Medication Order Review:
All medication orders should be reviewed by the pharmacist prior to medication administration to the patient. After-hours or ward stock orders shall be reviewed by the pharmacist at the earliest opportunity.
Prior to dispensing any medication, the pharmacist shall review the prescriber’s original written order or a direct copy to ensure that the prescriber’s medication order is authentic, accurate and appropriate. The pharmacist shall check the medication order for:
(a) the patient’s name;
(b) signature of authorized prescriber;
(c) the name of the medication and formulary status;
(d) dose, form and strength;
(e) route and frequency of admission;
(f) duration of treatment, if limited;
(g) complete directions for appropriate use;
(h) date order was written; and,
(i) for verbal and/or telephone orders, the name and signature of the person who received the order and the name of the prescriber.
The pharmacist shall ensure that a current computerized medical profile system is available. Patient medication profile should include:
(a) name of the patient;
(b) admission date;
(c) attending physician’s name and/or prescriber’s name;
(d) date of birth;
(f) weight ;
(g) allergies and/or sensitivities;
(h) list of current medication orders;
(i) list of medications which have been prescribed since admission to the hospital (in a chronological sequence)
(j) for each medication order: medication name, dose, route, dosage form, directions for use and administration times ;
(k) start and stop date of the medication, when applicable;
(l) date medications were dispensed, refilled or discontinued; and,
(m) signature or initials of the pharmacist or technician entering or verifying the transcription or computerized entry or medication orders into the medication profile.
The pharmacist shall have access to the following information, in addition to the medication profile:
(a) medication hospital admission;
(b) other pertinent monitoring data ;
(c) other therapies ;
(d) diagnosis on admission and updates when applicable; and,
(e) selected medical data and diet information relevant to medication profile.
The pharmacist shall review the profile information prior to dispensing the patient’s medications. The pharmacist shall assess the physician’s original medication order, utilizing the patient’s medication profile for the detection of:
(a) duplication of therapeutically similar medications;
(b) potential allergic or adverse drug reactions;
(c) possible drug-disease incompatibilities;
(d) significant drug-drug interactions;
(e) correct dosage and dosage interval;
(f) appropriate dosage form and route of administration;
(g) problems related to intravenous administration including potential incompatibilities, drug stability, volume of intravenous fluid for medication administration and rate of administration; and,
(h) appropriate length of therapy.
The pharmacist shall resolve any questions regarding the order with the prescriber and shall document the resolution in accordance with policy. Telephone and verbal orders received by the pharmacist shall be reduced to writing immediately on the order form in accordance with and legal requirements.
The use of preprinted medication orders, if considered necessary:
(a) shall be reviewed and revised as necessary by the pharmacy in-charge;
(b) shall be approved individually by the appropriate Medical Advisory Committee;
(c) shall have a copy that can be appended to the medical record; and,
(d) shall be signed by the prescriber and individualized according to the patient’s needs.
The pharmacist should provide pharmaceutical care to all patients. For selective monitoring, if resources are limited, the pharmacist may identify patients using criteria such as:
(a) patients whose clinical state or condition may affect medication absorption or disposition, alter dosage requirements or predispose them to adverse drug reactions or medication toxicity;
(b) patients (e.g., geriatrics, pediatrics or pregnancy) where age, weight or physiologic parameters are important considerations in determining appropriate medication therapy;
(c) patients on multiple drug therapy;
(d) patients taking medications with a low therapeutic index;
(e) patients taking investigational or emergency release medications;
(f) patients taking medications in doses greater or less than recommended by the manufacturer or recognized preferences; and,
(g) patients on parenteral nutrition.
The pharmacist should discuss the desired outcome of drug therapy with the physician, the patient or delegate and other health care professionals as required. The pharmacist shall actively evaluate patient needs to ensure that the patient is receiving drug therapy that is achieving the desired therapeutic outcome.
For patients monitored under the Pharmaceutical Care Program the pharmacist should:
(a) identify, prevent and resolve drug-related problems in patients. These include patients:
- i) needing pharmacotherapy but not receiving it;
- ii) taking or receiving the wrong drug;
iii) taking or receiving too little of the correct drug;
- iv) taking or receiving too much of the correct drug;
- v) experiencing an adverse drug reaction;
- vi) experiencing a drug-drug, drug-food interaction;
vii) not taking or receiving the drug prescribed;
viii) taking or receiving a drug for which there is no valid medical indication; and,
(b) document provision of pharmaceutical care in the patient health record in accordance with hospital and pharmacy policies and procedures.
The pharmacist should assess the patient for development of drug-related problems throughout the patient’s stay by evaluating:
(a) the patient’s response to medication therapy and achievement of the desired therapeutic outcome;
(b) adverse medication effects including allergies and sensitivities; and,
(c) changes in the patient’s clinical condition (including altered kinetics of drug absorption, distribution, metabolism or excretion) which necessitate an alteration in medication therapy or dosage.
The pharmacist should consider the potential cost implications of drug therapy for the individual patient and the health care system to ensure the most beneficial and most economical therapy is utilized.