, medications can be dispensed.

EMPLOYEE PRESCRIPTIONS May be authorized only by an

Occupational Health Provider.

AID and ATTENDANCE (A&A) Patients seeing non-VA physicians must send their prescriptions for filling to the appropriate clinic of jurisdiction pharmacy; i.e., the clinic which authorizes fee-basis treatment.

e. All prescriptions for controlled substances in Schedules II-V (narcotics and drugs with potential for abuse) must conform to procedures set forth in Medical Center Policy Memorandum 119-15.

f. When prescribing any controlled substances (Schedule II-V) for hospitalized patients, the prescriber will electronically initiate such orders through CPRS menus. Electronic orders must be signed and released by the provider to become effective.

g. Inpatient Pharmacy is responsible for stocking of all controlled substances in

Schedules II-V for facility use. Controlled substances will be replenished at least five (5) days per week based on the automated drug dispensing system usage reports. The automated drug dispensing system may be utilized for controlled substances inventory control and distributed according to established procedures.

h. Pharmacy Service will furnish all medications for patient use with the exception of specialty medications as designated by the FDA.

i. Use of multi-dose pen injector systems are prohibited on inpatient units except in the following circumstances:

(1) Patients being educated prior to discharge to use a patient-specific multi-dose pen injector.

(2) Eligible patients participating in the VA Medical Center’s Self-Medication Program.

(3) Patients requiring treatment with a medication delivered in a multi-dose pen injector, and no alternative formulation is available from the manufacturer for treatment while on inpatient units.

(4) Patients participating in a research protocol requiring a multi-dose pen injector while on a patient care unit.

(5) Pen injectors dispensed directly to the patient as an outpatient prescription.

j. Automatic Stop Order alerts will be provided electronically through VistA to theordering provider. Automatic Stop Orders will control medication prescribing in the following ways for hospitalized patients:

Medication Automatic Stop Order

(1) All intravenous medications and fluids.

Valid for 30 days unless otherwise specified (Exception: Antibiotics, anticoagulation, and Controlled Substances).

(2) Schedule II controlled substances

7 days.

(3) Oral, IV and intramuscular antibiotic agents.

7 days unless otherwise specified.

(4) All other medications. 30 days.

k. All adverse drug reactions will be reported on the FDA MedWatch Form 3500, according to procedures set forth in Medical Center Policy Memorandum 119-22.

l. Medications brought into the medical center by patients who are being admitted should be handled according to procedures set forth in Medical Center Policy Memorandum 119-11.

m. "PRN" medication orders will be qualified with administration schedules and purpose of administration (i.e., Aspirin 325 mg Q6H PRN pain).

n. “PRN” medications orders for hospitalized patients shall include clear instructions on when to administer (e.g. pain score, blood pressure measurements, etc.) in the order comments. If there is more than one PRN medication ordered for the same purpose (e.g.

pain control, blood pressure control, etc.), the comments shall clearly define when to administer each medication using objective, measurable parameters.

o. Range orders (ex. “1 to 2 tabs”) for hospitalized patients are not allowed. The provider shall enter two separate orders for each dose with the appropriate indication and appropriate instructions on when to administer (e.g. pain score).

p. Each practitioner who prescribes medication must clearly state administration times or the time interval between doses. The schedule of medication administration for hospitalized patients is as follows:

(1) Standardized medication administration times for medicine, surgery, ICU, and SCI:

Daily 0900 BID* = every 12 hours 0900 / 2100 Every 12 hours (Q12H) 0900 / 2100 TID*= every 8 hours 0500 / 1300 / 2100 Every 8 hours (Q8H) 0500 / 1300 / 2100

QID* 0900 / 1300 / 1700 / 2100

(except antibiotics) Every 6 hours (Q6H) 0500 / 1100 / 1700 / 2300 Every 4 hours (Q4H) 0900/ 1300 / 1700 / 2100 / 0100. / 0500 Every 3 hours (Q3H) 0300 /0600/2100/1200/1500/1800/ 2100/0000 Every 2 hours Odd hours: 9, 11, 1, 3, 5, etc.

5XD = Five times daily 0500 / 0900 / 1300 / 1700 / 2100 6XD = Six times daily 0600 / 0900 / 1200/ 1500 / 1800/ 2100 Bedtime (QHS) 2100 A.C. 30 Minutes before meal P.C. 30 Minutes after meal Every 2 hours (q2H) Odd hours: 9, 11, 1, 3, 5, etc.

BID Diuretics 0700/1300 Insulin – Short Acting 30 Minutes prior to meals Insulin 30 Minutes prior to meals Digitalis Preparations Never within one hour of antacids (1300) See Comments

*Exceptions Sustained release nitroglycerin products

7 a.m. / 12N / 5 p.m.

Buspirone 0700/1200/1700 Digoxin 1300 Fentanyl Patch 1500 Warfarin 1700 Oral Hypoglycemics With meals or 30 minutes after meals

(2) Standardized medication administration times for Mental Health Service:

Daily 0700 Except Digitalis Preparations - 1300 Warfarin - 1700 Antabuse - 2100 (unless ordered otherwise)

BID** 0700 / 2100

TID** 0700 / 1200 / 2100

Every 4 hours 0600 / 1000 / 1400 / 1800 / 2200 / 0200 Every 6 hours 0500 / 1100 / 1700 / 2300 (including antibiotics, QID)

Every 8 hours 0600 / 1400 / 2200 (including antibiotics, TID) Every 12 hours 0600 / 1800 (including antibiotics, BID) Bedtime 2100 A.C. 30 Minutes before meals P.C. 30 Minutes after meals

**Exceptions BID 0700 / 1700 - NSAIDs TID 0700 / 1200 / 1700 - Lithium

(3) When a medication order is written, excluding antibiotics, the time of administration of the first dose will be adjusted to meet the next standard scheduled dosage interval. If initiation of the medication is urgent, the physician must override the described sequence by writing STAT or Now.

(4) Non-standard or non-approved abbreviations will not be used in medication orders.

3. RESPONSIBILITY: The Chief, Pharmacy Service is responsible for carrying out the policies and procedures as set forth in this policy memorandum.

4. PROCEDURE:

a. All drugs for use on patients either as investigational drugs or for clinical evaluation will be dispensed by Pharmacy Service and will be approved by the Human Studies Subcommittee and the Medication Use Committee prior to use. Patients receiving investigational drugs will have VA Form 10-9012 placed in their medical record which will identify the contact person, the investigator, and the potential drug side effects if a manufactuer’s package insert is not available.

b. All drugs should be ordered and prescribed by generic name and by metric system units. The use of the leading decimal point without a leading zero, is prohibited. The use of a trailing zero after a decimal point is prohibited.

c. Non-formulary and restricted items with established critera for use must be approved by an individual authorized (by the Medication Use Committee) to approve Prior Authorization Drug Requests (PADR). The non-formulary or criteria for use medications must be requested through a Prior Authorization Drug Request consult in CPRS. If the request is disapproved, the requesting provider will be view alerted.. The electronic patient narrative will be updated with PADR approval information to include: medication, date, and initials of person updating information. Prior authorization medications, once approved, will not require re-approval for subsequent admission or re-order unless approved for limited time frame, required subsequent monitoring is specified, or otherwise required by the Medication Use Committee.

d. Medications utilized as ward stock for clinics and special units will be stocked in automated dispensing cabinets when available. Requests for new ward stock items are sent to Pharmacy for review. If a clinic does not have an automated dispensing cabinet available, then ward stock requests are generated using the Automatic Replenishment Ward Stock menu in VistA.

e. Medications stored in an automated dispensing cabinet will be replenished at least five

(5) days per week based on the automated drug dispensing system usage reports. Offsite locations with automated dispensing cabinets will be replenished at least two (2) days per week.

f. All outdated, used or damaged drugs and medications on the wards and clinics will be destroyed using the appropriate pharmaceutical waste bins, which may be obtained through the Safety Service. All unused, unopened medication will be returned to Inpatient Pharmacy Service (Bed Tower, Room DB1102).

g. All medications administered to medical center patients will be appropriately recorded in the patient's medical record by the individual who administered the medication. Bar Code Medication Administration (BCMA) software will be utilized prior to administration of medications when available.

h. The patient will be identified prior to medication administration.

5. REPORTING REQUIREMENTS: None.

6. RESPONSIBLE OFFICE: Pharmacy Service (119).

7. REFERENCES: VHA Handbook 1108.07, 1108.01, 1108.06, 1108.05; JC Standards.

8. RESCISSION: Medical Center Policy Memorandum 119-2, dated April 18, 2016.

Medical Staff Concurrence: Date: April 4, 2019

/s/

THOMAS FERGUSON, M.D.

Chief of Staff

/s/

DAVID K. DUNNING, MPA

Medical Center Director