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 JC has it right - pharmacists should review all non-urgent drug orders prior to administration

From the July 26, 2000 issue

PROBLEM: Administering a drug before a pharmacist has reviewed the order and screened it for safety increases the risk of a medication error, most notably administering drugs to which patients are allergic, at unsafe doses, or with unrecognized food or drug interactions. If patient harm could result from delayed therapy, the benefit of administering a drug in an emergency or urgent situation may outweigh the safety of prospective pharmacy review of the order. But it's unsafe to routinely bypass such a crucial step for convenience or to remedy process problems such as excessive order turn-around time. For example, whether medications are obtained from floor stock or automated dispensing cabinets, it's risky to remove and administer non-critical first doses and other routine medications that can safely wait until a pharmacist is able to review the order. Such a practice is also likely to result in a Joint Commission Type I recommendation. Standard TX.3.5.2 requires a pharmacist to review all medication orders before administration except in emergency situations when time does not permit review, or where a licensed independent practitioner controls ordering, dispensing, and administration (e.g., in the ED or during surgery). Ensuring prospective pharmacy order verification is difficult when drugs are readily available in patient care units. Even if automated dispensing cabinets offer the capacity for pharmacy verification before drug administration, users may allow varying capabilities to "override" this feature.

SAFE PRACTICE RECOMMENDATION: If there is an urgent clinical need for administering a drug before a pharmacist can reasonably be expected to review the order and dispense the drug, it is important to have readily accessible medications. Yet, a clear process is needed to determine when such an urgent situation exists, and safeguards must be established for the storage, removal, and administration of drugs available in automated and non-automated floor stock. Carefully select floor stock and provide drugs in limited quantities, single concentrations, and in unit doses. If automated dispensing cabinets are linked to the pharmacy computer system, establish a restricted list of urgent or emergent drugs that may be available via the "override" feature. As needed, apply warnings (allergy alert, etc.) to the packages of "override" drugs to enhance safety. Even if an ordered drug is on an "override" list, nurses should ask, "Does the clinical need for quick administration outweigh the safety of having a pharmacist review the order first?" For example, PEPCID (famotidine) may be on an "override" list and its quick administration before pharmacy review may be warranted for a patient in serious gastric distress. The order should be reviewed before subsequent doses are administered (or immediately after the pharmacy reopens). However, pharmacy review may be accomplished without compromising care for the first Pepcid dose for a newly admitted, comfortable patient who's been taking the drug at home. Before administration, drugs obtained through the "override" feature should be independently double-checked by a second practitioner. Timely order verification and minimal turn around time is also important to avoid unnecessary use of floor stock. Decentralized pharmacists can speed these processes. Monitor "override" drugs regularly and consider determining a monthly "override" rate (# of drugs given before pharmacy review/total # of drugs administered). Reduce the rate over time. If using floor stock or automated dispensing cabinets without pharmacy interface, nurses should follow the same process to carefully determine if a drug should be given before pharmacy review. Since nurses have no way to determine if pharmacy has reviewed an order, at best, they could wait a set period of time to allow for pharmacy review before retrieving the drug from floor stock. Again, decentralized pharmacists could improve communication.

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