Medication Orders & Requirements
The five elements required on a medication order
- Patient name and Date of birth
- Medical record number
- Medication
- Dose/route/frequency
PRN orders must include an indication.
The maximum time allowed between preparation and administration for an 'Immediate Use' CSP under USP <797>
What is 4 hours?
The purpose of USP <795> and type of compounding it applies to
Minimum standards for compounding non-sterile preparations
- Preparation, Packaging, & Storage of Non-Sterile medications
- To ensure they are high-quality, safe, and pure.
The specific aux labels that must be attached to the vial when dispensing insulin vials
- High Alert sticker
- "28 day discard" sticker
To prevent date related confusion, the "28 day discard" sticker must be positioned to cover the manufacturer expiration date.
The frequency that the inventory is done in the CII safe
Daily accessed medications and the whole inventory once weekly
In the emergency department, the electronic process where pharmacist review of orders is bypassed. Allowed only in urgent / emergency situations.
What is Medication Order Auto-Verification?
The maximum Beyond-Use Date (BUD) for a Category 1 CSP stored at controlled room temperature?
What is less than or equal to 12 hours?
According to standard garbing sequence, this specific task must be performed after putting on shoe covers but before donning the gown.
What is hand hygiene?
Non-Controlled expired medications follow this specific disposal path: From expired bins to red totes, and finally are sent back to this reverse distributor.
What is INMAR?
When wasting a dose of controlled substances, what specific documentation must be completed on Pyxis or the controlled substances disposition sheet (yellow sheet) for reconciliation
- Two RNs electronic or physical signatures on the floors
- Two pharmacist signatures in the pharmacy.
During order verification, the pharmacist must evaluate these six clinical factors:
- Drug Interactions,
- "Dose/Route/Frequency"
- Therapeutic duplication,
- Lab values,
- Drug-Drug Interactions, Drug-Diagnosis Conflict
- Allergies
While sterile compounding requires powder free gloves, this practice is specifically required when handling hazardous drugs (HD).
What is double gloving?
While sterile compounding requires ISO-classified air and rigorous garbing, non-sterile compounding is done on this type of designated, well-lit, and controlled space
What is a Designated Non-Sterile Compounding Area?
To ensure safety during preparation of chemotherapy and other hazardous drugs, staff must use these supplemental engineering controls, abbreviated CSTDs and the brand that is used
What are Closed System Transfer devices?
- Equashield
To report suspected drug diversion anonymously within the hospital, staff can use this specific incident report platform or call x63395.
What is VERGE?
The 5 posters that TJC requires to be updated yearly
- Do not crush
- High alert
- Look alike Sound alike
- Hazardous drugs
- Do Not Use Abbreviations
The practical assessment part of general training requirements for USP 797
What is Glove Finger Test & Media Fill
When stored at controlled cold temperatures, this is the maximum allowable Beyond-Use Date for Non-Sterile Water-Containing Oral Formulations.
What is 14 days?
Process for Receiving and Handling Hazardous Drugs
Must wear Proper PPE
- Chemo gown, gloves, N95 mask
Inspect the condition of container
- Check for any leaks or damage
Store in manufacturing packaging and store in a way that reduces risk of breakage.
The different pain scales and the frequency that pain scale is assessed
- Numerical Rating Scale (NRS) 0-10
- Wong-Baker FACES
- FLACC Scale
- Assessed on admission, once per shift, and 30-60 mins after medication administration
- Cannot have duplicate pain meds (ex: Ordering both Oxycodone 5 mg and Hydrocodone 5 mg for "Pain Scale 4–6.")
The Non-Formulary Medications Process
- Provider fills out NF form & management evaluates appropriateness
- 72 hour timeframe to procure drug once approved
- Once medication approved, management signs the form and the files
- Order will then be verified once medication has been procured
When cleaning the Primary Engineering Control (PEC), this agent requires a 3 minute contact time, whereas sterile isopropyl alcohol only requires 30 secs - 1 min.
What is Micro-Kill Bleach?
Required elements of a Master Formulation Record (MFR) under USP <795>
-Official drug name, strength, dosage form
- Ingredient quantities
- Mixing instructions
- Container used in dispensing
- Packaging and storage
- Located in Simplify
In order to manage an accidental exposure immediately, this must be stored and easily accessible in every location where hazardous drug spills are possible.
What is an HD spill kit?
- 2 powder free gloves
- Gown, Safety goggles , N95 respirator mask, shoe coverings
- 3 absorbent towels and pads, 2 chemo waste bags
- Caution sign, Scoop and Scraper
The electronic process for controlled substances during emergencies, where pharmacist review of orders is bypassed and medication is removed from Pyxis. Allowed only in urgent / emergency situations.
What is Medication Override?