Category: Procedure Logs

C3.1 R4(h): Provide continuity of care from in-hospital to outpatient setting (#1)

Patients at BCCA often require submissions to Special Authority and other mechanisms (such as drug company-sponsored coverage) because supportive medications are not covered by the Agency. I am involved with discharge prescription and medication calendar planning for the patients under my care, but I wanted to highlight a special case.

This is a 29 year old woman with Ewing’s sarcoma, undergoing (overall) her 25th cycle of chemotherapy (salvage therapy with possibly curative intent). As she has unfortunately suffered an episode of febrile neutropenia in the past, she qualifies for Special Authority for filgrastim for secondary prophylaxis. I submitted the request on behalf of the attending physician, and also provided the following:
– Submission of request to ANSWERS 3rd party program for any additional coverage in case the pt had not met her Pharmacare deductible
– Liaison with the community pharmacy to ensure adequate stock was available
– She also was interested in use of various NHPs with her chemotherapy: counselled that use of vitamin B12 had no concerns but the other supplement (a proprietary blend of mushroom extracts) would be ill-advised
– Counselling to call the BCCA immediately at any sign of fever or “feeling off”, as not all neutropenic patients can mount a fever.

C3.2 R5: Reconcile a patient’s medications on ADMISSION (#1)

Today there was a new admission to the ward. This was a good example of gathering information that was necessary for a MedRec but not necessarily having the complete info that would be gathered from, say, a workup. This patient was in for nausea and vomiting, and drainage of a pleural effusion. She received her most recent cycle of BRAVGEMP 4 days ago. There were a few things to reconcile from the information on Pharmanet:
– She was taking atenolol 50 mg daily, not 25 mg daily
– She was applying fentanyl 12 mcg/h, one patch q72h, not 1/2 patch day 1, then the other 1/2 patch 24 hrs later as it appeared on Pharmanet (this was a titrating regimen she had completed a while ago)
– She was no longer taking escitalopram and nifedipine, even though it did show it was filled 3 months ago for a 3 month supply.
– She was taking extended-release dimenhydrinate QHS (patient’s own medications) with good effect for nausea.

Overall this highlighted for me how important it is to not simply blindly trust Pharmanet as an accurate source of medication information. It also allowed me the opportunity to collaborate with the physician in reconciling the orders.

C3.2 R5: Reconcile a patient’s medications on DISCHARGE (#1)

During my first week at BCCA I had the opportunity to help take care of a patient (65 yo female) who was in for treatment of double-hit diffuse large B-cell lymphoma. During her admission, there were a few changes to her medication, in addition to adherence concerns as she missed a week of her SMX/TMP for PCP prophylaxis as there was confusion regarding blister packing. I made the following changes to her medications in collaboration with the doctor:
– Discontinued her ASA 81 mg PO daily that she was taking for primary CV prevention. She had a Hx of mitral valve prolapse, but in the absence of HF, A-fib or previous MI/stroke, there was no compelling indication.
– Increased her valacyclovir to 500 mg PO BID from PO daily as she was seropositive for HSV and suffered from an especially bad bout of mucositis (that was HSV-positive on swab) last cycle. The BID dose is usually for HIV-positive patients or leukemia patients, but given her aggressive regimen (daEPOCH-R), the doctor and I felt it prudent to increase the dose, also considering valacyclovir’s favourable safety profile.
– Increased her gabapentin from 600 mg PO QHS, adding 100 mg PO with breakfast and lunch, titrating q week to a target of 600 mg PO TID for fibromyalgia. There was a patient teaching point as well as I explained to her that one would develop tolerance to sedation as gabapentin is slowly titrated.

I made a med calendar for her, had her medications blister packed, prepared her discharge prescriptions, and explained the changes we made in hospital. What I hope to improve upon and apply in future is becoming more efficient with coordinating with the community pharmacy such that medications are delivered in good time when the patient goes home.

C3.2 R5: Complete the “Med Safety Game” and document in ePortfolio

I completed the game today via CCRS and attained a score of 4882. One thing that stood out for me was that a few of the questions I could answer much more easily now that I have had some exposure to the dispensary during my Drug Distribution rotation. One question was concerning how to process STAT orders. Very early on in my order entry/verification training, I would enter stat orders into Meditech. However useful that may be to the clinical pharmacist who would want to easily know if stat furosemide IV or midodrine PO was given, it is cumbersome and slows down order entry, and that information could be obtained from reading the MAR, nursing notes, or doctor’s orders. Now, that particular question was easy as I have gotten a better grasp on how orders are processed from the ward and to the pharmacy.

C3.2 R4(c): Clarify a medication order with a prescriber (#3)

This clarification has a bit more of a clinical slant to it. Truth be told, I was very happy to be able to make some interventions from the dispensary level as it does impact patient care, and adds some more checks and balances to medication safety.

Patient was a 39 yo female who was on quite a bit of antihyperglycemic medications:
– Metformin 1000 mg PO BID
– Linagliptin 5 mg PO BID
– Dapagliflozin 5 mg PO daily
– Gliclazide MR 60 mg PO daily

On her admission orders she was also ordered “continue Jentadueto 2.5 mg PO BID”. From my experience in community, this was an incomplete order as Jentadueto (a combination linagliptin/metformin product) comes in 2.5/500, 2.5/850, and 2.5/1000 mg tablets. In addition, the linagliptin was given at 10 mg a day, which is above the recommended daily dose, AND it didn’t appear on Pharmanet – it was handwritten into the MedRec. There was no A1c to go on while in hospital.

I decided that this was a complex situation that required clarification of how the patient takes her meds. Therefore, I liaised with the clinical pharmacist on the ward to clarify these aspects with her. This required some memory retrieval from undergraduate days (time flies!) as I learned that above 2 g/day, it is unlikely to gain much more benefit from maxing out the metformin dose. In addition, the trials that have to do with intensive A1c control (ACCORD and ADVANCE) do not apply to this patient, as she is 39 years old and ADVANCE and ACCORD included patients above 55 years old. The other medications could be reassessed by her GP/endocrinologist.

The linagliptin as it turns out was taken only once a day, as per the patient, and she had stopped taking Jentadueto “a while ago”. The clinical pharmacist on the unit eventually wrote the clarification orders, and it should show up on her discharge prescription, corrected and ready to go for her trip home.

C3.2 R4(c): Clarify a medication order with a prescriber (#2)

This particular patient came in for TURP surgery and had some post-op orders faxed to the pharmacy. On the post-op orders, the surgeon wrote “Plavix” as the antiplatelet agent to give. On the MedRec, Pharmanet revealed that the patient was taking clopidogrel 75 mg PO daily and it was confirmed that was how the patient took it at home. Unfortunately, the right column to reconcile the medications (the actual orders) were not checkmarked.

The action I took was to print an order sheet from FormFast and clarify the orders by writing it into the chart after deliberation with my preceptor. This activity illustrated the scope of practice that pharmacists have, when it comes to clarifying orders from MedRec in combination with what the surgeon intended to order, and taking into account the patient’s current clinical state (post=operative, medication history). It also demonstrates that clinical work could be carried out from the dispensary as well, which takes a bit of the load off the clinical pharmacists on the ward!

C3.2 R4(c): Clarify a medication order with a prescriber (#1)

It was day 2 of order entry (and what a steep learning curve it is!), and I am beginning to become familiar with navigating the PPOs, resolving them with newer orders, etc. I have had some experience with orders in a chart but I had no idea about the complexity when translating them into orders that you input into Meditech or PCIS.

For this procedure log, I clarified an order that read “HP-Pac x 1/52”. Seems simple enough for a pharmacist who has worked in community, as it is amoxicillin 1 g, clarithromycin 500 mg, and lansoprazole 30 mg all given BID. However, a nurse won’t know what to give!

However, there were two things to do for this order:
– The patient was on apixaban, which clarithromycin (a 3A4 inhibitor) decreases the clearance of
– Lansoprazole 30 mg is not on formulary and has to be interchanged with pantoprazole sodium 40 mg…not to mention the patient was already on scheduled IV and PO pantoprazole to start off with (oii veyyy) that would need to be D/C’d

So, for this one I made a call up to the ward to the clinical pharmacist to contact the doctor and clarify the order. About a half-hour later the clarification was faxed into formulary. From this, I learned that a great avenue to contact the prescriber from the dispensary are the clinical pharmacists, who probably have those issues on their monitoring sheets, but it’s nice to give them a hand to flag down issues.

C3.2 R4(b): Accurately transcribe a medication order onto the medication profile or health record (#3)

This time, I entered new orders for continuation of outpatient therapy for tamoxifen 20 mg PO daily after receiving a phone call in the dispensary. Truth be told, fielding my first couple of calls in a hospital dispensary was a bit nervewracking, as I couldn’t anticipate the types of calls I would receive, but I found my flow quickly. ERH supplies outpatient tamoxifen (reimbursed by the BCCA) via the hospital pharmacy that is picked up by patients or their agents during a specific time range during the weekdays. I actually wasn’t aware at all about how these orders should be processed, as I thought that we just inputted orders in the chart into MediTech, so it was completely new for me. However, an aspect which was familiar was the format of the prescription, which was exactly like an outpatient Rx you would see in community.

C3.2 R4(b): Accurately transcribe a medication order onto the medication profile or health record (#2)

For this procedure log, I had to use an order set to enter an admitting PPO. As PPOs have checkboxes indicating what the hospitalist intends to give, I had to remove orders from the pre-populated set. The thing that made this unique was that further orders in the chart (faxed at the same time) may override the PPO, so it is good to keep that in mind. The specific example involved post-surgical analgesic orders, where originally on the PPO it indicated giving morphine. However, the anesthesiologist ordered hydromorphone after, and as per the PPO, it stated that the anesthesiologist’s orders are to be taken as final.

Again, this was a good reminder that even when working dispensary, it is good to keep the patient’s whole situation in mind (such as avoiding duplication of therapy) when thinking through processing orders.

C3.2 R4(b): Accurately transcribe a medication order onto the medication profile or health record (#1)

Day 1 of the second week at ERH, and it’s arrived – order entry! After my preceptor gave me the basics of navigating MediTech for order entry and dealing with order sets for PPOs, plus a couple of tips and tricks along the way, it was my turn to go on my own. As I haven’t gotten a licence yet (and this was a first for ERH Drug Distribution residents apparently), I couldn’t verify orders but I could enter them into the system.

For this procedure log, I had to enter metoclopramide 5 mg TID 1/2 hr AC both PO and SC. I had to keep in mind that the PO route was much easier, so to avoid populating the MAR with both routes with timeslots (i.e. 0730, 1130, 1730), I had to enter in the order as usual but leave a full stop before the sig code. Also, I had to populate the label comments with directions for nursing to see the alternative order with the alternative route. It was a good exercise in keeping in mind patient values (I don’t think the patient would appreciate being used as a pin cushion receiving SC metoclopramide all the time!)