Pharmacy P&P

POLICY AND PROCEDURE MANUAL
OF THE
PHARMACY DEPARTMENT
OF UNIVERSITY HOSPITAL AT BROOKLYN
TABLE OF CONTENTS
Note: Related Policies & Procedures to JCAHO Standards Are Indexed with MM
Standard Reference and National Patient Safety Goals Are Indexed with
NPSG Reference
Chapter 1. Definition and use of Policy & Procedures Manual

Section A. Mission of Pharmacy
Chapter 2. Integration of Pharmacy Services into the Hospital Organization
Chapter 3. Personnel Issues

Section A. Pharmacy Staffing
Section B. Departmental Table of Organization
Section C. Emergency Evening/Night Staff Shift Coverage
Section D. On-Call/Re-Call System
1) Departmental Guidelines for Temporary Disability Calls
Section E. Break Periods
Section F. Dress and Grooming Codes
Section G. Job Description – Director of Pharmacy
Section H. Job Description – Associate Director
Section I. Job Description – T.H. Pharmacist/Senior Pharmacist
Section J. Job Description – T.H. Pharmacy Assistant (Technician)
Section K. Job Description T.H. Pharmacy Aide
Section L. Job Description – Staff Assistant II (Materials Mgr.)
Section M. Job Description – Hospital Attendant
Section N. Job Description – Secretary
Section O. Orientation and Continuing Education of Pharmacy
Section P. Committee Membership of Pharmacy Personnel
Chapter 4. Inpatient Dispensing of Medications MM.1.1.10, MM.3.20,

MM.4.10, MM.4.30, MM.4.40, MM.7.10
Section A. Main Pharmacy (Cassette Exchange) NPSG 2,3, and 8
Section B. Satellite Pharmacies
Section C. Unit Dose Drug Distribution Policy
Section D. Appendix to Unit Dose Distribution Policy
Section E. Prescription Writing Authority in the UHB; Approved Hospital
Abbreviations; Un-approved Abbreviation List
Section F. Investigational Drug Dispensing Policy MM.7.40
Section G. Verification and Reviewing of Prescription Orders NPSG 1, 2, & 3
Section H. Prescriptions For Non-FDA Approved Indications or Dosage of
Medications
Section I. DELETED
Section J. Patient Self Medication Policy MM.5.20
Section K. Floor Stock Medication and Distribution
Sub-Section I.: Insulin as Floor-stock
Section L. Intra-Hospital Distribution of Medication
Section M. Pass Medications
Chapter 5. Controlled Substances

Section A. Definition of Controlled Substances MM.2.20, MM.2.30, MM.
2.40, MM.4.40, MM.7.10
Section B. Inpatient Dispensing of Controlled Substances to Nursing Care
Areas
1. Verification of the Administration Record Entries for Controlled
Substances
Section C. Outpatient Dispensing of Controlled Substances to Clinic Nursing
Stations
Section D. DELETED
Section E. Storage of Controlled Substances
Section F. Inventory Control of Controlled Substances
Section G. Acquisition Process for Controlled Substances
Section H. Verification of DEA Numbers
Section I. Expired, Deteriorated, and Non-Reusable Controlled Substances
and heir Deposition MM.4.80
Section J. Issuance and Control of NYS Official Prescription Forms
Section K. Loss or Theft of Controlled Substances or Official New York State
Controlled Substance Prescription Books
Section L. Automatic Medication Stop Order Policy MM.7.10
Section M. Controlled Substances Approved Forms for Use at UHB
Section N. Administration of Controlled Substances to Visiting Family
Members
Chapter 6. Repackaging of Pharmaceuticals Either in Unit Dose or Unit of Use Form
Chapter 7.Compounding of Pharmaceuticals for Internal or External Use MM.4.20
Chapter 8. Absolute and 95% Alcohol

Section A. Definition of Absolute and 95% Alcohol
Section B. Ordering of Absolute or 95% Alcohol
Section C. Inventory Control and Storage of Absolute or 95% Alcohol
Section D. Dispensing of Absolute and 95% Alcohol
Section E. Licensing Requirements for the Purchase and Dispensing of
Absolute and 95% Alcohol
Chapter 9. Adverse Outcomes M.M.6.10, MM.6.20, M.M.8.10

Section A. Medication Errors and Hospital Incident Reporting Involving
Medication
Section B. Drug – Drug Interactions
Section C. (1) Drug – Food Interactions
(2) Drug – Food Interactions Monitoring
(3) Formulary Drugs Tagged in the Computer Mainframe for Drug-
Food Interactions Patient Counseling
(4) Guide to Food & Drug Interaction Patient Counseling
*Section D. Drug Recalls M.M.4.70
Section E. Adverse Drug Reaction Reporting
Section F. Poisoning and Antidotes
Section G. Antitoxins and Toxoids
Section H. Drug and Device Defects Reporting
Chapter 10. Handling of Non-Formulary Medications (including Home Medications

and Medications brought in by Practitioners) MM.2.40
Chapter 11. Nursing Station Inspections MM.2.20
Chapter 12. Automatic Medication Stop Order Policy MM.7.10
Chapter 13. Outsourcing of Medications
Chapter 14. Procurement of Pharmaceuticals MM.2.10

Section A. Choosing a Vendor
Section B. Prime Vendor Program
Section C. Borrowing or Loaning of Pharmaceuticals from/to Other Hospitals
*Section D. Drug Return Policy M.M.4.80
Section E. Sales Representatives
Section F. Inventory and Purchasing Controls
Chapter 15. Emergency Drugs and the Pharmacy’s Emergency Responsibilities

M.M.2.30
Section A. Pharmacy Responsibility for Crash Carts/Boxes
Section B. Controls and Security of Emergency Medications in Crash Carts
Section C. Crash Cart Inspections
Section D. Drugs Maintained on Crash Carts MM.7.10; NPSG 3
Section E. Crash Cart Distribution at UHB
Section F. Pharmacy’s Disaster Cart
Section G. Pharmacy Disaster Plan
Section H. Emergency Drug Supplies Provided to the Emergency Room
Section I. Infant Abduction Policy
Section J. Hospital Evacuation/Transfer Procedures
Chapter 16. Handling of Multi-dose Vials of Inhalation, Injectable, and Ocular

Medication MM.2.20; NPSG 7
Chapter 17. Storage of Pharmaceuticals MM.2.20

Section A. Look-Alike/Sound-Alike Drugs
Chapter 18. Antibiotic Control Program MM.8.10; NPSG 7

Section A. Antibiotic Surveillance/Control/Review Policy Hospital-wide
Section B. Approved Controlled Antibiotics List
Section C. Pharmacy Antibiotic Monitoring
Chapter 19. Drug Information and Staff Education

Section A. Drug Information to Hospital Services
Section B. Drug Information to Discharge and Ambulatory OPD Patients
Section C. Patient Medication Profile System MM.1.10; NPSG 8
Section D. Continuing Education of the Pharmacy Staff
Section E. Pharmacy Staff Meetings
Chapter 20. Prescription Transmission to the Pharmacy Via Fax Machine
Chapter 21. Hospital & Patient Confidentiality

Section A. The Pharmacy Department’s Patient Confidentiality and Data
Security Policy
Section B. Patient Bill of Rights and Pharmacy Code of Ethics
Section C. DELETED
Chapter 22. Inter-Departmental Pharmacy/Nursing Policies

Section A. Administrative Table of Organization for the Department of
Nursing Services
Section B. Drug Weight Conversion Charts on Nursing Care Areas
Section C. Medication Orders for Discharge Patients
Section D. Medication Storage Areas MM.2.2, 2.3, 2.4
Section E. Medication Orders for Heparin NPSG 2 & 3
Section F. Dispensing Concentrated Sodium Chloride (23.4%) for Sputum
Induction MM.7.10; NPSG 3
Chapter 23. Out-Patient Prescription Dispensing MM.1.10

Section A. Medication Dispensing on Prescription Orders
Section B. Verification of Practitioner’s Name, License/Registration, and
Signature on Ambulatory/Discharge Prescriptions
Section C. Weekend and Holiday Dispensing of Ambulatory Care
Prescriptions
Section D. Prescription Pricing Policy for Ambulatory Care Prescriptions
Section E. Cash Transactions Involving Ambulatory Care Prescriptions
Section F. Collection Procedures for OPD Pharmacy Services
Chapter 24. Safety Policies

Section A. General Safety
Section B. Fire/Emergency Alarm Codes
Section C. Pharmacy Fire Control Units
Section D. Pharmacy Key Control
Section E. Power Failure
Section F. Authorized Signatures and Computer Security
Chapter 25. Infection Control MM.4.20; NPSG 7
Chapter 26. Pharmacy and Therapeutics Committee MM.2.10, MM.6.10, MM.6.20,

M.M.8.10; NPSG 2, 3, & 9
Section A. Requesting an Addition of a Drug to the Formulary
Chapter 27. Administration of Drugs within University Hospital at Brooklyn

Section A. Medication Administration Schedule M.M.5.10
Chapter 28. Drug Samples on University Hospital at Brooklyn Property
Chapter 29. Sterile Parental Compounding MM.4.20; NPSG 7

Section A. Policy Statement on the Compounding of Sterile Parenteral
Admixtures
Section B. Staffing Responsibilities and Supervision in the Sterile Parenteral
Compounding Laboratories
Section C. Aseptic Manipulations
(1) Working under the Lamina Air-Flow Hood
(2) Syringe Manipulations
(3)Reconstitutions and Transfer of a Drug to a Parenteral Solution
Section D. Preparing the Sterile Parenteral Admixtures
Section E. Discontinued Parenteral Preparations MM.4.80
Section F. Sterility and Quantitative Testing of the Parenteral Solutions
Section G. Procedures and Addendums for the Operation of the Automix®,
Micromix®, and IV Laboratory Computer Systems
Section H. Physician Order Forms for Parenteral Admixtures
Section I. Cytotoxic Drug Admixtures
Chapter 30. Dispensing of Albumin Solutions
Chapter 31. Dosing of Cardiac Medications: Nitrates and Other Anti-Anginals

MM.7.10
Chapter 32. Pharmaceuticals Education for Patients and Family Members
Chapter 33. TPA Injection for Catheter Clearance
Chapter 34. Management of the Pyxis® Medication
Chapter 35. High Risk Electrolyte Solutions NPSG 3
Chapter 36. Therapeutic Interchange Policy NPSG 3
Chapter 37. Medication Reconciliation NPSG 8
Chapter 38. Advance ECHO Lab Emergency Medication Box
Chapter 39. Patient Medication Orders MM.3.20; NPSG 1 & 2
Chapter 40. Medication Security when Patients are Transferred between Services
MM.2.30, MM.4.10, MM.8.10, NPSG #8
Chapter 41. Labeling of Medication/Solution in Perioperative and Procedural Areas

NPSG 3D
Chapter 42. Look-Alike/Sound-Alike Drugs NPSG 3C
Chapter 43. Chemotherapy Ordering and Dispensing MM.3.10.3.20,4.10-4.80,

5.120-5.20
Chapter 44. Ordering and Dispensing of Parenteral Chemotherapy for Non-Oncology

Indications (PHA- 19)
Chapter 45. Medication Orders for Contrast Media for Imaging Procedures (RAD-12)
Chapter 46. Titration of Medication Continuous Infusion (PHA-18)
Chapter 47. Management of Extravasation Injuries (PHA-20)
Chapter 48. Fentanyl Patches
Chapter 49. Thalidomide
Chapter 50. ID Pharmacy PGY-2 Resident Qualifications and Obligations
Chapter 51. IV to Oral Antimicrobial Conversion Program

SUNY DOWNSTATE MEDICAL CENTER
UNIVERSITY HOSPITAL OF BROOKLYN
POLICY AND PROCEDURE
No: ___CH. 1___
Subject: DEFINITION AND USE OF THE POLICY AND Page ____1__ of ___1__
PROCEDURE MANUAL
Prepared by: NICHOLAS GALEOTA Original Issue date: 3/17/00
Reviewed by: WILLIAM GERDES Implementation Date: ___8/17/99__
Approved by: CONSTANCE SHAMES, M.D. Distribution:

Administrative Manual
Department Manual
Patient Care Manual
AOD Manua
Issued by: Regulatory Affairs
I. Purpose: To serve as a guide to all personnel for the proper operation of the Pharmacy service within the
Hospital.
II. Definition(s): Each policy and/or procedure covers a specific phase of activity in detail in order that all personnel
will accomplish the same function in a manner similar to that of their working associates and thereby obtain the
same results.
III. Policy: The manual is not intended to be a static reference. It will be updated on a continuing basis and it is
expected that all members of the Pharmacy Staff will contribute ideas and suggestions for the improvement of
procedures thereby resulting in revision of the manual contents. Everyone must feel free to constructively
criticize any procedure described herein and enter into a free discussion with the Director of Pharmacy Services
on any phase of any and all policies in order to improve departmental or organizational performance.
IV. Responsibilities (Include all departments/services involved in development/implementation and/or monitoring):

N/A
V. Procedures/Guidelines: The policy and procedure manual is also utilized as the basic tool for the orientation of
new staff members.
All items in this Policy and Procedure Manual relating to the use, distribution, and storage of drugs and the
monitoring of the use of medication modalities have been reviewed and approved by the Pharmacy and
Therapeutics Committee of the Medical and Dental Staff at SUNY-Downstate Medical Center and the Executive
Committee of the Medical Board.
VI. Reasons for Revision:

 Changes in regulatory or statutory laws or standards
 System failures/ changes
 Institutional/operational changes
VII. Attachments: NONE
VIII. References: NONE
Date Reviewed Revision Required (Circle One) Responsible Staff Name and Title
12/9/04 Yes No NICHOLAS GALEOTA MS, RPH
Yes No
Yes No
7
Chapter 1. Section A.
Mission of the UHB Pharmacy Department
The Mission of the Hospital Pharmacy is:
a. The basic guiding philosophy for the Pharmacy Staff is to provide the most, accurate
complete, safe, neat and expedient Pharmacy service for the patients of the UHB that is
expedient Pharmacy Service for the patients of UHB that is possible to render. This is to be
accomplished with the utmost regard to the patient’s rights, dignity and privacy. Nothing less
than compassion and total commitment to patient care shall be acceptable from the
Pharmacy staff.
b. To provide the benefits, protection, and pharmacological knowledge of a hospital pharmacist
to the patient, the institution, and members of all health professions within the hospital. This
includes provision for patient and family education on the safe and effective use of
medications.
c. To educate future practitioners in hospital pharmacy practice.
d. To increase the dissemination of pharmaceutical knowledge providing for drug information
education of hospital staff and patient.
This mission is accomplished by:
1. Filling, labeling, and dispensing of all drugs, chemicals, and pharmaceutical preparations issued to
nursing units, in-patients, and out-patients and dispense in-patient drugs in unit dose form.
2. Provide parenteral dosage forms in ready to use unit dose IV additive/admixture forms.
3. Bulk compounding or pharmaceuticals.
4. The establishment and supervision of control procedures for the distribution and use of all narcotic
drugs, controlled substances, alcohol, and other prescribed drugs.
5. Inspection of medications on all nursing units at monthly intervals.
6. Maintaining an approved stock of emergency drugs in each nursing unit including the ambulatory
care areas and exchange trays for all code carts.
7. Participating in the teaching of a course in Clinical Pharmacy Practice to undergraduate students of

Long Island University and Pharm. D. based curriculum to post-graduates.
8. Encouraging graduate study in the fields of pharmacy, pharmacology, and pharmaceutical

chemistry/kinetics as they relate to hospital pharmacy.
9. Assisting members of the hospital staff in studies involving investigational drugs and act as the
Pharmacy of Record for the protocol.
10. Providing pharmaceutical dosage forms, including extemporaneous compounding, as prescribed for
patient care by the medical and surgical staff.
11. Participation on the Pharmacy and Therapeutics Committee.
12. Cooperation in the Nursing In-Service Education Programs.
13. Participation in the publication of the Pharmacy news letter which is of interest to the Nursing and
medical staff.
8
14. Furnishing information concerning medications to physicians, dentist, nurses, and other members of
the hospital staff.
15. Keeping abreast of the latest advances in Hospital Pharmacy practice.
16. Provide Clinical Pharmacy services via satellite Pharmacy sites and patient team rounding at the
selected areas in the hospital.
17. Purchase and stock all medications.
18. Prepare, under aseptic conditions, parenteral fluids with added medications.
19. Conduct in-service educational programs as needed for the Pharmacy staff.
20. Supply Pharmacy items to other departments as required.
21. Provide Pharmacy service in those specialized areas requiring decentralized distribution via a
Satellite Pharmacy program.
22. Provide drug information to all healthcare providers.
23. Counsel patients and their family members on demand about heir drug therapies.
24. Maintain up-to-date medication databases.
25. Utilize computer and automation technology to maintain the highest degree to safety, security and
accuracy when dispensing medications.
9
No: ___CH. 2___
Subject: INTEGRATION OF PHARMACY SERVICES Page ____1__ of __1__

INTO THE HOSPITAL ORGANIZATION
Reviewed by: WILLIAM GERDES Implementation Date: 6/1/2001___________
Approved by: CONSTANCE SHAMES, M.D. Distribution: Administrative Manual

Department Manual
Patient Care Manual
AOD Manual
I. Purpose: To demonstrate the integration of Pharmacy Services within the continuum of care of the
hospital.
II. Definition(s): N/A
III. Policy: The chain of accountability within the hospital radiates downward form the President (the
Governing Body) through his designated administrative staff to all departments. Some departments
and services are directly accountable to the Senior Associate Administrator while others are assigned
to designated staff members.
IV. Responsibilities: N/A
V. Procedures/Guidelines: The Pharmacy Director is under direct administrative control and direction of
the Senior Associate Administrator for Support Services. He/she reports directly to him/her on all
major matters and in the resolution of problems that cannot be satisfactorily settled in routine fashion
or require a major administrative decision.
A descriptive diagram of the Hospital Table of Organization follows this sheet for a ready reference.

VII. Attachments: Downstate Table of Organization
VIII. References: none
Date Reviewed Revision Required (Circle Responsible Staff Name and Title
One)
Yes No
Yes No
10
No: ___CH. 3 SECT. A___
Subject: PHARMACY STAFFING Page ____1__ of ____1__
Reviewed by: WILLIAM GERDES Implementation Date: 2/16/03

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide adequate staffing to address the pharmaceutical needs of the hospital 24 hours
per day 7 days per week.
III. Policy: It shall be the responsibility if the Departmental Director or his designee to implement and
maintain a staffing schedule that will insure coverage by Pharmacists and Pharmacy Technicians that
shall be adequate to provide timely service in keeping with work load and traffic flow. The hours of
operation for the services provided by the Pharmacy Department are as follows:
The Pharmacy Operational Hours are as Follows:
Main Pharmacy: Room ALL 1-469
 OPD: 8:30 A.M. – 5:00P.M., Monday through Friday

 IPD: 24 hours per day, 7 days per week, including holidays
Hyperalimentation Lab:
 8:30A.M. – 5:00P.M.,Monday through Friday and as needed on WHEN tours
Oncology Services: Room A6-401
 8:30A.M. – 5:00P.M., Monday through Friday
Operating Room Satellite Pharmacy: Room A2-481
 6:30A.M. – 3:00P.M., Monday through Friday
Parenteral Admixture Lab: Room ALL1-516
 7:00 A.M. – 6:00 P.M., Monday through Friday
Investigational Drug Lab: Room ALL1-514A
 8:30 A.M. to 5:00 P.M., Monday through Friday, On-Call status during other hours
11
V. Procedures/Guidelines:
1. Daily assignment sheets shall be prepared prior to 8:30 A.M. which allow adequate coverage of all
service areas that the Pharmacy Department provides.
Chapter 3. Sect. (A) continued
2. Staff Pharmacists shall rotate equally on weekend day shifts and, in case of emergencies, evening
and night weekend and weekday shift coverage.
3. Full time technicians shall rotate equally on weekend coverage during Pharmacy operational
weekend hours 8:30 A.M. – 12:00 Midnight, and in emergencies through the night shift.
4. Pharmacists shall cover all shifts, Tours I, II, and III Monday through Sunday.
5. Staff Pharmacists and technicians covering weekends shall take time off Monday and Tuesday (for
weekend evening coverage compensation) and Wednesday and Thursday (for weekend day
coverage compensation) of the week following the assignment.
6. Monday through Friday, the staff shall report to the department at 8:00 A.M., 3:30 P.M., or 11:30
P.M. according to a pre-assigned schedule.
7. Vacation schedules will be adapted to the situation and work-load at the time of request and follow
departmental request procedures.
8. Under no circumstances should the Pharmacy be open for service without a pharmacist on duty.
9. The operational hours of the OR satellite pharmacy are 6:30 A.M. through 3:00 P.M., Monday –
Friday. Service after these hours reverts to the Control Drug Module or the Main Pharmacy.
10. Official NYS holiday shifts (day, evening, or night) shall be covered by a pharmacist and Pharmacy
assistant. All staff pharmacists and Pharmacy assistants shall share in this responsibility except
for those pharmacists who in the judgment of the Pharmacy Administration would adversely affect
the Pharmacy’s operations if they were to participate in the holiday shift duties subsequent
compensatory time off.
When personal needs require changes in the schedule for weekend or holiday duty the person
desiring a change is responsible for working out alternate coverage at peer level and advising the
Director or his designee.
Whoever assumes the assignment shall make the change on the weekend/holiday schedule and
indicate acceptance and responsibility for the change by placing his/her initials on the schedule and
must inform the Associate Director of Pharmacy.

VII. Attachments: none
Yes No
Yes No
12
No: ___CH. 3 SECT. B___
Subject: DEPARTMENTAL TABLE OF ORGANIZATION Page ____1__ of ____1__

12/1/04
Reviewed by: WILLIAM GERDES Implementation Date: ___________

Department Manual
Patient Care Manual
AOD Manual
_______________________________________________________________________________________
I. Purpose: To serve as a guide to all personnel for the proper functions of Pharmacy Service areas and
reporting lines..
III. Policy: The administrative authority and responsibility within the Pharmacy Department begins with
the Director and runs down through the appropriate titles within the department.
V. Procedures/Guidelines: Functions of Pharmacy Service Areas
Materials Management:
 Drug and supply purchase requisitions
 Receipt of merchandise
 Reconciliation of invoices and purchase orders
 Returns of un-usable or expired merchandise
 Processing drug recalls
 Purchase order record keeping
 Inspection of merchandise
 Borrowing/lending merchandise between hospitals
 Annual inventory supervision sand planning
 Prime vendor management
 Drug usage reports
 Formulary additions/deletions to and from information management system
 PI activity participation
 Inventory management
Satellite Pharmacies:
 Drug cassettes filling and exchanges
 Maintenance of Nursing station supplies
 Review patient medical records
 Provide drug information
 Dispensing record and prescription record keeping
 Orientation of new medical house-staff or Nursing staff
13
 Inventory control of the satellite
 Rounding with physicians
 Inter-disciplinary committee participation
 Nursing station inspections
 Patient and family education and discharge counseling
 Telecommunications of orders to Main Pharmacy via FAX
 Controlled drug dispensing from the OR Satellite
Drug Admixture Services:

 Parenteral drug compounding of oncology drugs
 Parenteral compounding of hyper-alimentation and cardioplegia solutions
 Record keeping of parenteral orders and data management in pc databases
 Verification and clinical screening of all admixture orders
 Maintenance of patient profiles
 Drug information and education to medical house-staff and Nursing staff
 Distribution of completed admixtures
 Preparation of samples for chemistry and microbiology lab testing
 Maintenance of lab result testing of solutions
Main Pharmacy:
 OPD prescription dispensing
 IPD prescription dispensing
 Controlled drug dispensing
 Investigational Drug dispensing and record keeping
 Prescription record keeping
 Nursing station inspections
 Extemporaneous drug compounding
 Patient and family education and discharge counseling
 In-service education to medical house-staff and Nursing staff
 Pharmacy student education
 Cassette drug filling and exchange
Pharmacy Support Area:

 Pre-packaging
 Drug label printing
 Prescription and floor-stock order record keeping
 Inventory management
 Unit-dose packaging
 Computer charges for medications
 Drug order and admixture order delivery
 Drug returns and credits processing from Nursing care areas
 Separation and discard of deteriorated/expired drugs from inventory
Crash cart drug reconciliation and stocking

VII. Attachments: Administrative T of O; Departmental T of O
VII. References: none

One)
12/9/04 Yes No NICHOLAS GALEOTA, MS, RPH
Yes No
Yes No
14
ADMINISTRATIVE TABLE OF ORGANIZATION, 12/05:
Robert Jacobs, M.D.

CEO
Anny Yeung, RN, MPA

AVP Hospital Operations &
Perioperative Services
William Gerdes
Senior Associate
Administrator
Pharmacy Therapeutics
Committee
TH. Staff Assoc.
Materials Manager
Staff Asst II.
Adjunct Clinical Donald Caracciola
Pharmacist Associate Director
Research Clinical (6) Senior Pharmacists

Pharmacist
(11) Pharmacists
(14) Pharmacy Techs
Pharmacy Aide Pharmacy Attendant

Hospital Clerk
15
Table of Organization Pharmacy Department UHB, (2/05)
Nicholas Galeota
Director
M. Islam
TH. Staff Assoc.
Lawrence Melisi
Materials Manager
Raquel Bell
Staff Asst II.
Roopali Sharma
Donald Caracciola
Adjunct Clinical
Associate Director
Pharmacist
Motria Mishko
Ira Dinerman Helen Pruski
Research Clinical
Senior Pharmacist Senior Pharmacist
Pharmacist
Alan Hui Jihan Hanna
Elizabeth Iroku
Senior Clinical Senior Pharmacist
Senior Pharmacist
Pharmacist
Samia Youssef Henry W. Tseng Miyoung Hahn Mahammad Ali

Senior Pharmacist Pharmacist Pharmacist Pharmacist
Sung Kew Jung C. Dufour-Bazelais Digna Roberts Elena Shak

Pharmacist Pharmacist Pharmacist Pharmacist
Irene Saleh Rosa Aburto Kwame Sarfo Eveline Dorval

Pharmacist Pharmacist Pharmacist Pharmacist
Reynaldo Rivera Jairho Taboclaon Joan Watson Gloria Safo

Pharmacy Tech Pharmacy Tech Pharmacy Tech Pharmacy Tech
Mohammad
Irina Kuleshova Olga Rivera J. Flemming
Edreis
Pharmacy Tech Pharmacy Tech Pharmacy Tech
Pharmacy Tech
Roy Mustard Arlene J. Blyden Morvette Spencer Edith Bobmanuel

Pharmacy Tech Pharmacy Tech Pharmacy Tech Pharmacy Tech
Siu Hoe Oh
Joyce W. Savage
Pharmacy Tech
Pharmacy Tech
Leon Gantt Sandra Cunningham

Pharmacy Aide Alva Watson Pharmacy Attendant
Hospital Clerk
16
No: ___CH. 3 SECT. C___
Subject: EMERGENCY EVENING/NIGHT STAFF Page ____1__ of ____1__

COVERAGE

6/22/01

Department Manual
Patient Care Manual
AOD Manual
_______________________________________________________________________________________
I. Purpose: To inform all personnel the proper procedure when there is an emergency with staff
coverage.
III. Policy: The Main Pharmacy will remain open 24-hours per day, 7 days per week.
IV. Responsibilities: It is the responsibility of Pharmacy Associate Director to seek a pharmacist for this
assignment. The Associate Director shall also keep all records of time worked and grant equivalent
scheduled time off.
V. Procedures/Guidelines: In the event that the assigned pharmacist is unable to work his or her shift
due to an emergency beyond their control, he or she is required to call the Pharmacy office that
morning no later than 10 A.M. so that adequate staffing can be arranged.
The procedure to obtain emergency coverage will be as follows:

1. A volunteer pharmacist from the day shift shall be sought.
2. In the event that there is no volunteers, then the pharmacist with the least seniority shall be
assigned to perform the extra shift, which extends his or her services to 12:00 Midnight or to 8:00
A.M.
3. A record shall be maintained for the emergency duty performed.
4. On the next occasion for emergency coverage the next least senior person shall be assigned the
duty in the event of no volunteer.
5. The pharmacist assigned the duty shall be granted equivalent scheduled time off.


17
One)
Yes No
18
No: ___CH. 3 SECT. D ___
Subject: ON-CALL/RECALL SERVICES Page ____1__ of __1__

6/22/01
Approved by: CONSTANCE SHAMES, M.D Distribution: Administrative Manual

Department Manual
Patient Care Manual
AOD Manual
_______________________________________________________________________________________
I. Purpose: To provide a system for supplementing staffing in the event of a staff shortage or
emergency.
III. Policy: The Pharmacy Department shall maintain at least one (1) pharmacist on an On-Call/Recall
basis via beeper. A pharmacist shall be On Call at all times to cover staff shortages and emergency
situations. TH Pharmacists, TH Senior Pharmacists, and TH Pharmacy Assistants may be re-called at
any time if the Pharmacy or hospital operations require the re-call.
The on-call pharmacist shall carry a long-range beeper (1-917-760-0496) with the state page at
extension 2121.
IV. Procedures/Guidelines:
A) When a question or emergency situation arises from the medical staff, nursing staff or
administrative staff of UHB, the pharmacist On-Call shall be paged.
B) The pharmacist shall respond to the page by calling the telephone number appearing
on the beeper.
C) The pharmacist shall answer the questions as best as his/her professional knowledge
will allow.
D) If an emergency situation exists, the On Call pharmacist shall be recalled to UHB, 445
Lenox Road, Brooklyn, Pharmacy Department by either the Director or Associate Director of
Pharmacy.
E) The Pharmacist shall be allotted a reasonable amount of time to report to the work site
(usually within 1 hour).
F) When the pharmacist arrives at UHB, he/she must first sign the recall logbook and then
proceed to the assigned Pharmacy area and work till the emergency is resolved.
19
G) The pharmacist shall be compensated according to UHB Policy and UUP contractual
agreements for On Call/Recall services.
H) The pharmacist shall report their On Call/Recall hours on the bi-weekly NTP Report of
On Call/Recall services, HSCB form # 0017.
I) A monthly report form titled Monthly Overtime Analysis Form (see attached) for
Pharmacy Employees shall be compiled every month by the Director of Pharmacy and
forwarded to the Senior Associate Administrator responsible for Pharmacy. This form shall
provide data for administrative decisions concerning staffing, overtime usage, and budget
allocations. This form shall be used for UUP and CSEA employees.

VII. Attachments: Pharmacy Staff Names and Addresses

Sample of On Call/Recall Reporting Forms
One)
Yes No
Yes No
20
No: ___CH. 3 SECT. E___
Subject: BREAK PERIODS Page ____1__ of ____1__
6/22/01
Reviewed by: WILLIAM GERDES Implementation Date: ________

Department Manual
Patient Care Manual
AOD Manual
_______________________________________________________________________________________
I. Purpose: To advise all personnel the rules of break periods according to their Union Agreements.
III. Policy: Break periods are to be taken according to union agreements by all staff members.
A. Non-Professional (CSEA):
Department personnel are entitled to two (2) fifteen minute breaks in the work routine
of each routine of each shift worked. This is in addition to the standard thirty minute
meal period. The following guidelines shall apply to the scheduling utilization of this
commonly-called “coffee break”.
1. Break periods shall not be regularly scheduled because of unpredictable

fluctuations in the work load.
2. Personnel desiring such a break can take it after approval by a supervisor.
3. Such breaks can be taken inside or outside of the department. If it is to be

spent within the department it must be in the conference room area that is not
within a line-of-sight of the main entry to the Pharmacy or the Pharmacy
window.
4. Such breaks cannot be added to scheduled meal periods.
B. Professional (UUP):
According to the UUP agreement, there is no provision for scheduled break time.
However, professional employees are entitled to one hour scheduled meal periods,
which shall be scheduled by a supervisor.
21
V. Procedures/Guidelines: All break periods/lunch breaks are scheduled with the Pharmacy
supervisor prior to commencing the break.
.

One)
Yes No
Yes No
22
No: ___CH. 3 SECT. F__
Subject: DRESS AND GROOMING CODES Page ____1__ of ____1__

6/22/01
Reviewed by: WILLIAM GERDES Implementation Date: _______

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To serve as a guide to all personnel to for the proper procedures for dress and grooming
codes.
III. Policy: Pharmacy personnel shall observe the following dress and grooming code. (see procedures
and guidelines)
V. Procedures/Guidelines
1. Clothing styles shall be of a nature that will not cause medications to be
accidentally dislodged from low shelves during normal movement about the
department and that shall preserve modesty when it is necessary to obtain
items from the high shelves.
2. Footwear shall be of a nature that will protect the foot in the event of dropped or
falling objects striking that part of anatomy. Sandals are not permitted.
3. Hair shall be worn in a fashion that permits restraints being properly worn when
working in the clean room or compounding medications.
4. White lab coats shall be worn by all Pharmacy personnel.
5. The approved updated hospital ID tag shall be worn at all times while on
hospital property.
6. For the professional staff, the NYS Department of Education’s Board of

Pharmacy official white name tag is also to be worn (Reference: Pharmacy
Handbook, NYS, Article 130, Section 6808-a, page 33) in place of the
hospital I.D. tag, if chosen, while in Pharmacy service areas.


23
One)
Yes No
Yes No
24
No: ___CH. 3 SECT. G___
Subject: JOB DESCRIPTION: DIRECTOR OF PHARMACY Page ____1__ of ___1__

6/22/01
Reviewed by: WILLIAM GERDES Implementation Date:

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To serve as a description for the Director of Pharmacy position and duties.
III. Policy: The positions in this job family dispense appropriate doses of drugs to inpatients and
outpatients as prescribed by a physician; manufacture sterile and non-sterile prescriptions; deliver
drug information and instruction to health care professionals, patients, and their families based on
pharmacological expertise and the interpretation of Pharmacy policy.
Teaching Hospital Director of Pharmacy:

Develops, implements, directs and manages pharmaceutical service programs consistent with the
needs of medical staff, patients and the institution. Controls and is accountable for drug products
throughout the hospital; develops and implements, with medical staff participation and approval when
required, policies and procedures regarding departmental operations and the criteria for evaluation,
selection, preparation, procurement, storage, distribution and all other matters relating to drug use in the
hospital. Collaborates in the development and implementation of programs of records and documentation
management ensuring Pharmacy activities involving review, interpretation and therapeutic monitoring of
all drug order, the maintenance of patient medical profiles and participation in patient care. Develops
programs to evaluate the effectiveness of drug utilization and departmental function; oversees the
preparation of the department’s budget for staff, supplies and equipment. Ensures the maintenance of
departmental practice standards and satisfactory operation of staff, nursing, medical staff and students.
Ensures compliance with Hospital policies and procedures, local, state, and federal regulations, rules and
regulations of the medical staff mandatory JCAHO standards and other regulations and they pertain to
Pharmacy operations; develops and maintains effective liaison with all other hospital departments and all
appropriate external agencies; maintains the formulary and reference text sand journals; consults with
and advises medical staff concerning medication (such as: warnings, incompatibility, contraindications,
uses, expenditures, etc.). Participates on various committees (note: e.g., Medical Records Committee, the
Nutrition Committee, Infectious Control Committee, and The Pharmacy Therapeutic Committee).
Functions independently with collaborative supervision. Responsible for in-service program and
instruction to medical staff, residents, students and staff. Provides administrative supervision to
Pharmacy staff.
25
V. Procedures/Guidelines: N/A

One)
Yes No
Yes No
26
No: ___CH. 3 SECT. H___
Subject: JOB DESCRIPTION: ASSOCIATE DIRECTOR Page ____1__ of ____1__

OF PHARMACY

6/22/01

Department Manual
Patient Care Manual
AOD Manual
_______________________________________________________________________________________
I. Purpose: To serve as a description for the Associate Director of Pharmacy position and duties.
IV. Policy: N/A
Teaching Hospital Associate Director of Pharmacy:

Assists the Director of Pharmacy in the daily operation of the Pharmacy ensuring that all sections of
the Pharmacy Department are functioning properly,; endures that all documents related to Pharmacy
operations (note: e.g., floor stock sheets and controlled drug sheets, orders and prescriptions) have been
computerized, counted and stored as required; ensures that all devices are in working order (note: e.g.,
pharmaceutical balances, refrigerators, and laminar flow hoods); interprets Pharmacy administrative
policies and procedures and makes decisions relative to them; assumes responsibility of Director in
his/her absence. Advises the Director of all problems pertaining to the operation of the Pharmacy (note:
e.g., specific patient care, drug utilization and materials management); supervises the conduct of
departmental studies, and the completion of periodic reports, permit applications and surveys for outside
agencies (note: e.g., NYS Department of Health, State Board of Pharmacy); ensures that drug recalls are
handled expeditiously, including removal of drug from pharmacy shelves, and all hospital locations;
maintains and develops work scheduled for Pharmacy staff. Periodically evaluates performance of
subordinates; prepares evaluations of requests to add drugs to the Formulary: disseminates or oversees
dissemination of information related drug therapy and departmental policies and procedures; ensures the
proper resolution and reporting of patient and professional staff complaints; coordinates investigational
drug studies and oversees staff participation; represents the department on appropriate committees.
Studies and modifies work flow pattern; evaluates operating procedures within the Pharmacy; assist in
preparation of the Pharmacy budgets, the purchase of drugs and supplies and maintenance of inventory
control records, approves or obtains approval for requisitions and orders for necessary pharmaceuticals
and supplies; develops programs institutes by the Pharmacy, including training sessions. Ensures
repackaged medications are in compliance with departmental requirements, that labeling is regulations
relating to controlled substances and the maintenance of accurate inventories. Reports to the Director of
Pharmacy and may supervise the T.H. Senior Pharmacist, T.H. Pharmacist and T.H. Pharmacist Assistant.
27
One)
Yes No
Yes No
28
No: ___CH. 3 SECT. I___
Subject: JOB DESCRIPTION: T.H. PHARMACIST/ Page ____1__ of ____1__

TH SENIOR PHARMACIST
6/22/01

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To serve as a description for the TH Senior Pharmacist and TH Pharmacist positions and
duties.
III. Policy: N/A
Teaching Hospital Pharmacist:

Compounds and dispenses medications and other pharmaceutical supplies, reviews orders and
prescriptions for appropriateness and patient safety. Enters medication orders onto medication
profiles and updates medication profiles as required; this includes checking for drug interactions,
incompatibilities and optimum drug therapy; participates in narcotic drug and controlled drug
distribution program as required; prepares or oversees preparation of parenteral nutrition and other
sterile solutions using aseptic preparation of parenteral nutrition and other sterile solutions using
aseptic techniques; check medication carts and makes necessary corrections, maintain records of
prescriptions or orders filled; provides explanation and directions for proper use of all prescriptions
for outpatients. Participates in the department’s in-service education program. Performs monthly
nursing unit inspections as assigned in accordance with J.C.A.H.O. Requirements. Participate in
Performance Improvement and Drug Utilization Evaluation Programs; provide drug information to
professional staff and patients; participate in the On Call/Recall program during hours when the
Pharmacy is closed.
Supervising Responsibility:
Position is supervised by the T.H. Director of Pharmacy, the T.H. Associate Director of Pharmacy, and
the TH Senior Pharmacist Supervisor. This title will supervise T.H. Pharmacy Assistant (Technicians),
students, and Pharmacy Aides, Pharmacy clerical staff and any Hospital attendants or volunteers
assigned to the Pharmacy.
29
One)
Yes No
Yes No
30
No: ___CH. 3 SECT. J__
Subject: JOB DESCRIPTION: PHARMACY ASSISTANT Page ____1__ of __1__

(TECHNICIAN)

6/22/01
Reviewed by: WILLIAM GERDES Implementation Date: ________

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To serve as a description for the Pharmacy Assistant (Technician) position and duties.
III. Policy: The Teaching Hospital Pharmacy Assistant is under the direct supervision of the Director and
Associate Director of Pharmacy as well as T.H. Pharmacist/T.H. Senior Pharmacist in their daily duties.
IV. Responsibilities:
The duties of the Pharmacy Assistant are:
a) Receiving written prescriptions
b) Typing prescription labels
c) Keying prescription data for entry into a computer generated file or retrieving prescription data
from the file in accordance to the following:
1. A technician may key prescription data for the approval of the pharmacist,
provided that when the pharmacist enters the date into the file along with his or
her initials as the dispenser of the prescription
2. A technician may retrieve prescription data from the file for review by the
pharmacist, provided that when the prescription is to be refilled, the pharmacist
shall enter his or her initials as the dispenser of the refill together with the date
on which the prescription was refilled
d) Obtaining drugs from stock and returning them to stock

e) Obtaining prescription files and other manual records from storage and locating prescriptions
f) Counting dosage units of drugs
g) Placing dosage units of drugs in appropriate containers affixing the prescription label to the
container
h) Affixing the prescription label to the container
i) Preparing manual records of dispensing for the signature or initials of the pharmacist
j) Handling or delivering complete prescriptions to the patient or the patient’s agent
k) Filling cassette exchange carts from patient profile records
l) Assist in the preparation of parenteral solutions
m) Run cart-fill function in the automated dispensing system
31
One)
Yes No
Yes No
32
No: ___CH. 3 SECT. K___
Subject: JOB DESCRIPTION: PHARMACY AIDE Page ____1__ of ____1__

6/22/01

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Incumbents of positions in this class perform routine manual and clerical activities in
receiving, storing, repackaging and issuing pharmaceutical supplies in a pharmacy serving the
residents of a State facility. Incumbents also maintain an inventory of pharmaceutical supplies,
prepare orders for new supplies and prepare some standard stock solutions according to
prescribed formulas. Incumbents also deliver medication supplies throughout the hospital.
Positions in this are found in various facilities of the Departments of Mental Hygiene, Correctional
Services, and the State University.
II. Definition(s): CLASSIFICATION CRITERIA AND DISTINGUISHING CHARACTERISTICS

Pharmacy Aides are characterized by the performance of routine and repetitive clerical
and manual tasks in the receipt, storage, repackaging and issuance of pharmaceutical supplies, in the
preparation standard stock solutions, ointments and other preparations and in the maintenance of
uncomplicated records. Although repetitive, the majority of tasks performed by Pharmacy Aides
require accuracy, timeliness, strict adherence to guidelines and precise attention to detain to insure
safe, effective and efficient operation of the pharmacy. Pharmacy Aides work under the supervision
and direct observation of a licensed pharmacist.
Other clerical classes responsible for performing a variety of stores and supply activities include
Stores Clerk and Mechanical Stores Clerk, incumbents of which perform routine clerical manual work
involving the receipt, storage and distribution of a variety of perishable and non-perishable goods,
materials and equipment in a stockroom or warehouse. The activities and tasks performed by these
two classes are similar, the main distinction being the type of materials and supplies handled.
Typically, Stores Clerks are assigned to stores programs handling a wide variety of goods, materials
and equipment, household and office equipment and supplies, and printing supplies. Mechanical
Stores Clerks receive, store and issue such mechanical stores as tolls, construction materials, and
such ground supplies as seed and fertilizer.
Position engaged in the practice of pharmacy are classified a Pharmacist or Senior Pharmacist.
III. Policy: N/A
IV. Responsibilities: TYPICAL ACTIVITIES, TASKS AND ASSIGNMENTS

Unpacks, sorts and counts pharmaceutical supplies for storage or distribution following specific instructions
and standard procedures.
 Checks incoming shipments for breakages or shortages.
33
 Stores supplies in designated areas including some, which require special handling and/or
refrigeration.
 Restocks storage areas as needed.
 Removes outdated drugs.
 Replenishes ward stock items.
 Records receipt and distribution of supplies on standard forms.
 Process orders for alcohol withdrawals.
Chapter 3. Sect (K) Continued
Fills various sizes and types of packages or containers by hand or by machine from bulk manufactured or
purchased quantities.
 Repackages bulk supplies, e.g., soaps, rubbing alcohol and disinfectant into smaller amounts and
containers.
 Prepackages prescription medications in unit-dose/robotic form for dispensing at a later time.
 Prepares various standard preparations according to prescribed procedures.
 Assists licensed pharmacist in filling and preparing drug orders.
 Operates electronic capsule and tablet counter, which automatically distributes a certain number of
capsules or tablets into smaller containers. This includes pneumatic packaging devices for robotics
packaging.
 Prepares labels under the supervision of a pharmacist by hand or by operating a labeling machine.
 Affixes labels by hand or by operating a labeling machine.
 Maintains and clean equipment used in the pharmacy.
 On occasion, delivers supplies to wards or clinics.
Performs a variety of clerical tasks in support of a pharmacy’s operation.
Prepares and maintains records for inventory control, such as purchase orders, receipt records, floor stock
records, prepackaging records, supplies dispensed and patient Profile.
 Notifies the pharmacist of inventory levels for placement of orders.

 Brings to the attention of the pharmacist unusual requests made by nursing units.
 May answer routine factual telephone inquiries and/or refer caller to pharmacist.
 May screen incoming mail to the pharmacy.
May perform a variety of light housekeeping tasks in order to maintain a safe and clean environment in the
pharmacy.
May assist the pharmacist in conducting ward inspections.
V. Procedures/Guidelines: RELATIONSHIPS WITH OTHERS
Pharmacy Aides have frequent written and oral communications with their supervisor, a licensed pharmacist,
who provides frequent instructions and directions. Incumbents also have brief written (forms) and oral
communications with personnel employed at the facility who pickup deliveries to wards and clinics.
On request incumbents submit brief oral and written factual reports to the pharmacist describing the
condition of stock, inventory level and the status of orders.
NATURE OF SUPERVISION
Typically, positions in this class are non-supervisory. The majority of tasks performed by positions in this
class are closely supervised by a Pharmacist or Senior Pharmacist. Certain tasks, once
learned and performed satisfactorily, however, are usually performed independently. Initially, incumbents
receive on-the-job training consisting of step-by-step instructions and in-process review. After initial training,
incumbents perform many specifically prescribed tasks under close observation and continuous evaluations
to accuracy, neatness and progress.
34
Typically, all activities undertaken by Pharmacy Aides are assigned by pharmacist who give detailed
instruction concerning work methods and procedures, demonstrate work techniques, closely supervise work
in progress and review completed work.
JOB REQUIREMENTS
 Working knowledge of the accepted methods and practices used in receiving, storing and issuing
pharmaceutical supplies.
 Working knowledge of inventory procedures.
 Working knowledge of precautions needed to maintain secure and sanitary conditions.
 Working knowledge of the generic, chemical and proprietary names of commonly prescribed drugs.
Chapter 3. Sect (K) Continued
 Working knowledge of the classification of drugs.

 Ability to operate various small machines such as a label printing machine, a mixer, and electronic
tablet and capsule counter and an automatic unit dose strip-packaging machine.
 Ability to perceive details, errors or omissions on work orders, checking printed labels.
 Ability to perform repetitive activities.
 Ability to understand and carry out both oral and written instructions.
 Ability to work with metric apothecary systems and abbreviations.
 Ability to perform basis pharmaceutical calculations.
 Ability to bend, lift, climb, stoop and kneel.
 Ability to understand and operate a mainframe computer and/or pc.

One)
Yes No
Yes No
35
No: ___CH. 3 SECT. L__
Subject: JOB DESCRIPTION: TEACHING HOSPITAL Page ____1__ of ___1__

STAFF ASSISTANT II (MATERIALS MANAGER)

6/22/01

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To serve as a guide for the Teaching Hospital Staff Assistant II (Materials Manager) position.
IV. Policy: N/A
IV. Responsibilities: Direct and specific areas of responsibility, which encompass the complete spectrum
of financial transactions regarding Pharmacy purchases. May prepare monthly and year-end journal
entries and assistance to outside CPA firm during the audit and additional assistance to department
during audit season as necessary. Full theoretical understanding of general ledger activity and
financial reporting. Specific knowledge of financial principles and their application to the health care
industry within the N.Y.S. system. Appointee should be proficient in all areas of functional
responsibilities. Work involves analytical and problem-solving skills requiring moderate independent
judgment; final approval rests with higher authority. Prepares operational reports, which may impact
hospital finances. Leadership limited to fulfilling daily work assignments or carrying out projects;
regular contact with clerical staff and other finance related areas, occasional but limited outside
contacts. This position is responsible for the daily ordering of supplies, the maintenance of all storage
areas, accountability of computer inventory records, conduct an annual inventory, supervise drug
returns for re-use/credit/destruction, and provide monthly an on-demand usage reports for specific
drugs or drug categories.


36
One)
Yes No
Yes No
37
No: ___CH. 3 SECT. M__
Subject: JOB DESCRIPTION: HOSPITAL ATTENDANT Page ____1__ of ____1__

6/22/01

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To serve as a description for the Hospital Attendant position and duties.
III. Policy: N/A
IV. Responsibilities: When this title is assigned to the Pharmacy the duties shall be:
 Maintain general orderliness and cleanliness of main pharmacy, labs, storerooms, and satellite
pharmacies.
 Deliver supplies to other hospital departments, nursing care areas, and between the pharmacy
service areas.
 Assist in the break down and storage of supplies.
 Work with Pharmacy Aides in the packaging areas of the Pharmacy. This position is restricted
to non-clinical, on-professional, and non-judgmental task.
V. Procedures/Guidelines: This position is to be supervised by the Pharmacy Aide, Pharmacy Assistant

(technician), T.H. Senior Pharmacist, T.H. Pharmacist, Associate Director of Pharmacy and Director of
Pharmacy.

One)
Yes No
Yes No
38
No: ___CH. 3 SECT. N_
Subject: JOB DESCRIPTION: DEPARTMENT SECRETARY Page ____1__ of ____1__

Staff Assistant II

6/22/01

Department Manual
Patient Care Manual
AOD Manual
I. Purpose: To serve as a description for the Department Secretary position and duties.
II. Definition(s): A full time secretarial person serving in a supportive position to the Department
Director and other staff members for secretarial and clerical functions.
III. Policy: N/A
IV. Responsibilities: DUTIES

1. Departmental Typing
2. Interdepartmental Charges
3. Maintain Literature Files
4. Compile Pharmacy Statistics
5. Process Patient Charges
6. Audit Patient Charges as Required
7. Maintain Productivity Records
8. Maintain Stock Records
9. Audit Invoices
10. Follow through on Shorts
11. Maintain Purchasing Group Records
12. Perform committee work as needed
13. Completes Performance Improvement Reports
14. Such other duties as may be assigned
EDUCATION
High School graduate or equivalent
EXPERIENCE
One year in business office environment
SKILLS
Typing essential, minimum 50 words per minute. Good command of English language, high level
spelling ability. Knowledge of computer based programs for word processing and spread sheet creation.
39
CONTACTS
Pharmacy personnel, Nursing staff, other hospital employees, sales representatives, Medical Staff
members.
PHYSICAL DEMANDS
Lifting light-weight objects, stooping for filing, on feet approximately 20% of shift

One)
Yes No
Yes No
40
No: ___CH. 3 SECT. O__
Subject: ORIENTATION AND CONTINUING EDUCATION Page ____1__ of ____1__

OF PHARMACY PERSONNEL

6/22/01
Reviewed by: WILLIAM GERDES Implementation Date: __________

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To inform all new employees to participate in Orientation and Continuing Education
programs.
III. Policy: All new Pharmacy employees shall be oriented to the complete operation of the department as
the cornerstone of the employee education program. All staff members shall also participate in relevant
education programs including in-ser vice and external continuing education programs.
IV. Responsibilities: The immediate supervisory shall have the responsibility to complete the orientation
process prior to commencement of duties for all new employees. The staff member has the
responsibility to adhere to all policies & procedures for both the Pharmacy Department and the
Hospital. Pharmacy administration and Hospital Administration shall maintain all the appropriate
records of in-service/continuing education.
Departmental:
The immediate supervisor of the incoming staff member shall conduct an orientation session
during the first day of employment to cover the following subjects:
 Performance program
 Functional and management relationships within the Pharmacy Department and interdepartmentally
 Organizational structure within the hospital
 Performance evaluation process
 Licensing and credentialing of professional staff
 Overview of Pharmacy’s Policy & Procedure Manual
 Attendance reporting
 Requirements for continuing and in-service education
 Hours of operation
 Location of fire alarms, extinguishers, and exit routes within the department
 Location of Disaster Cart, its use, and personnel responsibilities
 Patient confidentially and data security
All employees are to receive copies of all written policies and procedures that fall within their job description.
Each new employee is to be told to ask questions of his/her immediate supervisor so as to develop
competency in the following areas:
41
1) Outpatient Dispensing
2a) Inpatient Dispensing from Main Pharmacy
2b) Inpatient Dispensing from Satellite – Unit Dose Pharmacy
3) Non-sterile manufacture of pharmaceuticals
4) Hyperalimentation & IV Additive Preparation
5) Providing of Drug Information
6) Q/A/DUR/ADR/DUE/CQI Team Participation
7) Controlled Substance Dispensing
8) Investigational Drug Dispensing & Record Keeping
9) Patient and Family Education Requirements
10) Patient Rights and Confidentiality and Data Security
11) Age Specific Competency
12) Clinical Data Evaluation
Chapter III Sect. O Continued
The employee shall complete an orientation record form after the orientation process is completed. He/she
shall sign this document and the document will be placed in the individual’s Departmental personnel
file (see attached)
VI. The appropriate hospital department shall provide the following orientations to the new
staff members:
 Fire & Safety

 Infection Control
 AIDS Confidentiality
 Employee Benefits
 Right to Know
 Sexual Harassment Prevention Training
 Patient Confidentiality
 Patient Bill of Rights
 Hospital Policy & Procedure
 Medical and Chemical Waste Management
 Data and Information Security
VII. Continuing Education:
Pharmacy administration shall schedule appropriate pharmaceutical in-service education

programs for the Pharmacy staff. Records of attendance shall be maintained in the Pharmacy Office.
Records of participation in the Pharmacy office unless mandated by law for a licensee to maintain their own
records.

VII. Attachments: Pharmacy Orientation Records
One)
Yes No
Yes No
42
No: ___CH. 3 SECT. P__
Subject: COMMITTEE MEMBERSHIP OF Page ____1__ of ____1__

PHARMACY PERSONNEL
Reviewed by: WILLIAM GERDES Implementation Date: ___6/22/01____

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: The Pharmacy staff shall be represented and participate in the various Clinical and
Administrative Committees within the hospital, the university, and within the Pharmacy Department. The
Pharmacy staff shall also participate in the interdisciplinary patient care teams.
III. Policy: N/A
V. Procedures/Guidelines: A member of the Pharmacy staff is appointed by the Director of Pharmacy,

Hospital Administration, or the Executive Committee to serve as a representative of the Pharmacy on the
following Committees within the hospital:
1. Health Care Review (Institutional Review Board)

2. Infection Control
3. Nutrition
4. Pharmacy & Therapeutics and its sub-committees
5. Ancillary Support, Technical, Q/A, PI Committees
6. CPR
7. Support Services
8. Interdisciplinary
9. Ambulatory Q/A Committee
10. Quality Management Panel
11. Nursing – Pharmacy Committee
12. CQI Teams
13. JCAHO Survey Preparation and Standards Review Task Forces
14. Parenteral Nutrition Team
15. Tumor Board
16. Oncology Grand Rounds
17. Medication Usage Sub-Committee of the P&T Committee
18. Ad Hoc project committees
19. Patient and Family Education
43
Within the Department of Pharmacy
1) Intradepartmental Q/A Committee
VI. Reasons for Revision

One)
Yes No
Yes No
44
No: ___CH. 4__
Subject:: INPATIENT DISPENSING OF MEDICATION Page ___1__ of ___1__
Reviewed by: WILLIAM GERDES Implementation Date: ___6/22/01___

Department Manual
Patient Care Manual
AOD Manual
_____________________________________________________________________________________
I. Purpose: To establish policies and procedures for pharmacists to follow for inpatient dispensing of
medication in a safe, efficacious, and legal manner.
III. Policy: All medication for in-patients will be dispensed by a licensed pharmacist from the Main
Pharmacy, the Pharmacy labs, or satellites in unit dose form, if available and appropriate, upon receipt of a
written prescription order from an authorized practitioner. A cassette exchange system shall be utilized daily
to provide a 24-hour supply of medication based on current, active physician orders.
No verbal orders from authorized prescribers for medication shall be accepted by the Pharmacy staff.

One)
Yes No
Yes No
45
Chapter 4 Sect. A
A) #1 Main Pharmacy (Cassette Exchange)
Procedure: (a) An authorized prescriber writes a complete prescription order on the prescription
section of the Physician’s Order Form in the patient’s medical records. A complete order contains:
 First and last name of the patient
 Patient ID number
 Date
 Drug
 Dosage
 Route of Administration
 Frequency
 Duration (maximum is 30 days unless drug falls under automatic stop order
policies for shorter durations)
 Signature of prescriber and time of the prescribing
 Stamped or printed name of the prescriber
Note: Diagnosis can be obtained form the patient’s medical record or medication profile. Allergies,
height, weight, OTC and herbal medications, pregnancy and lactation data are taken prior to or upon
admission and are obtained form the daily computer Allergy & Weight Report as well as the patient’s
medical record, medication profile information provided by the EAGLE System.
b. A nurse picks up the medication order, signs it and places the time on the order that it is
picked up by the nurse.
c. The order is then give to the Nursing station clerk to affix a patient label.
d. The order is picked up by Pharmacy Technicians during their daily rounds, faxed,
delivered by pneumatic tube, or via messenger service to the Pharmacy services. STAT
orders may be delivered to the Main Pharmacy via hospital messenger or Nursing personnel.
e. The doses of medication are prepared for dispensing after a pharmacist enters the order
into the robotics database this creating the patient profile and the technician performs the
necessary cart fill function. First doses and STAT doses are dispensed immediately and
the continuation therapy is delivered in the cassette exchange. The charge and the
backup file is generated daily and these charges are picked up by the EAGLE system for
the appropriate charges to patient accounts.
f. Upon receipt of the written prescription order, only a pharmacist shall check the order for
accuracy, proper dosage, safety, and possible drug, food, or disease interactions.
g. The pharmacist shall make any corrections or initiate any phone inquiry to clarify the
order. Any correction to the medication order shall require a new order to be written by
the prescriber in the medical record and an order written to discontinue the previous
incorrect order.
h. The pharmacist shall double check the prescription against the contents of the vial, bottle,
robotics package, or injection envelope.
i. The pharmacist shall then sign or initial the prescription order as well as stamp the
prescription with their identifying stamp. The entry of orders into the robotics database
can only be done by pharmacists. The patient profile indicates which pharmacist was
responsible for the order. An auxiliary label shall be placed on the immediate drug
container by a pharmacist. A WARNING OF SOUND ALIKE – LOOK ALIKE ERROR
POTENTIAL SHALL BE PLACED IN THE PATIENT MEDICATION CASSETTE BY THE
PHARMACIST IF THE POTENTIAL EXISTS BASED ON DESIGNATED DRUG LIST.
j. Completed prescription orders from the cart-fill function shall be placed in a cassette
drawer and delivered during the cassette exchange cycle for the Nursing station. Doses in
46
between cassette exchanges shall be placed on a delivery bag marked with the nursing
station number and delivered to the Nursing Station either by Pharmacy personnel or hospital
messenger.
k. STAT orders will be processed immediately upon receipt from a nurse or hospital
messenger and returned directly to these individuals after completion for delivery back to the
nursing station.
Requirements for in-patient labeling for non-robot packaged medications:
 Date
 Patient ID#
 Nursing Station
 Patient’s First and Last Name
 Drug Name (proprietary and/or generic)
 Strength or Potency of the Drug
 Dosage Prescribed
 Route of Administration
 Frequency
 Duration
 Amount Dispensed
 Precautionary and Auxiliary Labels
 Dispenser’s Initials
B) Satellite Pharmacies:
All procedures are to be followed as in the Main Pharmacy cassette exchange dispensing of
medication and the Policy on Unit Dose/Cassette Dispensing of Drugs. (See Chapter 4, Section C)
47
No: ___CH. 4. SECT. C__
Subject: UNIT DOSE DISTRIBUTION SYSTEM Page ____1__ of ____1__
Reviewed by: WILLIAM GERDES Implementation Date: __6/22/01__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To direct pharmacists to dispense drugs in unit dose form where available utilizing the unit
dose distribution system provided by the robotics dispensing device..
III. Policy: In-patient drugs shall be dispensed in unit dose form, where available and appropriate, using a
cassette exchange system.
IV. Responsibilities: The support staff shall pick-up the written medication orders to be brought to the
Pharmacy./ The Pharmacy technician shall fill the cassette supervised by a pharmacist. The Pharmacy
technician shall deliver the cassette to the nursing stations.
V. Procedures/Guidelines: A copy of the prescriber’s original order shall initiate the dispensing of
individual patient orders for medications. The Pharmacy copies shall be sent via messenger,
Pharmacy Aide, technician or Fax machine to the Pharmacy.
As patients are admitted, the computer shall send a label for each patient to the nursing station. The
patient shall be assigned a drawer on the appropriate cassette. The allergy information section of the
profile shall be verified by the pharmacist. The patient’s weight and allergies shall be retrieved from
the computer profile system, the printed daily report, or the patient’s medical record. The diagnosis
shall be retrieved from the patient medical record (chart) or the medication profile.
A pharmacist shall review the Pharmacy copies of all medications orders and discontinuation
medication orders hall be checked for correct dose, compatibility, drug, food, disease interactions,
and for any prescription or transcription errors.
Documentation on the patient medication database profile must follow this format:
1. One line is used for each routine order, containing the name of the drug, dose,
strength, frequency, and duration of therapy. All entries on patient medication
profile are strictly the responsibility of a licensed pharmacist.
2. A 24-hour supply shall be placed in the patient cassette bin.
By 10:00 a.m. daily or at customized times daily, the cassettes shall be delivered to each unit. The
empty cassettes are removed from the units and returned to the Pharmacy. These empty cassettes are then
filled using the Pharmacy profile sheets. This task is usually done by a pharmacy technician.
Unit dose packaged tablets, oral liquid and injections, shall be place din clear plastic bags and labeled both
with a bar code and alpha description. All topical, ophthalmic, and otic preparations will be dispensed in the
48
smallest commercially available dosage form. These products when dispensed shall be placed in clear plastic
bag.
Oral solid dosage forms that are not available in unit dose form shall be labeled appropriately (refer to IPD
dispensing medication labeling.)
When all cassettes are complete, the registered pharmacist checks each order and initials the medication
order, profile, and label where appropriate. Upon checking the cassettes, any extra or excess medication
should be taken out of the cart and inquires made by the pharmacist to the nurse to ascertain the reason for
the returned doses. Only current drug orders are to be sent in the cassette. Drugs that are returned and that
have been ordered on specific schedules should be questioned. A determination of the status of the
medication order is to be made by the pharmacist. Communicating with the nurse and prescriber is essential
for the completion of this task.

One)
Yes No
Yes No
49
No: ___CH. 4__SECT D
Subject: APPENDIX TO UNIT DOSE DISTRIBUTION Page ____1__ of ____1__

POLICY

Department Manual
Patient Care Manual
AOD Manual
_____________________________________________________________________________________
I. Purpose: To inform employees of the Drug Dose Distribution Policy.
III. Policy: The following list of drugs is not available commercially in unit dose packaging. These drug
entities shall be dispensed in non-unit packaging by the Pharmacy Department in unit dose form. These
drugs are to be packaged, if appropriate, in robotic bar coded packaging. The quantities dispensed will be for
no more than a one-day cassette exchange cycle.
V. Procedures/Guidelines: The Drug Entities Are:

FLUOXETINE CAP 20MG PINDOLOL TAB 5MG
PINDOLOL TAB 10MG METHOTREXAT, TAB 2.5MG
BUSULFAN TAB 2MG NH2 CAPROIC ACIDE TAB 500MG
AMINOPHYLLINE, TAB 100MG ESTRAMUSTINE CAP 140MG
TERFENADINE TAB 60MG D-AMPHETAMINE TAB 5MG
SALSALATE TAB 500MG DEXTRO-PROPXPHENE CAP 32MG
SALSALATE TAB 750MG ALBUTEROL SA TAB 4MG
ALBUTEROL TAB 2MG GUANADREL SULFATE TAB 10MG
CYCLOPHOSPHAMIDE TAB 25MG DIETHYLSTILBESTEROL TAB 0.5MG
GUANADREL SULFATE TAB 25MG NORETHINDRONE TAB 0.35MG
DIETHTILBESTEROL TAB 1MG ETHINYL ESTRADIOL TAB 0.02MG
NITROFURANTOIN CAP 25MG ETHINYL ESTRADIOL TAB 0.5MG
ETHINYL ESTRADIOL TAB 0.05 MG MESORIDAZINE TAB 50MG
MESORIDAZINE TAB FLUOXYMETERONE, TAB 5MG
FLUDROCORTISONE TAB 0.1MG PERPHENAZINE TAB 8MG
FLUOXYMESTERONE, TAB 10MG MESORIDAZINE TAB 100MG
PERPHENAZINE TAB 16MG HYDROCORTISONE, TAB 5MG
NITROFURANTOIN CAP 25MG HYDROCORTISONE TAB 20MG
HYDROCORTISONE, TAB 10MG FLECAINIDE ACET. TAB 100MG
AURANOFIN CAP 3MG NEPHRO-VITE TAB
ETRETINATE CAP 10MG LIOTHYRONINE, NA TAB 25MCG
MED-P-GESTERONE TAB 2.5MG MED-PROGESTERONE TAB 10MG
MELPHALAN TAB 2MG MERCAPTOPURINE TAB 50MG
50
SELEGLINE HCL TAB 5MG METHAZOLAMIDE TAB 50MG
METHIMAZOLE, TAB 5MG METHIMAZOLE, TAB 10MG
METHYSERGIDE MALEATE TAB 2MG METYRPONE, TAB 250MG
NITROGLYCERINE TAB 0.3MG NITROGLYCERINE TAB 0.4MG
CHLORAMBUCIL TAB 2MG NORETHINDRONE TAB 5MG
NITROGLYCERINE TAB 0.6MG STURART NATAL TAB
PENICILLAMINE, CAP 250MG PYRASINAMIDE TAB 500MG
PROPYLTHIOUBACIL TAB 50MG SOD BICARB, TAB 325
QUINACRINE HCL TAB 100MG SULFADIAZINE, TAB 500MG
SOD BICARB, TAB 650MG THYROID, TAB 30MG
THYROID, TAB 15MG THYROID, TAB 120MG
THYROID, TAB 60MG MENADIOL, TAB 5MG
TRIMETHOBENZAMID, CAP 250MG ETHACRYCIN ACID TAB 50MG
KANAMYCIN, CAP 500MG METHYLPHENIDATE, TAB 10MG
PANCRELIPASE CAP METHENAMINE HIPPURAT TAB 1.0GM
DAPSONE TAB 100MG 6-THIOGUANINE TAB 40MG
PERPHENAZINE, TAB 4MG SOD. CHLORIDE TAB 1GM
PYRIMETHAMINE TAB 25MG BRONEDECON TAB
PROCARBAZINE CAP 50MG L-DOPA CAP 250MG
L-DOPA CAP 500MG THYROID TAB 180MG
L-DOPA TAB 100MG HYDROXYUREA CAP 500MG
RIFAMPIN CAP 300MG AL CARB, CAP
OXYMETHOLONE TAB 50MG MARAX, TAB
MYLANTA, TAB PRIMIDONE TAB 50MG
FLUCYTOSINE CAP 250MG PHENELZINE TAB 15MG
DIHYDROTACHYSTEROL TAB 0.2MG MEGESTROL ACET TAB 40MG
DANAZOL CAP 200MG DROMOCRIPTINE TAB 2.5MG
STILPHOSTROL TAB 50MG ZINC SULFATE CAP 220MG
CALCITRIOL, CAP 0.25MG MAGNESIUM , GLUCONATE TAB 500MG
PENICALLAMINE CAP 125MG MINOXIDIL TAB 10MG
LONITEN TAB 2.5MG LOMUSTINE CAP 10MG
AMINOGLUTETHIMIDE TAB 250MG
LOMUSTINE CAP 40MG

One)
Yes No
Yes No
51
No: ___CH. 4 SECT. E___
Subject: PRESCRIPTION WRITING AUTHORITY IN UHB Page ____1__ of ___1__
Approved by: CONSTANCES SHAMES, M.D. Distribution: Administrative Manual

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To inform pharmacists about which practitioners have prescription authority under their
New York State License.
III. Policy: Only those individuals legally authorized to have prescription authority under their New York
State licenses as granted by the State Education Department can write for prescription drugs. This
license must also include a current registration in the State of New York.
IV. Responsibilities: The Risk Management Department, the Medical Board Office, the Graduate Medical
Education (House-staff) Office, or the individual medical service administrations and/or Director’s of
Service shall arrange to have all signature samples of authorized individuals with license (registration)
numbers provided to the Pharmacy.
The Pharmacy shall dispense drugs only on the authority of the legally licensed and registered
individual.
V. Procedures/Guidelines: Only the following individuals can write for prescription drugs* within UHB:
a) Physicians licensed and currently registered in New York State. (License number and name
must be imprinted/stamped on each OPD prescription and name must be stamped or imprinted
on all IPD medication orders).
b) Physicians Assistants currently registered in New York State. These individuals, however do
not have authority to write for controlled substances or narcotics, without a counter signature
by a physician within 24 hours. All in-patient and out-patient prescriptions for controlled
substances must be counter-signed at the time of writing (registration number must be written
on all prescriptions).
c) Certified Nurse Practitioners licensed and currently registered in New York State and who have
met additional educational requirements pertaining to issuing prescriptions, and have written
practice agreements and protocols established with a collaborating physician. Further,
Certified Nurse Practitioners may write for controlled drugs and narcotics provided the
individual has a federal DEA number (license number must be written on all prescriptions).
52
d) House-staff (PGY-1 through PGY-7) currently enrolled in their Graduate Medication Education
Program. The five or six digit registry number assigned by the GME office must be marked on
all medication orders.
e) Medical students only if the order is countersigned by a house-staff supervising physician.
f) Opticians within the scope of their practice laws.
*It is UHB policy that all formulary medications require a prescription whether these medications have a
Federal legend caution status or are considered over-the-counter (non-legend) medications. This allows
accurate and comprehensive monitoring of all drug modalities that may impart any pharmacological effect on
the patient.

VIII. Attachments: Approved Abbreviations and Symbols List

Un-approved Abbreviation List
One)
Yes No
53
No: ___CH. 4 SECT. F___
Subject: INVESTIGATIONAL DRUG DISPENSING Page ____1__ of ___1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide safe handling of FDA designated investigational drugs placing the same directly
under the control of the Pharmacy..
II. Definition(s): Investigational and/or research study drugs are drugs or pharmaceuticals which:
B) are in Phase I, II, or III clinical trials or have an IND number or are under
investigation, and have not been released by the FDA for general distribution and
use. These drugs usually bear the following statement on their labels: “Caution –
New Drug – Limited by Federal Law to Investigational use”.
C) have FDA approval, but are being investigated for a non-FDA approved indication,
use, or a dosage that had not previously been approved by FDA.
D) have FDA approval for the intended use, are not on the hospital formulary, and are
being supplied to the Principal Investigator or comparison to the new study drug.
III. Policy: Upon presentation of a complete clinical protocol approved by the IRB, the Pharmacy shall
store and dispense investigational drugs or drugs used for an investigational study according to the
procedure for dispensing these agents. These agents shall be kept separate from the general
medication areas and placed under locked storage.
IV. The principal investigator shall provide the Pharmacy with a list of names of authorized
physicians along with their signature samples who can prescribe the study drug and a
telephone number where they can be reached in the event of an emergency.
V. Receipt of Investigational Drugs: It is the responsibility of the principal investigator to
direct the supplier of the investigational drug to send the trial material to the investigator.
The drug is the property of the investigator; the Pharmacy serves only as the storage and
distribution center.
Upon notification by the Pharmacy that the predetermined minimum inventory level has
been reached, the investigator shall be responsible for notifying the supplier of the trial
materials so that a new supply, if required to finish the study, shall be shipped before the
current supply is completely expended.
VI. Nursing Notification: It is the responsibility of the principal investigator to provide a

Nurse’s Data Sheet on the investigational drugs to the Nursing staff charged with
administered the drug to the patient, if applicable, and provide in-service education
concerning the study drug.
54
Pharmacy Responsibility
A) Dispensing investigational medications only upon receipt of a prescription or copy of the

physician’s original order signed by an authorized investigator or his designee.
B) When Dispensing for In-Patient Use:
1. The dispensing pharmacist shall sign the prescription, enter date of dispensing,
quantity dispensed, lot# of the drug and dispense the labeled drug to the
principal investigator or his designee.
2. When Dispensing for Out-Patient use:
The same procedures should be followed as when dispensing for in-patient use,
except the drug is dispensed directly to the patient.
C) The dispensing pharmacist is responsible for entering all required data on the
Drug Accountability Record.
D) The dispensing pharmacist shall confirm that the inventory is accurate and
balanced.
E) Periodic Review of usage to determine whether the investigational drug supplies
are still active or are no longer needed.
F) Maintain accurate records for the perpetual inventory of an investigational stock,
name of patients receiving the drug, data, quantity of each issue, patient’s
location, and physician’s name.
G) Store the drug according to the manufacturer’s specifications.
H) Provide suitable containers for storage and dispensing.
I) Notify the principal investigator when the previously determined minimum
inventory level is reached.
J) Disposal or returns to the manufacturers of unused or deteriorated drug supply is
the responsibility of the principal investigator.
It should be noted that the institutional policy and procedure for the handling of investigational drugs should
be reviewed by the pharmacist before undertaking a new investigational drug study.
A) Upon receipt of a prescription for an in-patient or an out-patient for an investigational drug, the
following elements of the prescription must be present:
1. Name of the hospital, patient name, and IPD or OPD number
2. Location of the patient
3. Date
4. Name of the drug
5. Dosage or study number for blinded randomization
6. Frequency
7. Duration
8. Quantity to be dispensed
9. Principal investigator’s signature or his designee
10. Printed name of prescriber
11. Investigational Drug Registration number if applicable
VII. A copy of the patient’s informed consent must accompany the medication order for the
investigational drug.
VIII. The drug shall be labeled as follows:
See attachment titled: “Requirements For Labeling Investigational Drugs”
IX. The properly labeled drug shall be dispensed directly to the principal investigator and/or
his designee.

55
VII. Attachments: IRB documents
One)
Yes No
56
No: ___CH. 4 SECT. G___
Subject: VERIFICATION AND REVIEWING OF Page ____1__ of ____2__

PRESCRIPTION ORDERS
Reviewed by: WILLIAM GERDES Implementation Date: 7/3/01

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To give direction to all licensed Pharmacist to review, verify and interpret medication orders
as well as resolution of questions or problems.
III. Policy: Review, verification, and interpretation of medication orders as well as the resolution of
questions or problems shall be performed by a licensed pharmacist prior to dispensing.
IV. Responsibilities: The pharmacist shall review any questions that he/she may have in the course of
filling, dispensing, and checking the prescription and document all necessary changes. The physician
is expected to discontinue the incorrect prescription order in the medical record and issue a new
order.
V. Procedures/Guidelines: A direct copy of the medication order shall be reviewed by the pharmacist.
The pharmacist shall verify:
1. Identity of the patient (to include first and last name and second identifier
such as MR#, IPD Admission #, DOB)
2. Location of the patient
3. Drug name
4. Drug dosage (expressed in the metric system; see attachment)
5. Drug frequency
6. Drug route
7. Duration
8. Signature of a physician and charting nurse
The pharmacist shall interpret the medication order and resolve all questions or problems prior to dispensing.
These problems may take the form of:
9. Inability to identify the patient
10. Improper or incomplete prescription
11. Drug interaction (Drug – Drug, Drug – Food, or Drug – Disease)
12. Over-dosage/sub-therapeutic dose
13. Incorrect dosage form
57
14. Any questions the pharmacist may feel will have a direct impact on the care of the patient, the
outcome expected with the drug, or the potential for adverse events by filling the order as written.
15. Restricted drug status requiring expert approval.
16. Sound alike/look alike error potential, potential multiple dose, high-risk drug error potential*
17. Pregnancy and/or lactation incompatibility with the medication
18. Drugs that impact balance and increase risk of falls
Upon discovery of any discrepancies or problems that can not be supported by references available in the
Pharmacy such as exceeding the maximum average recommended dose, the pharmacist shall contact the
nursing station to discuss the nature of the problem with the prescriber. The pharmacist shall not dispense
the medication until the problem is resolved.
After agreement with the prescriber, the pharmacist shall document on the prescription the necessary
changes or verification of the order and proceed to dispense the medication. The label will reflect all changes
agreed to by the physician. The physician shall write a new medication order in the medical record and
discontinue the incorrect order.
Documentation should include the following:
1) Name of the physician

2) Date and time of communication
3) Resolution of the problems
4) Necessary references of scientific literature to validate the physician’s order
5) Pharmacist initials and stamp
The pharmacist shall instruct the physician to discontinue the incorrect order and write a new medication
order in the patient’s chart accordingly so that the nurse shall be aware of any changes.

VII. Attachments: Metric Conversion Chart; List of drugs that impact balance and increase risk of falls
IX. References: none
* IN ORDER TO MINIMIZE/ELIMINATE DISPENSING ERRORS ASSOCIATED WITH SOUND
ALIKE/LOOK ALIKE DRUGS, DRUGS AVAILABLE IN MULTIPLE DOSAGE STRENGTHS, OR
HIGH-RISK DRUGS (CHEMOTHERAPEUTIC AGENTS, DOPAMINE, DOBUTAMINE, HEPARIN,
INSULIN, MAGNESIUM, NARCOTICS AND OPIATES, NEUROMUSCULAR BLOCKERS,
POTASSIUM CHLORIDE) DRUG STORAGE BINS ARE MARKED RED FOR SOUND
ALIKE/LOOK ALIKE ALERT, GREEN FOR MULTIPLE STRENGTH ALERT, AND ORANGE
FOR HIGH RISK ALERT.
One)
Yes No
58
No: ___CH. 4 SECT. H___
Subject: PRESCRIPTIONS FOR NON-FDA APPROVED Page ____1__ of ____1__

INDICATIONS OR DOSAGES OF MEDICATIONS

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To insure that there exists adequate scientific documentation for the non-FDA approved
uses and/or doses of medications prescribed.
III. Policy: A prescriber may lawfully prescribe a different dosage of a drug for his/her patient or
otherwise vary the conditions for use from what is approved in the FDA approved package labeling.
This does not violate the spirit of the FD&C Act or FDA regulations. However, the pharmacist must
verify the dosage and usage of the prescribed drug. The policy applies to OPD or IPD medication
orders.
IV. Responsibilities: The pharmacist shall document verbal references and maintain all backup
documents in a file. The prescriber shall provide documentation on request in support of his/her medical
decision. Members of the P&T Committee under the direction of the Chairperson shall review the incidences
of drugs used for non-FDA approved uses.
V. Procedures/Guidelines: When a pharmacist determines that a drug falls outside of FDA approved
indications, dosage, routes of administration, etc., the pharmacist shall contact the prescriber for
verification. The pharmacist shall mark on the prescription the following:
A) Date
B) Time
C) Physician’s name
D) The reference cited from scientific literature by the physician to support the medication order
for a non-FDA approved use or dose.
The medication shall then be dispensed after the verbal verification is taken. The prescriber shall
provide to the Pharmacy a copy of the cited reference within seven working days. If the
documentation is not received, a follow-up call shall be made by the Pharmacy before referring the
matter to the Quality Management, Clinical Q/A Committee of the Service, and/or Risk Management
Departments in a written report. A file shall be maintained within these approved usage prescriptions
shall be reviewed by the Pharmacy and Therapeutics Committee on a quarterly basis. The P&T
Committee shall recommend appropriate action when the incidences are reviewed, if necessary.
59
One)
Yes No
60
No: ___CH. 4 SECT. J___
Subject: PATIENT SELF MEDICATION Page ____1__ of ____1__

Department Manual
Patient Care Manual
AOD Manual
_____________________________________________________________________________________
I. Purpose: To direct pharmacists on the proper procedures to dispense medication to the nursing care
areas for self-administration use of medication by the patients.
III. Policy: Upon authorization by the prescribing physician on the face of the prescription, the Pharmacy
Department shall dispense medication to the nursing care area for self-administration use by the
patient. The container shall be labeled “Self Medication”.
IV. Responsibilities: The physician shall determine the competency of the patient to participate in a self-
medication program. The pharmacist is responsible to prepare a label for the drug container in layman’s
language so that the patient may understand the directions for use.
The nurse shall supervise and instruct the patient during the course of self-medication.
The pharmacist shall only dispense self-medication upon written authorization by the physician on the
prescription. The pharmacist shall provide labeling intelligible to the patient. The pharmacist shall provide
the medication only to the nurse.
A) A physician shall write on the face of the completed medication order “Self Medication”.
B) The physician shall determine the competency of the patient who would administer
medication.
C) Self-medication shall be supplied by the Pharmacy to the Nursing staff who shall supervise
and instruct the patient on the use and administration of the medication. The nurse shall
supervise patient’s progress using this mode of treatment.
D) The Pharmacy shall limit the amount of medication provided for self-medication to a
maximum of a seven-day supply if prescribed for this duration.
E) The label provided on the prescription container shall have language that is understandable
by the patient e.g., Lasix® 40mg po daily = 1 tablet orally daily; 5ml po three times a day = 1
teaspoon orally 3 times a day.
j. Reasons for Revision:

61
One)
Yes No
62
No: ___CH. 4 SECT. K___
Subject: FLOOR STOCK MEDICATIONS AND Page ____1__ of ___1__

DISTRIBUTION

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To inform support staff in the Pharmacy about the procedures relating to floor stock
medications and their distribution.
III. Policy: Floor stock medications are those medications not directly chargeable to a patient. Quantities
of floor stock medication are kept to a minimum. Only those items on the approved floor stock list
may be ordered as floor stock. All other medications are dispensed only upon presentation of a valid
prescriber’s medication order for a specific patient.
IV. Responsibilities: Nursing personnel are responsible for checking quantities of floor stock items and
for requesting replacements. It is the responsibility of Nursing personnel to store all floor stock items
properly, e.g., externals separated from internals, refrigerated medication under proper temperature.
The Pharmacist is responsible for:

III. Preparing items not on the Floor Stock Form for delivery to the Nursing care areas.
IV. Checking the work of the Pharmacy Aides for accuracy and completeness
V. Inspecting Nursing care areas for the proper storage of medication during the monthly
Nursing unit inspection.
The Pharmacy Aide shall fill and deliver floor stock supplies pursuant to a completed Floor Stock
Form.
V. Procedures/Guidelines: NOTE: Those areas with Pyxis machines have floor stock items
contained therein, otherwise,
A) Upon receipt of a completed Pharmacy Floor Stock Form (see attached), the Pharmacy Aides
shall fill the respective order.
B) Floor Stock is filled Monday through Friday except Wednesday.
C) Critical care areas, intensive care areas, operating rooms, and recovery room can request floor
stock during any of the Pharmacy’s operational hours.
D) Items that are not listed on the Floor Stock Form and are requested from the critical care areas
listed in (C), are to be labeled, packaged, and checked by a pharmacist.
63
E) A pharmacist shall supervise and check the completeness and accuracy of the filling of the Floor
Stock Form by the Pharmacy Aide.
F) A Pharmacy Aide shall deliver the completed order to the Nursing care areas and obtain
acknowledgement of receipt by a signature of receipt on the Floor Stock Form by a nurse or an
LPN.
G) All floor stock requests are charged to the respective nursing care areas.
VI Reasons for Revision:

VII. Attachments :Floor Stock Order Form
One)
Yes No
64
No: ___CH. 4 SECT. K Sub-Sect. I___

Subject: INSULIN AS FLOOR STOCK Page ____1__ of ____1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide for the safe distribution of the high risk drug insulin.
III. Policy: The Pharmacy shall provide insulin vials on a floor stock basis to Nursing care/clinic areas in
order to eliminate waste and prevent in-appropriate accumulation of individually labeled vials
occurring due to insulin dose variations and titration, discharged patients, transferred patients, etc.
IV. Responsibilities: It is the responsibility of the Pharmacy to provide insulin on a floor stock basis to
Nursing care/clinic areas. It is the responsibility of the nurse to store insulin under refrigeration and to
follow the multi-dose vial procedures when the vial is opened.
V. Procedures/Guidelines (for Nursing care areas without Pyxis machine access):

1) The nurse responsible for preparing the Floor Stock Order Form shall list all types of insulin
required for the respective unit and submit it to the Main Pharmacy.
2) The Pharmacy Aide shall prepare the requisition for delivery to the Nursing care/clinic areas.
3) The Pharmacy’s hospital attendant/aide shall deliver the supplies to the unit daily.
4) The nurse shall place the insulin vials in the medication refrigerator on the respective unit.
5) The nurse shall date the vial of insulin with an expiration date when opened (see Chapter XVI,
Multi-dose Vials) and chart in the usual fashion.
6) The nurse shall administer insulin pursuant only to written order by a licensed prescriber.
7) The prescription shall be processed through the clerk and forwarded to the Pharmacy for review
by a pharmacist.
8) If a problem is identified with the prescription, the pharmacist shall call the prescriber or nurse for
clarification or correction.
9) During the monthly Nursing care area inspections a pharmacist shall inspect the medication
refrigerators and remove excess insulin stock or stock that has been compromised or has not
been dated for expiration upon opening.
65
One)
Yes No
66
No: ___CH. 4 SECT. L
Subject: INTRA-HOSPITAL DISTRIBUTION OF Page ____1__ of ____1__

MEDICATION

Department Manual
Patient Care Manual
AOD Manual

______________________________________________________________________________________
I. Purpose: To insure the staff will distribute all medications in an organized, efficient and a safe system.
III. Policy: The Director of Pharmacy shall insure that the distribution of all medications follows an
organized, efficient, and safe system so as to address patient needs quickly, support the activities of
the nursing and medical staffs, and provide for the maintenance of the manufacturer’s
recommendations on the storage of medications as well as the security for general and controlled
substance medication.
V. Procedures/Guidelines: The following flow charts for the path of medication ordering and distribution
are to be followed for each respective drug class. (See attached pages for flow chart)

VII. Attachments: Flow charts
One)
Yes No
67
No: ___CH. 4 SECT. M
Subject: PASS MEDICATIONS Page ____1__ of ___1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures to safely dispense medication to patients in the event that they are
going home on a pass.
III. Policy: Pursuant to a written ambulatory care prescription, a pharmacist shall label and dispense
medication for a duration specified by the prescriber to provide a continuum of medication therapy
while the patient is out of the hospital on a pass period, if authorized by the attending physician.
IV. Responsibilities: It is the responsibility of the prescriber to write an ambulatory prescription order for
pass medications. It is the responsibility of a pharmacist to label the medication in language
understandable by the patient and dispense in child-proof containers the pass medication to the
nursing station from where the patient will be sent on pass.
1) Upon receipt of a written ambulatory care prescription, a pharmacist or pharmacy assistant
shall prepare the prescribed medication for dispensing.
2) A pharmacist shall review the prescription to ascertain that all the elements of a valid
ambulatory care prescription are present and call the prescribing physician if clarification
or correction is necessary.
3) A pharmacist shall label and dispense the medication child proof containers following OPD
Medication Dispensing on Prescription Policy, Chapter 23 Section A, Procedures.
4) The medication shall be sent by messenger to the nursing station from where the patient
shall be sent on pass.

68
One)
Yes No
69
No: ___CH. 5 SECT. A
Subject: DEFINITION OF CONTROLLED SUBSTANCES Page ____1__ of ___1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To inform staff the rules, regulations, and definitions of Controlled Substances.
III. Policy: Controlled Substances are defined as those substances listed and controlled by the following
legal authorities:
A) Chapter II Administrative Rules and Regulations:
1. Sub chapter K:
2. Controlled Substances:
3. Part:
4. 80 Rules and Regulations Controlled Substances:
5. Public Health Law, SS 3305 (1) (d), 3007 (2), (3) 3308 (2), Act. 3 and its
amendments:
6. Under Authority of NYS DOH
And/or
B) Title 2 of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970,
Public Law 91-513 and its amendments under authority of the Federal Drug Enforcement
Administration.

70
One)
Yes No
71
No: ___CH. 5 SECT. B
Subject: INPATIENT DISPENSING OF CONTROLLED Page ____1__ of ____1__

SUBSTANCES TO NURSING CARE AREAS
WITHOUT PYXIS CABINETS

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish the rules of Inpatient Dispensing of Controlled Substances to Nursing Care
Areas without Pyxis® cabinets.
III. Policy: All Nursing Station orders for controlled substances without Pyxis® cabinets shall be
dispensed according to the established procedure contained in Chapter V, Section B, of the
Pharmacy’s Policy & Procedure Manual.
IV. Responsibilities: A pharmacist shall take the controlled order form the nurse. A pharmacist shall
enter the information on all forms and make an entry and deduction from the IPD inventory. A
pharmacist or Pharmacy Assistant shall deliver the controlled drug supplies to the nursing station. A
RN shall deliver the controlled drug supplies and place them in a double lock cabinet at the Nursing
station.
(1) Monday, Wednesday, and Friday a Pharmacist shall call all Nursing Stations by 8:30A.M. to
obtain their controlled drug orders.
(2) The orders are transferred to “Controlled Drug Order Sheet” by a pharmacist.
(3) Each drug is written up on a “Controlled Drug Administration Record and is signed and
dated by the dispensing pharmacist. The following information is entered by the
Pharmacist:
 Name of Drug
 Strength
 Requisitioning Station
 Drug Number
 Dispensing Pharmacist
 Date Dispensed
 Dosage Form
 Quantity Issued
 Expiration Date
(4) The Pharmacist shall issue an order number in triplicate. One number is placed on the
container of the drug, one is placed on the administration record, and the final number is
placed on the nursing station receipt.
72
(5) The number is logged in the IPD Controlled Drug Inventory Log under the corresponding
drug record.
(6) The Pharmacist shall decrement the IPD inventory accordingly.
(7) The drugs, the Administration Records, and the Controlled Drug Order Sheet are placed in
a bag marked with the appropriate nursing station and stapled closed for delivery.
(8) The orders are then delivered to each nursing station by a Pharmacist or Pharmacy
Assistant.
(9) At the nursing station, the nurse shall count and verify the controlled drug order. The
nurse shall sign and date the receipt, the administration sheet and the controlled drug
order sheet and place the drug in a double locked cabinet.
(10) The Pharmacist or Pharmacy Assistant shall bring the receipt and Control Drug Order
Sheet back to the Pharmacy to be filed. The receipts are filed by nursing station.
(11) The Pharmacist or Pharmacy Assistant shall accept any completed Administration Record
or drug returns after verifying all the information written on the administration record and
confirming the number of doses to be returned, including double signature for wastage.
(12) The returned completed Administration Records shall be matched against the original
receipt, staples, and filed by the drug name.
(13) The Controlled Drug Order Sheets are filed by nursing station after the drugs are charged
to the nursing station by a Pharmacy Aide through the computer.
(14) Orders called into Pharmacy after 8:30A.M., on Tuesdays, Thursdays, Saturdays, and
Sundays, and on Holidays, are processed similarly as above with the exception that the
requesting nurse comes to the Pharmacy and after presentation of proper identification
shall sign for the controlled substances
(15) A daily (Monday through Friday) physical IPD control drug inventory will be conducted by a
Pharmacist and entry made in the inventory log.
Note: Only RN’s can sign for the drugs. Agency nurses or LPN’s are not permitted to sign for the
drugs.

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Yes No
73
No: ___CH. V SECT. B SUB. I
Subject: VERIFICATION OF THE ADMINISTRATION Page ____1__ of ____1__

RECORD ENTRIES FOR CONTROLLED
SUBSTANCES

Department Manual
Patient Care Manual
AOD Manual

______________________________________________________________________________________
I. Purpose: To insure all pharmacist and pharmacy assistants verify all required information present on
the Controlled Drug Administration Record.
III. Policy: A Pharmacist or Pharmacy Assistant shall verify that all required information is present on the
Controlled Drug Administration Record.
IV. Responsibilities: The pharmacist or pharmacy assistant shall verify all data entries on the control
drug administration sheet. A Physician or an R.N. upon the authority of an authorized prescriber’s
written medication order is authorized to withdraw drugs for the nursing station sub-stock and enter
data on the sub-stock Control Drug Administration Record, and then administer the drug.
5) The completed Control Drug Administration Record shall be reviewed by a Pharmacist or
Pharmacy Assistant for the following data:
A) Date of Administration
B) Time of Administration
C) Patient’s Full Name
D) Professional Staff Administering the Drug
E) Name of Prescriber
F) Amount of Drug Administered
G) Wastage documented, if any. On the occasion of wastage, such as any partial
dose to be discarded or breakage:
1. Witnessing signature is required
2. Balance accuracy maintained
6) Verification of orders is done during the monthly nursing station inspection process and
upon receipt of a medication order.
7) If data is missing or a discrepancy is apparent either on the Administration Record or in the

physical count on the nursing station, the head nurse is contacted to resolve the
discrepancy.
74
8) If the discrepancy can’t be resolved, the Director of Pharmacy and the Director of Nursing
is informed and an investigation is conducted.
9) In the event that drugs are to be returned to the Pharmacy, the nurse and pharmacist shall
verify the count to be returned. The nurse and pharmacist shall sign and date the
Controlled Substance Administration Record to be returned to the Pharmacy. The drugs
returned shall be re-inventoried if in unit dose form or destroyed/surrendered to the NYS
DOH Bureau of Controlled Substances according to approved procedures or set aside in
the Main Controlled Drug wall safe for return to the manufacturer according to legal
requirements for such.
10) Controlled drug administration verification from Pyxis® cabinets are handled according to
procedures established in Chapter 34.

One)
Yes No
75
No: ___CH. V SECT. C
Subject: OUTPATIENT DISPENSING OF CONTROLLED Page ____1__ of ____1__

SUBSTANCES TO CLINIC NURSING STATIONS

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures for the dispensing of controlled drugs to clinic Nursing stations.
III. Policy: All outpatient clinic Nursing station orders for controlled substances shall be dispensed
according to the established procedures contained in Chapter V., Section C, of the Pharmacy P&P
Manual. These orders are limited to one dose or “STAT” orders.
IV. Responsibilities: A pharmacist shall take the controlled drug order from the nurse. A pharmacist or
Pharmacy assistant checked by a pharmacist shall prepare the controlled drug supplies for pick up. A
RN shall sign for the controlled drug supplies and place them in a double locked cabinet at the clinic
Nursing Station.
1) When requested by a registered nurse, controlled substances shall be dispensed to outpatient
clinic Nursing station sub-stock Monday through Friday.
2) The orders are transferred to the “Controlled Drug Order Form” by a pharmacist.
3) Drugs shall be dispensed to outpatient clinic areas from the IPD work safe.
4) Each drug ordered shall be written up on a Controlled Drug Administration Record and is
signed and dated by the dispensing pharmacist. The following information shall be entered by
the pharmacist:
 Name of Drug
 Strength
 Requisitioning Station
 Drug Number
 Dispensing Pharmacist
 Date Dispensed
 Dosage Form
 Quantity Issued
 Expiration Date
76
5) The pharmacist shall issue an order number in triplicate placing one number on the drug
container, one on the receipt, and one on the Controlled Drug Administration Record.
6) The number is logged in the IPD controlled drug inventory log under the corresponding drug
record.
7) The pharmacist shall decrement the inventory accordingly.
8) The drugs, the Administration Record, and the Controlled Drug Order Sheets are placed in a
bag marked with the appropriate clinic and stapled closed for pick up.
9) The orders shall be picked up in the Main Pharmacy by the registered nurse who must be
present his/her hospital I.D. card as proper identification.
10) The receipt and Controlled Drug Order sheet shall remain in the Pharmacy.
11) Controlled drugs are not to be dispensed to the Lefferts, Throop, Parkside Dialysis, or Mid-
wood satellites.
12) Controlled drugs utilized in the ED are dispensed from the Pyxis cabinet according to the
Policy and procedure set forth in Chapter 33.

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Yes No
77
No: ___CH. 5 SECT. E
Subject: STORAGE OF CONTROLLED SUBSTANCES Page ____1__ of ____1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To direct the Pharmacy staff on the proper procedures for the storage of controlled
substances according to rules, regulations, and legal mandates.
III. Policy: All controlled substances shall be stored in a locked substantially constructed safe or a double
locked cabinet.
IV. Responsibilities: It is responsibility of the pharmacists to keep the controlled drug storage safes
secured and locked at all times. The combinations for the work safes are disclosed only to the
pharmacists. Only designated pharmacist, the Associate Director, and the Director have access to the
main walk-in safe. The head nurse of the nursing care area has the responsibility to insure that the
controlled drugs are secured and locked in a double locked cabinet on the unit at all times and that
shift change verification of stock is completed daily.
1) When drugs are received from a manufacturer or supplier, the bulk supply shall be placed by a
designated pharmacist into the walk-in Main Wall Safe.
2) Supplies for IPD and OPD nursing units shall be stored in the IPD controlled substance floor safe.
3) Supplies dispensed for IPD and OPD nursing unit use shall be stored in double locked cabinets on
these units.
4) All supplies dispensed to the OR satellite Pharmacy shall be stored in the Mosler floor safe in this
service area.
5) Controlled Substances requiring refrigeration shall be stored on a locked cabinet within the walk-
in refrigerator.


78
One)
Yes No
79
No: ___CH. 5 SECT. F
Subject: INVENTORY CONTROL OF CONTROLLED Page ____1__ of ____1__

SUBSTANCES

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish inventory controls for controlled substances within the Pharmacy..
III. Policy: A strict accountability record shall be kept for all controlled drugs in safe storage areas and
physical inventories shall be conducted on a pre-assigned schedule.
IV. Responsibilities: It is the responsibility of the Director of Pharmacy or his/her designee to maintain
accurate accountability of all controlled substances in the Pharmacy.
I. OPD Inventory Control [SUSPENDED] (if OPD re-opens) :
The only procedure accepted for inventory control of a controlled substance for outpatients is
as follows:
1) The pharmacist enters the prescription date, prescription number, patient name and
quantity of drug dispensed on the corresponding controlled substance inventory sheet.
2) The pharmacist shall then debit the balance on hand by the quantity dispensed and
make the appropriate entry on the balance on hand section of the sheet.
3) The pharmacist shall confirm the balance on hand against the physical inventory and
sign his or her name next to the entry, (In the event of discrepancies the pharmacist
shall then inform a pharmacy supervisor and an immediate investigation will follow to
rectify the problem).
A pharmacist shall be assigned daily, Monday through Friday, to conduct the physical inventory on all
the controlled substances stored in the OPD safe. The physical inventory shall be conducted between the
hours of 2:00p.m. – 4:00p.m.
II. IPD Safe Inventory Control:

After the routine daily dispensing and logging in the inventory book (Refer to Chapter V.,
section B), a pharmacist shall be assigned to conduct the physical inventory.
III. Inventory Control Main Safe:

All quantities of drugs stored in the main safe shall be entered in a corresponding inventory
log sheet upon receipt from the manufacturer/supplier and maintained in a file kept in the main safe. A bi-
annual inventory shall be conducted on odd years for all controlled substances storage areas in the
st
Pharmacy, no later than June 1 of that year.
80
A record shall be maintained in the main safe and a copy filed with the Director of Pharmacy.
A physical inventory shall be conducted at the time of either receipt or withdrawal occurs for a
particular item form the main controlled substance withdrawal occurs for a particular item from the main
controlled substance safe.
Satellite Pharmacy Controlled Substance Inventory Control:

No controlled substances shall be stored or dispensed from the satellite pharmacies with the
exception of the OR Satellite Pharmacy. All controlled substances shall be processed through the Main
Pharmacy.
Transfer of Controlled Substances Between Safes:

Whenever a controlled substance is transferred form one safe to another, the inventory log in the
issuing safe shall be debited for the controlled substance being transferred and the inventory log in the
receiving safe shall be credited by the quantity received.
All entries shall be recorded by a pharmacist and signed by the same.

One)
Yes No
81
No: ___CH. 5 SECT. G
Subject: ACQUISITION PROCESS FOR CONTROLLED Page ____1__ of ____1__

SUBSTANCES

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Establish procedures for the acquisition of controlled substances according to federal,
state, and local legal mandates.
III. Policy: The acquisition process for Class I and II controlled substances shall follow the Federal DEA
regulations using DEA Form 222 (Aug. 1990). The acquisition process for Class III, IV, and V controlled
substances shall follow standard acquisition procedures for legend drugs.
IV. Responsibilities: A pharmacist shall write the order for Class I and III drugs and the materials manager
will order Class III, IV, and V drugs upon notification of need. The Director of Pharmacy, Associate
Director of Pharmacy, or the TH Senior Pharmacist shall sign the DEA form 222 (Aug. 1990). A
pharmacist or the materials manager shall notify Pharmacy Administration as to the need to purchase
additional supplies of controlled substances based on inventory reports and controlled drug inventory
records.
A) For Class I and II:
1) A pharmacist with appropriate power of attorney shall complete DEA form 222 (Aug.
1990) in its entirety.
2) The Director of Pharmacy, the Associate Director of Pharmacy and TH Senior
Pharmacist hold the power of attorney of the Vice-President for Hospital
Affaires/Inpatient Care Services and have the only authorized signatures to sign DEA
Form 222 (Aug. 1990).
3) Once signed, the original and the second copy is given to the Materials Manager to
initiate a purchase requisition/order and it is sent to the vendor of record.
4) The third copy of DEA Form 222 (Aug. 1990) is maintained in the Main Controlled
Substance safe in the acquisition record file.
5) Once the drugs are received and inventoried, the invoice is matched with the third copy
of DEA Form 222 (Aug. 1990), date of receipt and quantity received are entered on the
DEA Form 222, and kept in the acquisition record file.
6) Any errors or incorrectly completed forms that are voided shall be recorded and
maintained in the acquisition record file.
B) Class III, IV, and V:
82
1) No special forms are required to acquire these drugs. Most of these drugs are acquired
through the current prime vendor wholesaler. Daily invoices are stored in the Main
Pharmacy Wall Safe and monthly purchase reports are stored in the Director of
Pharmacy’s office.
2) The acquisition procedure is initiated by the Materials Manager upon notification of
need by the TH Senior Pharmacist and all record keeping procedures for the purchase
process are maintained by him/her.
3) Once the drugs are received and inventoried, the invoice is matched against the
purchase requisition and is maintained in the acquisition record file.

One)
Yes No
83
No: ___CH. 5 SECT. H
Subject: VERIFICATION OF DEA NUMBERS Page ____1__ of ____1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide a guide for pharmacists to verify the validity of federally issued DEA numbers..
locked cabinet.
IV. Responsibilities: The pharmacist is responsible to verify all DEA numbers on prescriptions written for
controlled substances. Pharmacy Administration is responsible to contact the Medical Board office or
the Federal DEA office when verification of the DEA number cannot be accomplished within the
department.
A) Upon receipt of a controlled substance prescription, the pharmacist can verify the DEA number
using the following files:
1) DEA number record of staff Physician’s Attendings, Dentists, or Certified Nurse

Practitioners.
2) In-house Graduate Medical Education Institutional numbers for Residents, PGY1-PGY7
e.g. 91025 (91=the year of graduation) or the new six digit numbers
3) Apply the mathematical formula for testing the validity of DEA numbers.
Method to determine validity of physicians – DEA number: (e.g. AG 4476429)

a) Add Digits 1, 3 and 5 (4+7+4=15)
b) Add Digits 2, 4 and 6 (4+6+2=12) then multiply by 2=24 Add a+b totals =
15+24=39
B) If the DEA number cannot be verified using methods 1, 2, or 3 in Chapter 5, Section H,

procedure A, the pharmacist shall notify Pharmacy Administration. Pharmacy Administration shall contact
the Medical Board office to verify the credentialing of the physician or contact the DEA Washington, D.C.:
Registration Branch
Drug Enforcement Administration
P.O. Box 28083, Central Station
Washington, D.CV. 20005
Telephone: 1-202-254-8255
C) The Graduate Medical Education Institution number shall only be honored when:
84
1) Accompanied by the institution’s DEA number on NYS official triplicate prescriptions
(AH 3303992) as a suffix
2) For prescriptions written by house-staff from the hospital clinic areas and filled only
written UHB.
One)
Yes No
85
No: ___CH. 5 SECT. I
Subject: EXPIRED, DETERIORATED, AND Page ____1__ of ____1__

NON-RESUABLE CONTROLLED SUBSTANCES
AND THEIR DISPOSITION

Department Manual
Patient Care Manual
AOD Manual

______________________________________________________________________________________
I. Purpose: For staff to be aware of how to handle expired, deteriorated, and non-reusable controlled
substances and their disposition.
III. Policy: All expired controlled substances shall be removed from active inventory and stored in the
Main Wall Safe for appropriate disposition.
IV. Responsibilities: It is responsibility of the pharmacist in charge of controlled substance distribution to

remove expired, deteriorated, or non-reusable drugs from inventory, keep records of these drugs, and
dispose of them properly according to the laws and applicable procedures set forth in this chapter.
A) Removal From Work Inventory:
1) During the monthly inspection of the Main Pharmacy, a pharmacist shall remove all
expired and deteriorated controlled substances from the active inventory and place
them in a segregated area of the Main Wall Safe for proper disposition.
2) During the daily controlled drug deliveries and the monthly nursing station or clinic
inspections, a pharmacist shall remove all expired, expiring deteriorated and non-
reusable controlled drugs from the nursing stations or clinics and place them in a
segregated area of the Main Wall Safe for proper disposition.
3) All expired, deteriorated, or non-reusable controlled drugs shall be listed on NYS DOH
Bureau of Controlled Substance form DOH 166 (1/90) (Controlled Substance Surrender
form) and all information about the drug is completed. If the drug is to be returned to
the manufacturer for credit, the drugs shall not be listed on DOH form 166 (1/90)
B) Surrender and Return of Controlled Substances:

1) If the controlled substance is returnable to the manufacturer for credit, the materials
manager shall contact the manufacturer and make arrangements for credit to our
account and then return the drugs via certified return receipt requested mail to the
manufacturer. A file of returned drugs shall be maintained in the Main Wall Safe or
Pharmacy Director’s Office of all drugs returned for credit and these records shall be
matched to the certified return receipt when received.
86
2) If the controlled substances are to be surrendered to the NYS DOH Bureau of
Controlled Substances, the drugs shall be packed with DOH form 166 (1/90) and mailed via
certified return receipt to the:
Bureau of Controlled Substances NYS DOH
433 River Street
Troy, New York 12180
Copy three (3) (pink) of the DOH form 166 (1/90) is maintained in the wall safe and is matched
against copy two (2) (yellow) and the certified return receipt when received.
2) In the event that on-site destruction is desired, the pharmacist shall follow the
procedure in Article 33 of the Public Health Law, and Part 80 of the Administration
Rules and Regulations for on-site destruction (see attached).
(4) Expired and deteriorated drugs can be returned to a manufacturer directly or to

a NYS DOH Bureau of Controlled Substances approved drug returns company
as long as all city, state, and federal laws are satisfied.

One)
Yes No
87
No: ___CH. 5 SECT. J

Subject: ISSUANCE AND CONTROL OF NYS OFFICIAL Page ____1__ of ____1__
PRESCRIPTION FORMS

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Establish controlled procedures for the issuance of official NYS Prescription Pads.
III. Policy: Acquisition, distribution and control of NYS Official prescription forms shall be conducted by
the Pharmacy Department and use of these prescriptions shall restricted to physicians at UHB.
IV. Responsibilities: The Director of Pharmacy shall order supplies of books or blank computer formats
and insure security for the supply of books. A pharmacist shall issue the books or formats to a nurse.
The nurse shall be responsible for proper storage of the book on the nursing station or clinic.
1) The Director of Pharmacy shall initiate an Institutional Order form (DOH Form – 248 [5/89]) for
official NYS prescriptions when supplies of these forms are needed or request the
pads/formats on-line.
2) When these prescription books are received each box if marked numerically in consecutive
order by the pharmacist in charge by controlled substance distribution.
3) These books are entered into a ledger by serial numbers and this ledger is maintained in the
OPD safe and the supply of books are maintained in the Main Wall Safe with a limited supply in
the OPD safe.
4) When a book is requested by a nursing station or a clinic, a pharmacist shall request a

completed book back cardboard from the area and log the return date. The pharmacist shall
then issue a new book to the nurse responsible for the area, after presentation of proper ID,
recording the date, service area, and signature of the nurse receiving the book. These entries
are made opposite the corresponding serial numbers for that book. A resident or employed LIP
may also request a book upon presentation of appropriate identification
5) Any returned completed book are marked “VOID” and are stored in a secure area for five (5)
years and then they are destroyed.
6) The nurse shall place the ONYSP book in the double locked controlled drug cabinet on the
nursing station or clinic.
7) Agency nurses and LPN’s are not authorized to receive prescription books.
88
One)
Yes No
89
No: ___CH. 5 SECT. K
Subject: LOSS OR THEFT OF CONTROLLED Page ____1__ of ____1_

SUBSTANCES OR OFFICIAL NYS CONTROLLED
SUBSTANCE PRESCRIPTION BOOKS

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To inform staff the rules and regulations on loss or theft of Controlled Substances or Official
New York State Controlled Substances Prescription Books and the procedures to follow..
III. Policy: All losses or thefts of Controlled Substances or Official New York State Controlled Substance
Prescription Books shall be reported to the Director of Pharmacy or his designee immediately upon
discovery of the loss or theft.
IV. Responsibilities: It is the responsibility of the Director of Pharmacy to file all required official
documentation pertaining to the loss or theft of controlled substances or official NYS prescriptions
and notify the appropriate authorities.
(1) Controlled Substances (Main Pharmacy) :
(A) The Director of Pharmacy shall be complete DEA Form 106 (Dec 1985) in its entirety
and submit two copies to the local DEA office and retain the original copy in the
Pharmacy office. This can also be done on-line.
(B) The Director of Pharmacy shall complete the NYS DOH Bureau of Narcotic Enforcement
“Report of Loss of Controlled Substances” Form DOH 2094 (3/06) and the original is
sent to the NYS DOH, Troy, N.Y., and a copy is retained in the Pharmacy office.
(C) The Director of Pharmacy shall notify Public Safety at X 2626 and report the loss of
theft of the controlled substances.
th
(D) If necessary, the Director of Pharmacy shall notify the 67 Police Precinct (718-287-
3211) and report the loss of theft of the controlled substances.
The Director of Pharmacy shall conduct an investigation surrounding the reported loss or theft or loss and
Human Resources shall notified at extension 3019.
(2) Controlled Substance (Nursing Station or Clinic Area) :
90
(A) In the event of a loss of theft of controlled substances on the nursing station or clinic
area, the head nurse shall immediately notify his or her Associate Nursing Director
and file a hospital Incident Report.
(B) The Associate Nursing Director shall immediately notify the Director of Pharmacy who
shall then follow the steps as outlined in Chapter 5., Section K., Procedures, #1.
(C) The discovering nurse shall file a hospital incident report and attach a copy of the
incident report to the Controlled Drug Administration sheet of the drug reported
lost or stolen and forward it to the Director of Pharmacy in the Main Pharmacy,
Room ALL1-469.
(3) Official NYS Prescription Books :
(A) In the event of loss or theft of Official NYS Prescriptions or Books, the
Director of Pharmacy shall complete NYS DOH Bureau of Narcotic
Enforcement form “Notification of Loss/Theft of Official New York State
Prescriptions” Form DOH-4387 (3/06).
(B) The Director of Pharmacy shall then follow steps C through F as outlines in
Chapter V., Section K, Procedures, #1.
(C) The discovering nurse shall file a hospital incident report and notify the
appropriate Associate Director of Nursing.
VI. Reasons for Revisions
One)
Yes No
91
No: ___CH. 5 SECT. L
Subject: AUTOMATIC MEDICATION STOP ORDER Page ____1__ of ____1__

POLICY FOR CONTROLLED SUBSTANCES

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Establish maximum durations for which controlled substances and other drugs that are
considered high-risk may be ordered before re-evaluation of the patient is required.
III. Policy: The maximum inpatient duration for a medication that a prescriber can order is based on the
period of medication therapy required to treat the patient (up to 30 days). However, all pre-existing
orders are canceled when the patient is transferred between nursing units. New orders must be
written by the medical team receiving the patient on the new nursing unit after the evaluation and
assessment of the patient’s status.
Further, certain orders, due to their potential for adverse side effects and toxicity, e.g., narcotics and
controlled substances, are valid for a limited period of time unless otherwise specified in a shorter
duration by the prescriber’s orders.
IV. Responsibilities: It is responsibility of the prescriber to see that orders are renewed. No nurse shall
administer a drug for which the order has expired. It is the responsibility of the nurse to notify the
physician prior to the discontinuance of these medications. It is the responsibility of the pharmacist to
dispense only the quantities of drugs needed to complete the prescriber’s orders for these drugs
within the above time frames. The pharmacist shall inform the nurse that he/she will only dispense a
72 hour supply when an order is written for a longer duration for the above drugs.
All scheduled Narcotics & Controlled Substances . . . 72 hours
Heparin* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 hours
Coumadin* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72 hours
Oxytocics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72 hours
Ketoralac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 days (no renewals)
TPN and parenteral solutions. . . . . . . . . . . . . . . . . . . . . .24 hours
Low molecular weight heparin*(Lovenox®, Fragmin®).72 hours
* Provided PTT tests are stabilized and therapeutic levels of anticoagulants are achieve, otherwise ONLY a 24
hour duration is to be in effect. Heparin or LMWH (i.e. Lovenox®) administered subcutaneously for DVT
prophylaxis may be written for a thirty (30) day supply. Lovenox® 40mg subcutaneously or 30mg
subcutaneously every twelve (12) hours are doses for DVT prophylaxis.

92
One)
Yes No
93
No: ___CH. 5 SECT. M
Subject: APPROVED FORMS FOR USE AT UHB WITH Page ____1__ of ____1__
CONTROLLED SUBSTANCES

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To inform the staff of the approved forms to be used for the disposition of any and all
contingencies involving controlled substances in UHB.
locked cabinet.
IV. Responsibilities: N/A.
V. Procedures/Guidelines: The Controlled Substances Forms Approved for Use in the UHB
Pharmacy Department are as follows:
(16) Class II, III, IV and V Controlled Drugs Order Sheet
(17) Narcotic and Controlled Drug Administration Form
(18) DEA Form 222 (Aug 1990)
(19) Destruction of Controlled Substances:
(a) Request of Approval of on Site Destruction of Controlled Substances
(b) Controlled Substances Surrender Form
(c) Statement of On-Site Destruction of Controlled Substances
(20) Inventory sheet (Main Stock Narcotic Record)
(21) Copy of NYS Official Triplicate Prescription
(22) Prescription Blank for Class III, IV and V
(23) Institution Order Form for Official New York State Triplicate Book
(24) DEA Form 106 – Report of Theft or Loss of Controlled Substances
(25) NYS DOH Bureau of Controlled Substance Form – Report of Loss of Official New York State
Triplicate Prescriptions
(26) Nursing Station Shift Report Narcotic Check Sheet
(27) NYS DOH Bureau of Controlled Substance Form DOH 2094 (6/90)
-Report of Loss or Theft of Controlled Substance
(13) DEA Form 222a (0/88) – Order Form Requisition to obtain DEA Form 222

VII. Attachments: see Procedures above.

94
One)
Yes No
95
No: ___CH. 5 SECT. N
Subject: ADMINISTRATION OF CONTROLLED Page ____1__ of ____1__

SUBSTANCES TO VISITING FAMILY MEMBER

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To instruct Pharmacy staff about the procedures to follow when dispensing controlled drugs
that are to be administered to a visiting family member of a patient.
III. Policy: A single dose of a controlled substance may be administered from an IPD Nursing Station sub-
stock of controlled substances to a visiting family member under emotional distress.
IV. Responsibilities: A physician is responsible for writing a prescription order for the single dose. A
nurse is responsible for withdrawing the drug from the nursing station sub-stock (Pyxis® or
otherwise)and attach the written prescription to the administration sheet. The pharmacist is
responsible to replace the single dose and file the written prescription.
(1) The physician in charge of the patient shall reduce to writing a prescription on the OPD
prescription blank, an order to the nurse to administer a single dose of a controlled
substance (note: All elements of an OPD prescription as stated in Chapter5, Section D,
Procedures, #1 of the Pharmacy P&P Manual must be present).
(2) The nurse receiving the prescription shall withdraw one (1) dose form the nursing station sub-
stock.
(3) The nurse shall attach the written prescription to the administration sheet and document on
the prescription the date and time of administration and sign the prescription.
(4) The nurse shall give the prescription to the pharmacist delivering the controlled substances
the next day.
(5) The pharmacist shall replace the single dose in the nursing sun-stock and file the prescription
in the Main Pharmacy’s Controlled Substance Prescription files for the appropriate controlled
substances.

96
One)
Yes No
97
No: ___CH. 6
Subject: REPACKAGING OF PHARMACEUTICALS Page ____1__ of ____1__

EITHER IN UNIT DOSE OR UNIT OF USE FORM

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Establish procedures for the safe re-packaging of pharmaceuticals from manufacturers’
original containers..
III. Policy: All drugs repackaged from the original manufacturer’s bulk container, shall be repackaged by a
pharmacist or by a Pharmacy Aide/Technician under the personal supervision of a pharmacist if the
FDA’s approved package insert permits repackaging outside the original manufacturer’s container.
IV. Responsibilities: It is the responsibility of a licensed pharmacist to provide the drug for repackaging,
check the label for the repackaged drug, and check the final repackaged dosage units for correctness
and accuracy before the repackaged drugs are placed in active inventory. It is the responsibility of the
pharmacy support staff member to repackage the drugs according to the proper procedure, prepare all
of the required documentation for these procedures and maintain all records for a period of five (5)
years.
A) Unit of Use Containers (defined as container that contains a sufficient quantity of medication
for one normal course of therapy):
1) For either oral solid, oral liquid or topical dosage forms, a pharmacist shall give the
manufacturer’s original bulk container of drug to the pharmacy support staff
member.
2) The support staff member shall break open the manufacturer’s original bulk
container and count the appropriate number of dosage units to be placed in the
container either using a counting machine or pill tray for oral solids. For liquids, a
graduated cylinder shall be utilized.
3) The unit of use container shall be closed with a child-proof closure except for
compounded creams or ointments manufactured within the Pharmacy.
4) The pharmacy support staff member shall fill out the “Drug Repackaging Work
Sheet” record (see appendix A) with all the pertinent information for the drug and
sign this record.
98
5) The pharmacy support staff member shall produce a sample label for the drug
repackaged using the Monarch Labeling Machine. The label shall contain the
following information:
Pharmacy department and name of the hospital,

telephone number of the pharmacy, and DEA
number of the hospital
Generic name of the drug
Trade name of the drug
Manufacturer of the drug
Strength and dosage form of the drug
Quantity of drug contained in the container
In-house expiration date of the repackaged drug (calculated as 6 months or 50% of the
time remaining to the manufacturer’s expiration date, whichever is less, from the date
of repackaging). For extemporaneous external preparations, the expiration date of the
active ingredient on the manufacturer’s container or 1 year form the date of preparation
shall be used.
In-house lot number of the repackaged drug (assigned as item of the day repackaged,
st nd
e.g., 1 item is A, 2 item is B, etc. and date of repackaging [e.g. A 021992] that is, the
st
1 items are packed on February 19, of the year)
6) The pharmacy support staff member shall print a sample label and present the label and the
filled unit of use container with the drug to the original assigning pharmacist for checking.
7) The pharmacy shall sign the sample label if it is correct for the drug presented to him/her.
8) The pharmacy support staff member shall paste the signed sample label to the Drug
Repackaging Work Sheet.
9) The pharmacy support staff member shall then proceed to print a sufficient quantity of labels
for the number of containers produced in the repackaging procedure.
10) The pharmacy support staff member shall sign the Drug Repackaging Work Sheet upon
completion and present the total quantity of labels, repackaged drugs to a pharmacist for final check
11) If the work is correct and accurate the original assigning pharmacist shall sign the Drug
Repackaging Sheet
12) The Pharmacy support staff member shall place the repackaged drugs into the active inventory
and place the repackaged drugs into the active inventory and place the completed Drug Repackaging
Work Sheet into the Repackaging Drug Log Book. These records shall be maintained for a period of
five (5) years. The balance of bulk stock in the original manufacturer’s container is to be placed in the
IPD active dispensing stock.
13) The equipment used for repackaging shall be cleaned after each procedure.
Exceptions: The following classes of drugs shall NOT be repackaged:
 Penicillin and all its derivatives
 Cyto-toxic Drug
 Immuno-suppressive Drugs
B) Unit Dose Repackaging (Defined as: repackaging drugs in a single unit-container for drugs
intended for administration by other than the parenteral route as a single dose, direct form the
container.):
99
1) A pharmacist shall give the manufacturer’s original bulk container of drug to the pharmacy
support staff member.
2) The support staff member shall break open the manufacturer’s original bulk container and
repackaged the dosage form, e.g., tablet, capsule, in unit-dose blister packages utilizing the tablet,
capsule, in unit-dose blister packages utilizing the Unit Dose Packaging Machine and the computer
control programs for this machine.
3) The pharmacy support staff member shall present one sample of the unit dose drug in a
labeled, unit dose blister package for approval to a pharmacist for checking
4) The labeled unit dose package must contain the following information:
 Generic name of the drug
 Trade name of the drug
 Dosage form
 Strength
 Manufacturer’s name
 Manufacturer’s lot number
 University Hospital at Brooklyn lot number
 Expiration date (Calculated as: six {6} months from the repackaging date; if the six
{6} months does not exceed 25% of the remaining times between the date of
repackaging and the expiration date on the original manufacturer’s bulk container.
In this case the date shall be assigned as 25% of the remaining time from the
repackaging date to the manufacturer’s expiration date).
5) A management Report shall be generated by the computer daily and a file maintained.
6) Packaging in robot-ready dosage forms follows all of the procedures in this chapter that apply
to unit-dose packaging. Computer printouts are generated daily for pharmacist approval and
signature of all drugs packaged in robot-ready packaging.

VII. Attachments: Drug Repackaging Work Sheet

One)
Yes No
100
No: ___CH. 7
Subject: COMPOUNDING OF PHARMACEUTICALS FOR Page ____1__ of ____2__
INTERNAL OR EXTERNAL USE

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To inform staff about the procedures to follow when extemporaneously compounded drugs
must be prepared by a licensed pharmacist.
III. Policy: All extemporaneously compounded drugs shall be prepared by a licensed pharmacist.
IV. Responsibilities: It is the responsibility of the Materials Manager to inform a Pharmacy manager, of
inventory shortages and to make the necessary adjustments to the inventory to decrement or increment the
inventory of the drugs used in the compounding and receipt of the finished product.
A Pharmacy manager shall assign a pharmacist to prepare the product. The pharmacist is responsible to
prepare the product and approve the labeling for the product. It is the responsibility of the Pharmacy aide to
prepare a label for the product. It is the responsibility of the Pharmacy support staff to gather the ingredients,
package the finished product, and label product with the pharmacist approved label.
(1) The Materials Manager shall inform a Pharmacy manager that a compound drug is in short
supply.
(2) A Pharmacy manager shall assign a pharmacist to compound the required product.
(3) The pharmacist shall go to the “Manufacturer Formulary” cards for the respective product and
gather the required ingredients. A T.H. Pharmacy Assistant shall obtain the necessary
ingredients for the pharmacist.
(4) The Pharmacist shall proceed to extemporaneously compound the drug product using the
appropriate equipment, e.g., scales, graduates, ointment slabs, etc. Note: all scales must be
balanced by a pharmacist prior to use.
(5) The pharmacist or the support staff (T.H. Pharmacy Assistant) shall package the bulk produced
product into the appropriate formulary size container e.g. bottles, ointment jars, etc.
(6) The T.H. Pharmacy Assistant shall clean and wash all equipment used for the preparation and
replace the equipment in the appropriate storage area.
(7) The Pharmacist shall make the following entries in the “Manufacturing Record Book”:
 Date of Manufacture
 Product Manufactured
 Assigned Pharmacy Lot Number
 Quantity Manufactured
 Signature of Compounding Pharmacist
The assigned lot number is derived as follows:

101
A031092 M
Indicated an extemporaneously manufactured drug

Year
Day
st
1 item
manufactured
that day Month
A031092M = The first item manufactured on March 10, 1992.
(8) The pharmacist shall complete the “Manufacturing Record and Inventory Adjustment Record”
(see attached) and record the following information:
 Date of Manufacture
 Item Manufactured
 Formulary Number
 Number of Units Manufactured
 Signature of Manufacturing Pharmacist
 Signature of Assisting T.H. Pharmacy Assistant (if any)
 Name of Items Used in Manufacturing
 Manufacturer’s Lot#
 Manufacturer’s Expiration Date
 Formulary Number of Drug Used
 Number of Units Used to Prepare the Product
 A Sample label Signed by a Pharmacist (The pharmacist shall provide the information
necessary to produce labels to a Pharmacy aide shall produce the exact number of labels to
label the quantity of product manufactured).
(9) The manufacturing Record and Inventory Adjustment Record” shall be retained for five years
by the Pharmacy Department.
(10) The completed, labeled drug shall be placed in inventory by the T.H. Pharmacy Assistant and
the appropriate computer receipt of the drug shall be made, also the appropriate decrement of
inventory for the drugs used to prepare the product shall be made using requestor code 0190.
(11) Partial units of drugs used for manufacturing shall be returned to inventory.
(12) The expiration date for the extemporaneously compounded shall be determined as follows:
a. Expiration date on the manufacturer’s container for the active ingredient.
b. One year from the date that the drug is compounded or whichever occurs first.
(13) For oral preparations, specific recommendations as stated in the manufacturer’s literature
concerning the use of their products in extemporaneous compounding shall be followed.

VII. Attachments: Drug Repackaging Work Sheet; Manufacturing and Inventory Adjustment Record
One)
Yes No
102
Subject: DEFINITION OF ABSOLUTE AND 95% ALCOHOL Page ____1__ of ____1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Inform the Pharmacy staff of the federal definition of Absolute & 95% Alcohol.
II. Definition(s): Absolute alcohol is defined as ethanol in a concentration of 100% by volume or 200
proof and requires the Department of the Treasury, Bureau of Alcohol, Tobacco, and Firearms,
Industrial Alcohol User Permit to purchase and New York State Liquor Authority Alcohol Permit to use,
dispense and purchase.
III. Policy: N/A
IV. Responsibilities: N/A.

One)
Yes No
103
Subject: ORDERING OF ABSOLUTE OR 95% ALCOHOL Page ____1__ of ____1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Establish procedures for the ordering of absolute alcohol.
III. Policy: Absolute or 95% Alcohol shall be ordered in quantities that meet the safe storage requirements
of the NFPA, meet the needs of the hospital and university, and is packaged in, volume containers.
IV. Responsibilities: It is the responsibility of the Materials Manager to order, receive and store absolute
or 95% alcohol according to BFPA, Department of Treasury, and New York State Liquor Authority
Regulations.
 The Pharmacy Materials Manager shall initiate a purchase requisition for absolute or 95%
alcohol not to exceed 1000 proof gallons physically on hand at any time. Purchase shall not
exceed 6000 proof gallons annually.
 The Materials Manager shall order either absolute alcohol packaged in pints or packaged in
wine gallons of 95% alcohol.
No dispensing drums shall be ordered.
 Upon receipt of the alcohol, the Materials Manager shall verify the shipment’s quantity and
enter receipts of either pints or gallons in the Alcohol Record Book.
 The Materials Manager shall divide the shipment and place a minimum quantity of pints or
gallons into the Pharmacy’s alcohol storage area, Room ALL1-468. All other supplies shall be
stored in the volatile storage cage in the Receiving Area of the Hospital.
 If a discrepancy is discovered in the shipment, the Materials Manager shall immediately notify
the manufacturer and the appropriate correction shall be made.


104
One)
Yes No
105
No: ___CH. 8 SECT. C
Subject: INVENTORY CONTROL AND STORAGE OF Page ____1__ of ____1__

ABSOLUTE OR 95% ALCOHOL

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Establish procedures for the maintenance of an ongoing inventory of absolute alcohol.
III. Policy: The hospital’s main inventory of absolute or 95% alcohol shall be accurately maintained
according to Department of Treasury, Bureau of Alcohol, Tobacco and firearms Regulations and safely
stored under NFPA, New York State Fire Inspection and local New York City Fire Department
regulations by the Department of Pharmacy.
IV. Responsibilities: It is the responsibility of Pharmacy Management to reconcile physical and record of
the inventory of absolute and 95% and maintain the storage of the same in a safe and secure manner.
It is the responsibility of the Director of Pharmacy to investigate all claims of discrepancies and file all
required documentation.
I. Storage
(1) Supplies of absolute or 95% alcohol for dispensing from the Pharmacy shall be stored
in the Pharmacy’s alcohol storage area, Room ALL1-468.
(2) This storage area shall meet all New York State and New York City Fire Codes and
Security Requirements of The Department of Treasury, Bureau of Alcohol, Tobacco and
Firearms and remain locked at all times. The fire code features required in this area
are:
 Type A,B,C Extinguisher
 Room Designations Indication:
o No Smoking Volatile Storage
o Reactivity and Flammability of Contents
o Safety Hazard
 Fire Rated Door

 Solid Ramp Type Door Saddle
 Overhead Sprinklers
 Spark Proof Light Switches and Electrical outlets
 Glass Enclosed Light Bulb Fixtures, if pumping from drums
 Certified Fire Rated Storage Cabinets
 No Paper or Cardboard in Area
106
II. Inventory Control:
(1) At the end of each month, a physical inventory of the balance on hand of Absolute and
95% Alcohol shall be taken by the Associate Director of Pharmacy.
(2) The physical inventory shall be compared against the Alcohol Record Book.
(3) If a discrepancy is discovered, the Director of Pharmacy shall be notified and an

investigation shall be initiated to resolve discrepancy.
(4) If the discrepancy can’t be resolved, the Director of Pharmacy shall notify the Senior
Associate Administrator responsible for the Pharmacy at extension 2401, Public Safety
Office at the Hospital, extension 2626, and the Department of Treasury, Bureau of
Alcohol, Tobacco, and Firearms Regional Office, 6 World Trade Center, NY, NY.
Procedures outlined in Part 213 of Title 26, code of Federal Regulations shall be
followed.
(5) Absolute or 95% Alcohol is received form the manufacturer and recorded in the Alcohol
Record Book in Wine Gallons (3784 ml).
(6) Monthly inventories shall be recorded in proof gallons.
(7) “Report of Tax Free Alcohol Users” [ATF Form 1451 15150] (8-83). This form shall
record balance on hand, quantity received, and quantity dispensed all in proof gallons.
(8) The “Report of Tax Free Alcohol User” for the year shall be maintained in the Pharmacy
Director’s Office for five (5) years.

One)
Yes No
107
No: ___CH. 8 SECT. D
Subject: DISPENSING OF ABSOLUTE AND 95% ALCOHOL Page ____1__ of ____1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Establish procedures for the dispensing of absolute and 95% alcohol according to federal
laws and NYS Fire Safety Codes.
III. Policy: Absolute or 95% Alcohol shall be dispensed by a Pharmacy aide, pharmacy technician or
pharmacist only pursuant to a Alcohol Request Form, in duplicate, signed by an authorized individual
from the requesting lab or service.
IV. Responsibilities: It is the responsibility of the dispensing individual to sign the Alcohol Request Form
and record information in the Alcohol Request Book. It is the responsibility of Pharmacy
Administration to monitor compliance to appropriate procedure for dispensing absolute or 95%
alcohol.
 Upon presentation of a signed Alcohol Request Form (UH 81-74) (see attached) with all
required information present, a Pharmacy aide, Pharmacy assistant, or pharmacist shall
dispense the exact quantity of either 95% or absolute alcohol to the requesting service.
 The person receiving the alcohol and the dispenser of the alcohol shall sign the requisition
form and the Pharmacy shall retain original and give the copy to the receiving person.
 The dispenser shall record in the Alcohol Record Book the following information:
o Date of Dispensing
o Requesting Department
o Quantity Dispensed
o The Decreased Balance on Hand
o Signature of the Receiving Individual
o Signature of the dispenser
 The alcohol shall be dispensed in the sealed, pre-filled gallon or pints to the requestor.
 Any wastage or breakage shall be recorded in the Alcohol Record Book, witnessed by a
pharmacist and recorded in the monthly entry to the Department of Treasury, “Report of Tax
Free and Alcohol User”.
108
 Pharmacy Administration shall verify entries and compliance to procedures handled during the
month.
 Storage of any alcohol product must be in a fire rated cabinet that is marked accordingly.

VII. Attachments: Alcohol Request Form (UH 81-74)
One)
Yes No
109
Subject: LICENSING REQUIREMENTS FOR THE Page ____1__ of ____1__

PURCHASE DISPENSING OF ABSOLUTE AND
95% ALCOHOL

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To designate legal documents required to purchase, store, and, dispense absolute and 95%
alcohol.
III. Policy: Absolute or 95% Alcohol shall be purchased or dispensed by the hospital pharmacy only under
the authority of a valid Department of Treasury Bureau of Alcohol, Tobacco and Firearms Industrial
Alcohol User Permit, issued to the hospital and a New York State Liquor Authority permit issued to the
hospital.
IV. Responsibilities: It is the responsibility of the Pharmacy Administration to keep current all licensing
documents for the purchase and dispensing of absolute or 95% alcohol.
 Department of Treasury Permit# TF-NY-1329 shall be maintained by Pharmacy Administration
as long as absolute or 95% alcohol is purchased.
2) New York State Liquor Authority Permit# AP10355 shall be maintained by Pharmacy
Administration as long as absolute or 95% alcohol is dispensed or purchased.

VI. Attachments: none

One)
Yes No
110
Subject: MEDICATION ERRORS AND HOSPITAL Page ____1__ of ____1__

INCIDENTS INVOLVING MEDICATIONS

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures to follow when discovering and investigating medication errors of
omission or commission.
II. Definition(s): See Administrative P&P Manual Chapter PHA-10, Medication Error Definition and
Classification
III. Policy: All errors of omission or commission involving medications shall be reported immediately to
the Director of Pharmacy and not later than 72 hours of the occurrence.
IV. Responsibilities: It is the responsibility of the nurse to file an incident report involving in-patients
whether Pharmacy is involved or not. It is the responsibility of the Director of Pharmacy to review all
incident reports involving medication and take the appropriate corrective and documentation actions.
I. In-patient Medication Errors Not Involving Pharmacy Dispensing:
 Once the error is discovered, the nurse involved with or discovering the error shall report the
error to the Assistant Nursing Director of the respective unit and the physician in charge of the
patient.
 An official UHB Hospital Patient Incident Report (UH-025) shall be filled out by the nurse and
record the names to whom the incident was reported and the times of reporting. This report is
forwarded to the Inpatient Q/M Department.
 The nurse shall then proceed to answer all questions and describe the incident on the form.
 The physician responding to the incident or the Assistant Director of Nursing shall describe
his/her findings and interventions and sign the incident report.
 The Assistant Nursing Director of the respective unit forwards the completed two part Incident
Report to the Associate Administrator for Inpatient Q/M at Nursing Quality Management (Box
95).
 After review, a copy of the Nursing Q/A copy is sent to the hospital’s Risk Management
Department at Box 23.
111
 The Risk Management Department forwards a photocopy of the report to the Director of
Pharmacy at Box 36.
 The Director of Pharmacy shall review all incident reports with the Medication Error Work
Group involving medication and will determine if each incident requires review and
recommendations for action by the Medication Usage Sub-Committee of the Pharmacy and
Therapeutics Committee to the Committee of the Pharmacy and Therapeutics Committee top
the P&T Committee for review and action due to prescribing errors, or systems deficiencies.
 These recommendations shall presented at the monthly annual Pharmacy and Therapeutics
Committee meetings as part of the Nursing Medication Error Report with a statistical analysis
of the errors along with NYPORTS classification of the errors.
 If the Committee determines that the incident involves inappropriate prescribing or

administration, the Secretary of the Pharmacy and Therapeutics Committee (Director of
Pharmacy) shall communicate with the respective service or to the Hospital’s Quality
Management office, describe the events surrounding the incident, describe the Pharmacy and
Therapeutics Committee’s determinations, and request a plan of corrective action from the
respective service. If the Q/M Department determines that this error is a possible sentinel
event, the Associate Administrator for Q/M shall convene an interdisciplinary group to
investigate the event.
 The corrective plan of action shall be reviewed by the Pharmacy and Therapeutics Committee
for approval.
 Effectiveness of corrective plans of action shall be monitored through the Pharmacy using
prescription documentation and any re-occurrences of similar incident reports.
II. In-patient Medication Errors Involving Pharmacy Dispensing:
1) All steps are to be followed as described in Chapter 9, Section A, Procedure I.
2) Pharmacy Administration shall retrieve the incorrectly dispensed prescription records form the
Pharmacy’s files and identify the dispensing pharmacist. The Assistant Director of Nursing
shall return the incorrectly dispensed drug directly to the Director of Pharmacy.
3) The pharmacist involved shall be counseled informally for the first occurrence and formally for
any subsequent occurrences. Persistent medication errors shall be dealt with in a disciplinary
fashion, e.g., request for disciplinary investigation, notice of discipline, suspension,
termination, if necessary, reporting to the State Education Department.
4) The Director of Pharmacy shall present all incidences of Pharmacy involvement in medication
errors at Pharmacy Staff meetings.
III. Out-patient Medication Errors Involving Pharmacy Dispensing Discovered by the Pharmacy:
1) All steps are to be followed as described in Chapter XI., Section A, Procedures II., 2 through 4.
2) Pharmacy Administration shall contact the respective clinic and inform the physician and
nurse in charge to contact the patient at home and tell the patient not to take the drug.
3) Pharmacy shall contact Public Safety, extension 2626, to arrange for a car to bring the correct
medication to the patient’s home and recover the incorrect medication.
4) The Director of Pharmacy shall file an Incident Report with Risk Management within 24 hours
of the incident.

VII. Changes in regulatory or statutory laws or standards
VIII. System failures/ changes
IX. Institutional/operational changes
112
X. Attachments: UHB Patient Incident Report
PHA-10
One)
Yes No
113
No: ___PHA-10
Subject: MEDICATION ERROR DEFINITION AND Page ____1__ of ____3__

SEVERITY CLASSIFICATION
Prepared by: NICHOLAS GALEOTA Original Issue date: 6/00
Reviewed by: WILLIAM GERDES Implementation Date: __8/01__

Patient Care Manual
AOD Manual

______________________________________________________________________________________
I. Purpose: To categorize medication errors according to NYPORTS classification for analysis and
required reporting.
II. Definition(s): NYPORTS: New York Patient Occurrence Reporting & Tracking System
o All alleged medication errors reported shall be deemed a medication error if it falls
within the following definition:
A medication error is any preventable event that may cause or lead to inappropriate medication use
and patient harm while the medication is in control of a healthcare professional, patient, or consumer. such
events may be related to professional practice, healthcare products, procedures, and systems including
prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing
distribution, administration, education monitoring, and use.
o QM – Quality Management Department
III. Policy: By standardizing a universal definition for medication errors and establishing a system for
severity classification, an interdisciplinary team can evaluate the root causes of the medication errors
and initiate a corrective action so that the error does not re-occur.
IV. Responsibilities: All medication errors shall be reported on a patient’s incident report to QM by all
hospital staff. Medication errors shall be reviewed by an interdisciplinary group from QM and Nursing.
Medication errors and rates are reviewed monthly by the Pharmacy and Therapeutic Committee.
Errors categorized in categories G, H, I should be reviewed by an AD HOX reporting to the NYSDOH.
o Once an alleged medication error has been confirmed as a true medication error by the
above definition, the medication error shall be classified into one of the following
categories:
Category A, No Error: Circumstances or events that have the capacity to cause error
Category B, Error, No Harm: An error occurred but that reached the patient but did not reach the patient.
Category C, Error, No Harm: An error occurred but that reached the patient but did not cause patient harm.
114
Category D, Error, No Harm: An error occurred that resulted in the need for increased patient monitoring but
no patient harm.
Category E, Error, Harm: An error occurred that resulted in the need for treatment or intervention and
caused temporary patient harm
Category F, Error, Harm: An error occurred that resulted in initial or prolonged hospitalization and
caused temporary patient harm
These categories are reportable to the NYSDOH and may require a sentinel event review:
Category G, Error, Harm: An error occurred that resulted in permanent patient harm.
Category H, Error, Harm: An error occurred that resulted in a near-death event (e.g., anaphylaxis, cardiac
arrest)
Category I, Error: An error occurred that resulted in a patient death.

XI. Changes in regulatory or statutory laws or standards
XII. System failures/ changes
XIII. Institutional/operational changes
VIII. References: NYSDOH, NYPORTS Classification of Medication Errors
One)
Yes No
115
Subject: DRUG-DRUG INTERACTIONS Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: In order to prevent injuries or adverse outcomes associate with drug-drug interactions,
pharmacist shall follow established procedures to evaluate drug combinations.
III. Policy: All Pharmacists shall check the patient medication profile for potential drug – drug interactions
before dispensing a prescription order written by authorized licensed/credentialed prescribers.
IV. Responsibilities: It is the responsibility of the pharmacist to all prescriptions for potential drug – drug
interactions and communicate with the responsible physician to resolve the problem medication order.
 Upon receipt of a prescription order, a pharmacist shall check either the computer medication
profile or in those satellite areas, the hard copy profile for potential drug – drug interactions
prior to dispensing.
 If after the pharmacist reviews the profile a determination is made that a potential drug
interaction is evident, the pharmacist shall contact the respective nursing station and speak to
the physician responsible for the patient.
 The pharmacist shall inform the physician about the potential interaction and discuss
alternative therapies.
 If the physician agrees with the alternative, the pharmacist shall instruct the physician to
discontinue the original order and write a new prescription order for the alternative.
 If the physician insists on the dispensing of the original order, and in the professional
judgment of the pharmacist that it neither poses a life threatening situation nor may produce
injury/immediate adverse effects in the patient, the pharmacist shall document the following
information on the prescription:
o Date of Contact with Physician

o Time of Contact with Physician
o Name of Physician
o Reasoning Give by the Physician for Dispensing or Backup Documentation Reference Given
by the Physician
o Signature of Pharmacist
116
 If in the pharmacist’s professional judgment dispensing the medication upon the physician’s
insistence the patient will be compromised in any manner, the pharmacist shall refer the matter
to Pharmacy Administration to resolve the issue with the attending physician.

XIV. Changes in regulatory or statutory laws or standards
XV. System failures/ changes
XVI. Institutional/operational changes
VII. Attachments: Top Ten Drug-Drug Interactions
One)
Yes No
117
No: CH. 9 SECT. C
Subject: DRUG – FOOD INTERACTIONS Page 1 of 1
Prepared by: Nicholas Galeota, MS, RPh Original Issue date: 8/1/98
Reviewed by: William Gerdes Implementation Date: 8/03/01
Alan Hui, Pharm.D.
Stefani Skidell, RD Revisions: 12/01/07
Approved by: Constance Shames, MD Distribution: Administrative

Department Manual
Patient Care Manual
AOD Manual

_____________________________________________________________________________
I. Purpose:
To provide a method to alert healthcare providers of patients that are at risk of potential drug - food
interactions, ensure appropriate medication administration, and counsel patients of any dietary modifications.
II. Definition(s): None
III. Policy:
The Pharmacy Department shall inform the hospitals clinical dietary services daily concerning medication
orders prescribed for in-patients that have a potential for drug - food interactions.
It is the responsibility of the Pharmacy Department to select drugs with a high profile for food – drug
interactions and tag the agents in the computer mainframe for Dietary reporting. It is also the responsibility of
the nurse or pharmacist to provide printed drug information for patient discharge interviews and participate, as
necessary, in the interview. It is the responsibility of the clinical dietician to review patient charts and make
recommendations to the physician or instruct the patient in diet modifications.
IV. Procedures/Guidelines:
1. The Pharmacy Department shall tag the following targeted drugs with a high potential for drug – food
interactions in the computer mainframe profile (THOMIS) for the drug.
a. Monoamine Oxidase Inhibitors
®
i. Phenelzine (Nardil )
®
ii. Tranylcypromine (Parnate )
®
b. Warfarin (Coumadin )
c. Fluoroquinolone Anitbiotics
®
i. Ciprofloxacin (Cipro )
®
ii. Levofloxacin (Levaquin )
®
iii. Moxifloxacin (Avelox )
d. HMG-CoA Reductase Inhibitors (“Statins”)
®
i. Atorvastatin (Lipitor )
ii. Simvastatin (Zocor)
®
iii. Rosuvastatin (Crestor )
®
iv. Lovastatin (Mevacor )
®
v. Fluvastatin (Lescol )
118
®
vi. Pravastatin (Pravachol )
e. Immunosuppressants
® ®
i. Cyclosporine (Neoral , Sandimmune )
®
ii. Tacrolimus (Prograf )
®
iii. Sirolimus (Rapamune )
f. Benzodiazepine
®
i. Diazepam (Valium )
®
ii. Midazolam (Versed )
®
g. Phenytoin (Dilantin )
®
h. Metronidazole (Flagyl )
i. Angiotensin Coverting Enzyme (ACE) Inhibitors
®
i. Captopril (Capoten )
®
ii. Enalapril (Vasotec )
®
iii. Benazepril (Lotensin )
®
iv. Fosinopril (Monopril )
® ®
v. Lisinopril (Prinivil , Zestril )
®
vi. Moexipril (Univasc )
®
vii. Perindopril (Aceon )
®
viii. Quinapril (Accupril )
®
ix. Ramipril (Altace )
®
x. Trandolapril (Mavik )
2. Upon arriving the daily robotics database input of medication orders in the Main Pharmacy, an upload of
data shall be received by the EAGLE system and a printout of the targeted drug shall be generated in the
Clinical Dietary Department with the following information:
o Name of Patient
o Location of Patient
o Date of the Medication Order
o Name of Targeted Drug
3. The clinical dietician shall then proceed to conduct a chart review of the patient for whom the drug has
been ordered and make recommendations as to diet changes, and if necessary, education the patient on
the diet restrictions required for a particular drug.
4. If the patient is to be discharged, the nurse in charge of the patient shall use the Micromedex ®
CareNotes and provide a printed drug information packet to be given to the patient concerning the drugs
that the patient is being surcharged with by the physician.
5. If necessary, the nurse may request that a pharmacist assist the nurse in the patient exit counseling
interview concerning the drug orders the patient shall take upon discharge, at extension 2854 or 2856.

VII. Attachments: Top 10 Drug-Food Interactions

®
VIII. References: MicroMedex
One)
8/01 Yes No NICHOLAS GALEOTA MS, RPH
8/04 Yes No Alan Hui, PharmD
12/07 Yes No Alan Hui, PharmD
119
Top 10 Drug-Food Interactions
Medication or Clinical Comments and
Offending Foods Interaction
Drug Class Relevance Recommendations
MAO-I Tyramine-containing High Risk of hypertensive Avoid tyramine-containing foods
(Monoamine Oxidase foods crisis and
Inhibitors) such as aged cheeses, cardiovascular
• Phenelzine (Nardil®) fermented meats, fava events
• Tranylcypromine beans, red wines, pickled
(Parnate®) fish, figs, and avocados
Warfarin Foods with high vitamin Moderate Vitamin K produces Large changes in dietary
(Coumadin®) K content such as blood-clotting consumption of foods high in
broccoli, spinach, kale, substances and may vitamin K should be avoided or
turnip greens, cauliflower, reduce the accompanied by careful monitoring
brussel sprouts effectiveness of of the international normalized ratio
anticoagulants (INR).
Fluoroquinolones Antibiotics Cations containing High Decrease absorption Avoid diary products. If taken
• Gatifloxacin (Tequin®) products: of these drugs by concomitantly, take one hour before
• Ciprofloxacin (Cipro®) • Dietary products chelation in the or two hours after ingestion of the
• Levofloxaxin (Levaquin®) containing calcium stomach resulting in cation containing product
• Moxifloxacin (Avelox®) • Iron, magnesium, and treatment failure
zinc supplements
• Antacids
HMG-CoA Reductase Grapefruit juice Moderate Increased Avoid grapefruit juice during
Inhibitors bioavailability of the therapy. Orange juice may be
• Atorvastatin (Lipitor®) “statins” resulting in substituted.
• Simvastatin (Zocor®) an increased risk of
• Lovastatin (Mevacor®) myopathy
Also know as the “statins”
Immunosuppressants Grapefruit juice High Increased Avoid grapefruit juice during
• Cyclosporine (Neoral®) bioavailability of therapy. If taken concomitantly,
• Tacrolimus (Prograf®) these medications monitor serum drug levels (if
• Sirolimus (Rapamune®) resulting in toxic possible) and signs of toxicity.
serum drug levels
Benzodiazepine Grapefruit juice High Increased Avoid grapefruit juice during
• Diazepam (Valium®) bioavailability of therapy. Monitor mental and
• Midazolam (Versed®) these medications respiratory status if taken
• Tiazolam (Halcion®) resulting in elevated concomitantly.
serum drug levels
Calcium Channel Blockers Grapefruit juice Moderate Increased Avoid grapefruit juice during
• Nifedipine (Procardia®) bioavailability of therapy. Monitor heart rate and
• Felodipine (Plendil®) these medications blood pressure if taken
• Verapamil (Calan®, resulting in elevated concomitantly since hypotension
Isoptin®) serum drug levels can occur.
Phenytoin Enteral Feeds Moderate Decrease absorption Hold enteral feeds 1-2 hours before
(Dilantin®) of phenytoin and after each phenytoin dose.
resulting in sub-
therapeutic drug
levels
Metronidazole (Flagyl®) Alcohol High A disulfiram-like Avoid ethanol ingestion while on
reaction (flushing, metronidazole therapy and for at
increased respiratory least three days after the
rate, tachycardia) discontinuation of metronidazole
may occur when treatment.
taken concomitantly
ACE-I Foods with high Moderate Increase serum Avoid eating large amounts of
(Angiotensin Converting potassium content such as potassium level foods high in potassium. Monitor
Enzyme Inhibitor) bananas, green-leafy serum potassium levels
• Captopril (Capoten®) vegetables, and oranges periodically.
• Enalapril (Vasotec®)
120
No: ___CH. 9 SECT. C 1
Subject: DRUG – FOOD INTERACTION MONITORING Page ____1__ of ____3__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
FOOD – DRUG INTERACTION MONITORING*

CLASSES OF DRUGS:
1) Hypo-glycemic drugs
2) Corticosteroids
3) Cardiac Glycosides
4) Beta blocker drugs
5) Anti-coagulants
6) Diuretics
7) Mono-Amine Oxidase Inhibitors
1) Hypoglycemics
1a. Oral Sulfonylureas and Insulin:

1b. Formulary Drugs chlorpropamide, tolazamide, and tolbutamide
1c. Effects can cause dose-related nausea, vomiting, metallic taste, heartburn, and dyspepsia
1d. Advice: no particular Food – Drug precautions
Insulin – be aware of sugar and/or carbohydrate contents of food.
Oral Hypoglycemics: take with food or after meals to minimize gastric distress; do not take
with alcohol or alcoholic beverages
2) Corticosteriods
2a. Mineral Corticoid

2b. Formulary Drugs: prednisone, cortisone acetate, prednisolone
2c. Effects: Decrease absorption of calcium, phosphorus; increase urinary ascorbic acid, calcium
potassium, zinc, nitrogen
decrease nitrogen balance; decrease serum zinc
increase blood glucose, serum triglycerides, serum cholesterol
promotes GI ulceration, delay wound healing
increases need for pyridoxine, ascorbic acid, folate, vitamin D
2d. Advice: Vitamin supplementation with a multivitamin preparation may be necessary. Take
after meals or with food.
Compiled by the Pharmacy Department at UHB.
3) Lanoxin®
121
3a. Digoxin
3b. Formulary Drugs: digoxin tablets, oral, liquids, or injection
3c. Effects: Toxicity symptoms include anorexia, nausea, vomiting, diarrhea, cachexia may
competitively inhibit glucose absorption
may increase urinary magnesium, calcium
3d. Advice: (1) Inform doctor to check for toxicity if patient exhibits anorexia, nausea, vomiting,
diarrhea, cachexia, (2) Monitor electrolytes, (3) Don’t take with milk or milk products or foods
high in calcium content
4) Betablockers (Cardiovascular)
4a. Betablockers
4b. Formulary Drugs: Inderal ®, Lopressor ®
4c. Effects: Can cause nausea, vomiting, constipation, abdominal, cramping, epigastric distress,
insignificant decrease in blood glucose.
4d. Advice: This class has caused hypoglycemia in humans and can cause potentiation of insulin
and oral hypoglycemics. Take before meals; may cause gastric distress
5) Anticoagulants
5a. Oral Anticoagulants

5b. Formulary Drugs: Coumadin ®
5c. Effects: Can cause nausea, vomiting, cramps, diarrhea, mouth ulcers
5d. Advice – Should not be taken with alcohol, alcoholic beverages, foods rich in vitamin K (green
leafy vegetables, fish, fish oils, onions), vitamin C (orange juice, etc), potato chips
6) Diuretics
6a. Thiazides
6b. Formulary Drugs: hydrochlorothiazide, acetazolamide, chlorthalidone
6c. Effects: (General) – May increase urinary thiamin, pyridoxine, calcium, magnesium, potassium,
phosphate may cause hypokalemia, hypomagnesaemia decrease zinc content of liver
Specific Effects: Acetazolamide can cause anorexia, increases urinary calcium, potassium
Chlorthalidone: Increases carbohydrate intolerance; increase urinary zinc, potassium
Ethacrynic Acid: Can cause anorexia, abdominal discomfort, dysphagia, nausea, vomiting, diarrhea after
several months. May decrease carbohydrate tolerance
Increases urinary calcium, magnesium, potassium, can hypokalemia hypomagnesemia
Furosemide: Can cause nausea, vomiting diarrhea. Possibly causes peculiar sweet taste, oral and gastric
burning sensation
Decreases serum calcium hypercalcemia
Decreases serum, muscle magnesium
Decreases serum, muscle potassium, total exchangeable potassium
Decreases carboyhydrate tolerance; may be diabetogenic
Spironolocatone: Increases urinary calcium, magnesium
Thiazides: Can cause anorexia, gastric irritation, nausea, vomiting, cramping, diarrhea, increase urinary
excretion of potassium, magnesium, zinc, riboflavin, decreases carbohydrate tolerance
Can cause potassium, magnesium depletion
Single dose increases calcium excretion, long term use tends to decrease calcium excretion and increase
serum calcium
Triamterene: Can cause diarrhea, nausea, vomiting, GI upset, dry mouth, antagonizes folate, may decrease
serum folate, may increase calcium excretion, does not increase magnesium excretion.
122
6d. Advice: Take in morning if single dose. Can cause dryness in mouth; may cause electrolyte
imbalance (hypokalemia, hypotremia); should not be taken with alcohol or alcoholic beverages
7) Mono Amine Oxidase Inhibitors
7a. MAO Inhibitors

Major interaction: Amine-containing foods
7b. This established interaction has major severity and occurs rapidly
Formulary Drugs: Phenelzine (Nardil) and Tranylcypromine (Parnate)
7c. Effects Marked: elevation of blood pressure, hypertensive crisis or hemorrhagic strokes may
occur if amine containing foods are consumed concurrently or after monamine oxidase
inhibitor therapy Mechanism: inhibition of monamine oxidase impairs normal metabolism of
tyramine and other amines found in certain foods.
7d. Advice: Do not take with alcohol or alcoholic beverages, banana, broad beans, excessive
quantities of caffeine, chicken, chocolate, cheese, figs, licorice, liver, meat prepared with meat tenderizers,
pickled herring, pineapple, yeast, yogurt, because they may cause hypertensive crisis.
123
No: ___CH. 9 SECT. C. 2
Subject: FORMULARY DRUGS TAGGED IN THE Page ____1__ of ____1__

COMPUTER MAINFRAM FOR DRUG-FOOD
INTERACTION MONITORING

Department Manual
Patient Care Manual
AOD Manual

______________________________________________________________________________________
The following Formulary Drugs are tagged in the computer mainframe so that a printout will be generated in
the Dietary department (NOTE: Generic equivalents may exist as the current formulary entry):
See attached Top 10 Drug-Food Interactions entries
124
No: ___CH. 9 SECT. C. 3
Subject: GUIDE TO DRUG-FOOD INTERACTIONS Page ____1__ of ____1__

PATIENT COUNSELING

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
The medicines you take are a very important part of treating your illness. At times, there are specific changes
that you must make in your usual diet to avoid any side effects from medicines. We have taken the most
commonly used drugs and provided instructions on how to take the medication and how to eat properly.
Every medication does not appear on these lists, therefore ask your pharmacist or physician if you have
additional questions.
125
No: ___CH. 9 SECT. D
Subject: DRUG RECALLS Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To advise Pharmacy staff how they shall initiate immediate steps to notify all in-patient
nursing units and out-patient clinic areas concerning the recall and immediately remove recalled drugs
from working stock of all Pharmacy service areas and Nursing Station and Clinic drug storage areas.
III. Policy: Upon official notification from the Food and Drug Administration, the New York State
Department of Health, New York City Department of Health, or a drug manufacturer, the Pharmacy
Department shall initiate immediate steps to notify all in-patient nursing units and out-patient clinic
areas concerning the recall and immediately remove recalled drugs from working stock of all
Pharmacy service areas and Nursing Station and Clinic drug storage areas.
IV. Responsibilities: It is the responsibility of the Material’s Manager to maintain purchase order history
files of all drug products purchased by the Pharmacy. It is the responsibility of the Material’s Manager
and the Pharmacy Aides to remove all recalled drugs from the Pharmacy service areas. It is the
responsibility of Pharmacy Management to dispatch a staff member to retrieve recalled drugs from the
nursing station or clinic areas. It is the responsibility of Pharmacy Management to notify Nursing
concerning the drug recall, maintain all appropriate documentation, and supervise the correct
disposition of the recalled drugs.
 When notice is received by the Director of Pharmacy concerning a drug recall, the Material’s
Manager shall be directed to search the drug purchase order history file for the recalled drug
by lot number.
 The Material’s Manager shall match the recalled drug’s lot number and manufacturer to his/her
purchase order history file.
 If no match is found, the Material’s Manager signs and dates the recall notice and places it in
the Drug & Device Recall File.
 In the event that a match between the recall notice and the inventory exists, the Material’s
Manager shall notify the Associate Director of Pharmacy in writing.
 If there is no match between the recall notice and the purchase order history, the Material’s
Manager and the Pharmacy Aides shall proceed to remove all of the recalled drugs from all
126
Pharmacy service areas and package the drugs for return to the manufacturer or to the
appropriate shipping address provided in the recall notice.
 The Associate Director of Pharmacy shall dispatch a Pharmacy staff member to all nursing
stations and clinic areas to retrieve all supplies, if any, of the recalled drug and proceed for
return as in Chapter IX, section D Procedure #5.
 A written memo (see attached) shall be sent to all nursing station and clinic area Assistant
Director of Nursing, as a notification of the recall or a computer message will be generated to
all Nursing Station and Clinic Areas concerning the recall.
 A notice of finds shall also be provided to the Safety Committee of the Hospital through Risk
Management (Box 23).
 A pharmacist shall prepare replacement supplies for all recalled drugs removed from nursing
stations or clinic areas.
 The recall notice shall be signed by a Pharmacy Manager and the following information shall
be documented on the notice:
o Name of Drug
o Lot #
o Manufacturer
o Quantity of Drug Recovered
o Date of Shipment to Recalling Agency
 In the event that the recall effects an ambulatory care prescription, Chap. 9, Sect. A,
Procedures, Sub-section III, #’s 2 through 4 are to be followed in addition to the above.

XVII. Changes in regulatory or statutory laws or standards
XVIII. System failures/ changes
XIX. Institutional/operational changes
VII. Attachments: Drug Recall Notice
One)
Yes No
127
Subject: ADVERSE DRUG REACTION REPORTING Page ____1__ of ____3__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures for the reporting and evaluation of adverse drug reactions reported
by any healthcare practitioner.
II. Definition(s): An adverse drug reaction is defined as any unwanted/unexpected event occurring in the
course of the use of a drug at normal dosages in professional practice which:
o increases a patient’s length of stay
o results in discontinuance or changing of a drug order
o requires treatment with another prescribed drug
o results in permanent or temporary disability
o requires hospitalization or re-admission
o is toxic to the patient, e.g. nausea, diarrhea, severe headache, increase in BUN, etc,
o is life threatening or fatal
o causes/results in a significant failure of expected pharmacological action
III. Policy: Clinicians and/or healthcare providers shall report any suspected adverse reaction to a drug
to the attending physician. The physician shall determine the presence or absence of any adverse
drug reaction.
All adverse drug reactions shall be reviewed by the Pharmacy and Therapeutics Committee.
IV. Responsibilities: It is the responsibility of all healthcare providers to report suspected adverse drug
reactions experienced by patients through the ADR hotline. It is the responsibility of the Director of
Pharmacy to present all of the suspected ADR’s reported to the Pharmacy and Therapeutics
Committee for review and disposition.
1) The nurse/clinician shall notify the physician of signs and symptoms indicative of a suspected
adverse drug reaction exhibited by the patient.
2) The physician shall treat the patient exhibiting the symptoms of a suspected adverse drug
reaction and stabilize the patient.
3) The physician/nurse/clinician shall call the Adverse Drug Reaction Hotline (X 1890) in the
Pharmacy. The hotline is available24 hours a day, 7 days a week. The information required is
as follows:
a) Date and Time of the call
b) Patient’s name. medical record number, and location of the patient at the time of the
event
c) Suspected drug causing the reaction
128
4) The nurse/clinician shall document in the patient’s medical record all of the signs and
symptoms that the patient has experienced to the suspected offending drug, the treatment
rendered, if any, and the outcome to the patient.
5) The physician shall validate or invalidate the reaction and document his/her findings in the
medical record. The suspected adverse drug reaction shall also be documented in the medical
record.
6) The Pharmacy staff shall record the information provided from all calls reported to the ADR
Hotline on a daily log of the adverse drug reaction hotline calls (see attached). This log shall
be given daily to the Associate Administrator for Quality Management for medical record
review.
7) ADR’s are also captured by clinical pharmacists at rounds, clinical Pharmacy students on
rounds, and through scrutiny of specific drug utilization data from the Pyxis machines.
8) The Director of Pharmacy in collaboration with a physician, shall classify the adverse drug
reaction in one of the three (3) severity levels:
Level 1. (Mild Reaction):

Confirmed reaction without the potential of significant adverse effect(s) on the
patient.
Level 2. (Moderate Reaction):
Confirmed reaction with the potential for significant adverse effect(s) on the
patient.
Level 3. (Severe Reaction)*:
Confirmed reaction with significant adverse effect(s) on the patient.
* A severe reaction is defined as unnecessarily prolonged treatment, complications, or re-admission; or

patient management which results in anatomical or physiological impairment, disability, or death.
9) If the suspected adverse drug reaction is not confirmed by the attending physician and the
symptoms indicate that an adverse drug reaction has occurred, the medical record shall be
sent to the Pharmacy and Therapeutics Committee for peer review by a physician member.
10) The Pharmacy and Therapeutics Committee physician shall confirm or reject the presence of
an adverse drug reaction. If the reaction is confirmed, the medical record shall be sent to the
Pharmacy and Therapeutics Committee for peer review by the Pharmacy and Therapeutics
Committee.
11) If the Pharmacy and Therapeutics Committee or its sub-committee review of a confirmed
adverse drug reaction by a peer physician member results in an item for action or Committee
recommendation for corrective action/clinical service response, a letter requesting a response
to the Committee will be forwarded to the clinical service by the Associate Administrator for
Quality Management for discussion, corrective action , and documentation in the service’s
Clinical Q/A Committee minutes.
12) The response from the clinical service shall be presented to the Pharmacy and Therapeutics
Committee by the Associate Administrator for Quality Management for acceptance or a request
for further action.
13) If the reaction is of severe nature, the Director of Pharmacy shall report the adverse drug
reaction to the FDA’s Med-Watch Program and the drug manufacturer using the Department of
Health and Human Service’s FDA form 1693 (7/86) see attached). This reaction may also be
designated as a sentinel event. In such case an ad hoc interdisciplinary committee shall
review the suspected adverse drug reaction.

XX. Changes in regulatory or statutory laws or standards
XXI. System failures/ changes
XXII. Institutional/operational changes
129
VII. Attachments: Daily log of Adverse Drug Reaction Hotline Calls Form; Suspected Drug Reaction
Confirmation Record Form; Med Watch Reporting Form; Vaccine Adverse Event Reporting Form; Pharmacy
Staff’s Adverse Drug Reaction Reporting Form
One)
Yes No
130
No: ___CH. 9 SECT. F
Subject: POISONING AND ANTIDOTES Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures to address poisoning cases, obtain poison information, and
maintain antidotes.
III. Policy: The Pharmacy Department shall maintain adequate references to assist the Nursing and
Medical Services of UHB in treating cases of poisoning and maintain the telephone number of the
regional Poison Control Center. The Pharmacy shall further provide the universal antidote (liquefied
activated charcoal) to all in-patient nursing and clinic areas.
IV. Responsibilities: It is the responsibility of the pharmacist to provide antidote information and the
regional poison control center telephone number to nursing or medical personnel reporting cases of
suspected poisoning. It is the responsibility of the Pharmacy Department to maintain adequate
supplies of drugs and drug information references to provide antidote information.
1) Upon notification from Nursing or a Medical Service of a suspected poisoning incident within
the hospital, a pharmacist shall search the references maintained in the Pharmacy to assist
the nurse or physician in providing immediate care for the patient [ Note: Nurse should
file a patient incident report (UH-025)].
2) The pharmacist shall call the regional New York City Poison Control Center at 1-212-345-
4494, if the references do not adequately provide sufficient information to treat the
poisoning case.
3) The pharmacist shall direct the nurse or physician to the universal antidote maintained on all
nursing stations and Clinic Areas if appropriate (Note: During the monthly nursing station
inspections, the pharmacist shall inspect for the presence and integrity of the universal
antidote on all nursing care areas and replace, as needed, missing or expired universal
antidotes).
4) The Material Manager shall maintain adequate supplies of antidotes for the treatment of
poisoning cases e.g. Cyanide Antidote Kit, charcoal suspension, Ca EDTA Injection,
disaster supplies for chemical and radiologic poisoning, etc.
131
5) A pharmacist shall insure that during the monthly nursing station inspection a sticker with
the Regional New York City Poison Control Center number is on all phones at the nursing
station or clinic areas.

XXIII. Changes in regulatory or statutory laws or standards
XXIV. System failures/ changes
XXV. Institutional/operational changes
VII. Attachments: Antidotes and Treatment Modalities Chart
One)
Yes No
132
No: ___CH. 9 SECT. G
Subject: ANTITOXINS AND TOXOIDS Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide direction to pharmacists on obtaining antitoxins and toxoids on demand.
III. Policy: In the event that an antitoxin or toxoid is non-formulary and is requested by the Medical Staff,
Pharmacy Administration shall make appropriate arrangements to obtain the antitoxin or toxoid.
IV. Responsibilities: It is the responsibility of the Pharmacy Administration to arrange for the
procurement of emergency biologicals (antitoxins or toxoids) in response to a written physician
request for emergency patient care.
I. For interventions provided by New York City DOH:
1) Pharmacy Administration shall contact the New York City DOH, Bureau of Labs
at 1-212-447-2533 and make suitable arrangements to provide the drug to UHB.
2) Pharmacy Administration shall contact Public Safety at UHB (extension 2626) to
arrange for a car to pick up the drug at:
New York City DOH

Bureau of Labs
st
455 1 Avenue
Room 100 – J
New York, N.Y. 10013
3) A pharmacy staff member shall accompany the Public Safety Office to the lab
and present a written physician request for the drug.
4) When the drug arrives at the hospital, it shall be immediately dispensed to the
requesting area by a pharmacist.
II. For inventions Provided by a Drug Manufacturer:

1) The Pharmacy’s Material Manager shall contact the respective drug company
and arrange for same day delivery of the drug.
2) Upon receipt of the drug it shall be immediately dispensed to the requesting
area by a pharmacist.
133
XXVI. Changes in regulatory or statutory laws or standards
XXVII. System failures/ changes
XXVIII. Institutional/operational changes
One)
Yes No
134
No: ___CH. 9 SECT. H
Subject: DRUG AND DEVICE DEFECTS REPORTING Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To instruct staff on how to report drug and/or device defects to the USP.
III. Policy: Upon discovery or a report of a drug defect or device defect within the Pharmacy service areas,
Pharmacy Administration shall initiate either a Drug Product Problem Report or Medical Device and
Laboratory Product Problem Report and isolate the suspected defective drug or device.
IV. Responsibilities: It is the responsibility of Pharmacy Management to report all suspected drug
product defects or Pharmacy related suspected device to the US Pharmacopeial Convention, the FDA,
and the manufacturer of the product.
1) Upon discovery or report of either drug or device defect the Material’s Manager and
Pharmacy Administration shall recover all suspected products, lots, or devices throughout
the hospital and isolate the recovered items in a locked storage area of the Pharmacy.
2) The Pharmacy Administration shall notify Nursing Administration (Box 95) and Risk
Management (Box 23) concerning the defect.
3) Pharmacy Administration shall make telephone contact with the USP Convention at 1-800-
638-6725 to file an initial verbal report.
4) Pharmacy Administration shall follow up the telephone report by completing either USP Drug
Product Problem Report [FDA 2519 F (3/85)], whichever applies, and mail it to (see attached):
The US Pharmacopeial Convention

12601 Twinbrook Parkway
Rockville, N.S. 20897-5211
5) Pharmacy Administration shall provide samples for testing to the FDA or manufacturers, via
certifies mail, as necessary.
6) The final analysis report from the USP, FDA, or the manufacturer shall be filed in the
Drug/Device Recall/Problem file in the Pharmacy and a copy shall be sent to Risk Management at
Box 23.
135
XXIX. Changes in regulatory or statutory laws or standards
XXX. System failures/ changes
XXXI. Institutional/operational changes
XXXII. Attachments: Medical Device and Laboratory Product Problem Reporting Form; USP Drug
Product Problem Reporting Program Form
One)
Yes No
136
No: ___CH. 10
Subject: Handling of Non-Formulary Page ____1__ of ____1__

Medications (including Home
Medications and Medications Original Issue date: 8/01/98
brought in by Practitioners)
Implementation Date: 8/06/01
Prepared by: Nicholas Galeota, MS, RPh
Distribution: Administrative Manual
Reviewed by: William Gerdes Department Manual
Alan Hui, Pharm.D. Patient Care Manual
AOD Manual
Approved by: Constance Shames, MD
_____________________________________________________________________________
I. Purpose: To establish a process to manage non-formulary medications in the hospital.
II. Definition(s):
Home Medications are defined as drugs brought to the hospital which a patient had taken
prior to admission
III. Policy: All drugs approved for use in UHB by the Pharmacy and Therapeutics
Committee for patient care shall be issued through the Hospital Pharmacy Department
and its satellite services.
IV. Responsibilities: The patient shall arrange for the disposition of their own medication to
a family member upon admission to the hospital. The physician shall request non-
formulary use of the medication if deemed necessary. The nurse shall administer the
non-formulary order bearing the statement “Patient is required to receive his/her own
medications”.
A. Request for Non-formulary Medications obtained by Pharmacy
1. In the event a prescriber requires for his/her patient to receive a non-formulary

medication that Pharmacy must obtain, the physician shall fill out a Non-Formulary
Purchase Request Form (see attached) and submit it to the Pharmacy with a written
prescription for the drug.
2. The prescriber must indicate specific therapeutic reason(s) for prescribing the non-
formulary medication(s) on the Form.
3. Because it will be necessary to obtain the non-formulary drug from outside the
hospital, there may be at least a 24-hour delay in obtaining such drugs.
4. Therefore, an equivalent formulary drug should be considered and used whenever

possible.
5. All non-formulary requests are reviewed by the Pharmacy and Therapeutics
Committee.
B. Handling of Patient’s Home Medications
1. A patient’s home medications shall be sent home with a family member. When the
patient is not accompanied by a family member, the medication shall be stored in the
locked medication storage area on the nursing unit, labeled with the patient’s name,
and returned to the patient at the time of discharge.
2. If the medication disposition does not warrant return to the patient, e.g., patient does
not wish to accept the medication back, the medication shall be sent to the Main
Pharmacy, Room ALL 1-469, for destruction.
3. Patients admitted to University Hospital must not use their own medication while in
the hospital except in the following situations:
a. When UHB’s Pharmacy Department does not stock the medication as an

approved formulary medication. In this case, if it is the opinion of the
attending physician that the medication is a medical necessity, the following
procedures are to be followed:
i. The physician shall indicate on the “Prescriber’s Order Form” that the
patient is required to receive his/her own medication and a must
specify the name, strength, dosage, frequency and duration of each
drug to be administered in compliance with “Patient Medication
Order” policy.
ii. The Nursing station personnel shall bring the medication to the Main
Pharmacy to affix a “Non-Formulary” UHB label on the container to
confirm the contents by Pharmacy.
iii. The medication shall be brought back to the nursing station for
administration to the patient by the Nursing staff and stored in the
patient medication cassette.
iv. The Pharmacy shall not re-label the medication (NYS Education laws
for the Practice of Pharmacy).
v.
b. When the patient must continue taking the medication during a scheduled
cycle, e.g., oral contraceptive medication, this also requires that the
procedure outline in (a) is followed.
C. Handling of Medications brought into the Hospital by Practitioners
1. Medications brought into the hospital by Practitioners for inpatient use is prohibited
since UHB’s Pharmacy Department cannot ensure the integrity and stability of such
products.

VII. Attachments: Non-formulary Request Form

One)
Yes No NICHOLAS GALEOTA MS, RPH
12/26/07 Yes No Alan Hui, Pharm.D.
Yes No
No: ___CH. 11
Subject: NURSING STATION INSPECTIONS Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To insure that medication is stored properly in Nursing care areas and that
expired/deteriorated medications are removed from these areas..
III. Policy:
1) The Director of Pharmacy shall assign a pharmacist or Pharmacy Assistant (technician)
every month to all designated Nursing Stations and clinic areas for the purpose of
inspecting medication storage areas.
2) The Pharmacist/technician shall utilize the established criteria for review of medication
storage areas and complete the inspection Q/C form (see attached). The pharmacist shall
also inspect the expiration date of all crash carts in the Nursing care area.
3) The pharmacist/technician shall inspect medication storage cabinets, drug storage
refrigerators, controlled drug cabinets, crash carts, Pyxis® machines, and designated drug
storage/drug preparation areas within the nursing stations or clinics.
NOTE: Pharmacy Assistants (technicians) shall inspect controlled drug cabinets.
4) The pharmacist/technician shall document compliance or deficiencies of the review

process on the inspection form.
5) The pharmacist/technician shall correct all outstanding deficiencies discovered in the
inspection process the same day, if within his/her control, as the inspection is conducted.
These deficiencies for immediate action are:
 Removal of Expired Drugs
 Removal of Un-labeled or Deteriorated/Unusable Drugs
 Removal of Drugs labeled With A Discharged Patient Name
 Removal of Excess Supplies
 Removal of Improperly Stored Drugs
 Removal of Drug Samples, if any
 Replacement of all Drugs Removed, if Required
6) After the review is completed, the pharmacist/technician shall sign and date the inspection
form.
7) The inspecting pharmacist/technician shall present his findings to the Assistant Director of
Nursing for respective unit.
8) Upon return to the Pharmacy, the pharmacist/technician shall submit all documentation to
the Associate Director of Pharmacy.
139
9) The Associate Director of Pharmacy shall review all documentation and, as necessary,
make spot checks of the inspection process to determine accuracy and completeness of
the inspection process to determine accuracy and completeness of the inspection. He/she
shall then sign and date the inspection form.
10) The Associate Director of Pharmacy shall have copies of the inspection form made and
distributed to the Associate Administrator for Inpatient Q/M. The original copy remains a
part of the Pharmacy’s permanent inspection records. The monthly findings shall be
reduced to a statistical report and presented to Nursing Leadership in its monthly Q/A
report.
11) All deficiencies that the Pharmacy can assist with shall be resolved with the Associate or
Assistant Director of Nursing for the respective unit or Nursing Administration.
12) All of the above data can also be entered into a laptop computer and posted on the
appropriate website for leadership viewing.
IV. Responsibilities: It is the responsibility of the Director of Pharmacy to assign a pharmacist or

Pharmacy Assistant (technician) monthly to inspect all designated storage areas within the hospital.
clinics, and its off-site satellites. It is the responsibility of a pharmacist and/or Pharmacy Assistant
(technician) to accurately and comprehensively inspect the nursing stations or clinics monthly.

XXXVI. Changes in regulatory or statutory laws or standards
XXXVII. System failures/ changes
XXXVIII. Institutional/operational changes
VII. Attachments: Medication Usage Quality Control Inspection Report
One)
Yes No
140
No: ___CH. 12
Subject: Automatic Medication Stop Order Policy Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish automatic stops on high-risk drugs so that a physician will re-evaluate the need
to continue the therapy based on lab data and/or patient response as well as risk of inducing a
negative outcome.
III. Policy: The maximum inpatient duration for a medication that a physician/authorized prescriber shall
order is 30 days. However, all pre-existing orders shall be canceled when the patient is transferred
between nursing units. New orders shall be written by the medical team receiving the patient on the
new Nursing unit after the evaluation of patient’s condition. Patient’s who are transferred between
units that are supervised by medical staff from the same discipline, e.g., NS 81 and CT ICU or the OR,
do not require medication orders to be re-written.
Further, certain orders, due to their potential for adverse side effects and toxicity, (e.g., narcotics),
shall be valid for a limited period of time unless otherwise specified in a shorter duration by the
physician’s medication orders.
IV. Responsibilities: It is the responsibility of the physician to see that orders are renewed. A nurse shall
not administer a drug for which the order has expired. It is the responsibility of the nurse to notify the
physician prior to the discontinuance of these medications. It is the responsibility of the pharmacist to
dispense only the quantities of drug needed to complete the physician’s orders for these drugs within
the above time frames. The pharmacist shall inform the nurse that he/she shall only dispense a 72
hour supply when an order is written for a longer duration for the above drugs.
V. Procedures/Guidelines: The maximum duration that a prescription shall remain in effect for the
following drugs are
All scheduled Narcotics & Controlled Substances….72 hours

Heparin Infusions * ………………………………………..72 hours
Coumadin ……………………………………………………72 hours
Oxytocics ……………………………………………………72 hours
Ketorolac …………………………………………………….5 days (no renewals)
TPN and parenteral admixtures…………………………24 hours
Low molecular weight heparin* (Lovenox®, Fragmin®).. 72 hours
* Provided PTT tests are stabilized and therapeutic levels of anticoagulants are achieved, otherwise
ONLY a 24 hour duration is to be in effect. Heparin or LMWH (i.e. Lovenox®) administered subcutaneously for
141
DVT prophylaxis may be written for a thirty (30) day supply. Lovenox® 40mg Sub-cutaneously or 30 mg sub-
cutaneously every twelve (12) hours are doses for DVT prophylaxis. .

XXXIX. Changes in regulatory or statutory laws or standards
XL. System failures/ changes
XLI. Institutional/operational changes
One)
Yes No
142
Chapter: 13
Subject: Outsourcing of Medications Page 1 of 2
Prepared by: Donal Caracciola, R.Ph. Original Issue Date: 01/01/2007
Reviewed by: Nicholas Galeota, M.S., R.Ph. Implementation Date:

12/4/2007
Approved by: Constance Shames, M.D. Distribution: Administrative Manual

Department Manual
Patient Care Manual
AOD Manual
William Gerdes
Issued by: Pharmacy Department
I. Purpose: To establish a standard procedure for utilizing the services of an additional

compounding facility (outsourced) to Kings Pharmacy for the following medications:
A) Oxytocin 10 units/ml 1ml syringes

B) Bupivacaine 0.375% 400mls (ON-Q Painbuster)
II. Definition: Outsourcing of the above preparations is defined as the use of an external
admixture laboratory for assistance in providing admixed drugs to our patients.
III. Policy: The above products will be accurately, safely, aeseptically compounded and labeled as
per JCAHO standards and NYS law by Kings Pharmacy on an as needed basis.
IV. Responsibility: It is the responsibility of the licensed off-site Pharmacy, Kings Pharmacy, to
ensure for the accuracy and integrity of all of the compounds.
Kings Pharmacy
357 Flatbush Avenue
Brooklyn, NY 11238
It is the responsibility of Downstate Pharmacy to maintain adequate inventory of these admixtures

and to periodically visit the compounding site for inspections.
V. Procedures / Guidelines:
 Downstate Pharmacy will call Kings Pharmacy at 718-230-3535 to order either oxytocin
syringes or ON-Q bupivacaine.
 The orders called in will be delivered by the next day.
 All orders called in on Friday, will be delivered on Monday, however, in an emergency

situation orders can be delivered on Saturday.
143
 All orders will be delivered with an invoice sheet.
 Upon delivery, the oxytocin will be placed in the appropriate bin, as well as the ON-Q
bupivacaine which is kept under refrigeration.

Changes in regulatory or statutory laws or standards
System failures / changes
Institutional / operational changes
VII. Attachments: NYS Board of Pharmacy Licensure
VIII. References: None
One)
Yes No
Yes No
Yes No
144
No: ___CH. 14 Sect. A
Subject: Choosing a Vendor Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Establish sound guidelines for the acquisition of P&T Committee approved formulary drugs
so insure safety and efficacy in the patient’s therapy.
III. Policy: After review, recommendation by the Pharmacy & Therapeutics Committee and approval by the
Executive Committee for the addition of a drug to the formulary at UHB, the Director of Pharmacy with
the assistance of the Pharmacy Material’s Manager shall determine the vendor from whom the drug
shall be acquired.
IV. Responsibilities: It is the responsibility of the Director of Pharmacy to choose a vendor/manufacturer

for drug items approved by the Pharmacy & Therapeutics Committee for addition to the formulary at
UHB. It is the responsibility of the Material’s Manager of the Pharmacy to adhere to New York State
Purchasing regulations when preparing purchase requisitions.
(1) The Director of Pharmacy shall verify that all drug product purchase from a vendor
meet current USP-NF, USP-DI, and FDA requirements for potency, safety, efficacy and labeling.
(2) The Director of Pharmacy shall verify that the vendor/manufacturer complies with
Federal Good Manufacturing Practices and meet the New York State Therapeutically Equivalent
Prescription Drug Standards if there are more than one product made for a particular drug.
1. The Director of Pharmacy shall select a vendor, after meeting the standards in
Chapter 14, Section A, Procedure, numbers 1 & 2, on the following basis:
 Quality of products (including safety efficacy)

 Ability to supply
 Competitive prices
 Adequate services, e.g., in-service training, returns policy, timely emergent
demand deliveries, etc.
(4) If a generic drug is to be purchased, the Director of Pharmacy shall select the vendor
based on the following criteria:
145
 Chemical composition shall be identical to the accepted standard (current USP-
DI, FDA) for this product and meet Equivalent Drugs
 Drug weight per dose shall be identical to the accepted standard (current USP-
NF, USP-DI, FDA) for this product and meet New York State standards for
Therapeutically Equivalent Drugs
 Drug weight per dose shall be identical to the accepted standard (current USP-
NF, USP-DI, FDA)
 The manufacturer/vendor shall be an established, FDA approved/licensed
pharmaceutical company with sufficient liability protection and one in which the
Director of Pharmacy has developed confidence based on past experiences
(5) The Director of Pharmacy shall instruct the Material’s Manager to initiate a purchase
requisition based on the ability of the manufacturer/vendor to meet the above criteria. This
requisition shall be processed adhering to New York State purchasing regulations. (Note: All
bids, price quotations, or contract arrangements shall be processed through the Office
Procurement services at SUNY-HSCB).
(6) If the vendor wishes to utilize any patient, financial, or hospital related data in its
course of doing business with UHB, the Director of Pharmacy shall require the vendor to sign
and enter into UHB’s Vendor Data Security and Confidentiality Agreement (see attached).
Note: If three vendor are required in order to obtain price quotes, the Director of Pharmacy
shall provide the names of three vendors that meet the above criteria to the Purchasing
Department.

XLII. Changes in regulatory or statutory laws or standards
XLIII. System failures/ changes
XLIV. Institutional/operational changes
VII. Attachments: Vendor Data Security and Confidentiality Statement
One)
Yes No
146
No: ___CH. 14 Sect. B
Subject: Prime Vendor Program Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish guidelines for the Pharmacy’s Materials Manager or the use of a NYS contract
approved prime vendor for pharmaceutical supplies..
III. Policy: The Prime Vendor of record shall be utilized to acquire those pharmaceuticals in short supply
on a daily basis or in emergent demand.
IV. Responsibilities: It is the responsibility of the Material’s Manager to utilize the prime vendor program
daily for those drugs in short supply or in emergent demand.
(1) The Material’s Manager shall utilize only the New York State approved prime vendor who has
met the criteria for choosing a vendor as stated in Chapter 14, Section B, Procedures, numbers 1
through 6.
(2) The Material’s Manager shall initiate a purchase order through the computer – modem link for
the drug item only in short supply or in emergent demand. All other inventory supply requisitions are
to be processed through the Office of Procurement Services at SUNY-HSCB.
(3) The Material’s Manager shall insure that all purchase orders from the prime vendor are
received within 24 hours.
(4) Upon receipt of the drugs from the prime vendor, the Material’s Manager shall record in the
inventory all supplies received, reconcile the requisition with the receipt, and give the drug supplies to
a pharmacist to dispense to answer t he demand for the drug or to a Pharmacy Aide to place the drugs
received into the respective stock/storage area.
• Changes in regulatory or statutory laws or standards
147
• System failures/ changes
• Institutional/operational changes
One)
Yes No
148
No: ___CH. 14 Sect. C
Subject: Borrowing or Loaning of Pharmaceuticals to Page ____1__ of ____2__

Other Hospitals
Reviewed by: WILLIAM GERDES Implementation Date: __8/00701__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Establish guidelines for the borrowing or lending of drug supplies (other than controlled
substances) between area hospitals..
III. Policy: The Pharmacy Department shall maintain adequate supplies of all drugs on UHB’s formulary.
The Pharmacy shall only borrow drugs from other local hospitals in the event of a complete outage of
a drug causes by an unanticipated use of the drug. The Pharmacy shall provide drugs on loan to other
local hospitals in the event of emergent need at these institutions.
IV. Responsibilities: It is the responsibility of the Material’s Manager of the Pharmacy to insure prompt
return of borrowed drugs and to insure that loaned items are recovered within one week. It is the
responsibility of the Director of Pharmacy to determine reasons or to review all documentation that
has caused the complete outage of a drug and take correction actions if necessary.
I. Borrowing From Local Hospitals
(1) In the event that a drug must be borrowed from a local hospital, the Material’s Manager
shall contact a local area hospital to ascertain the availability of the drug.
(2) Upon confirmation of availability, the Material’s Manager shall complete an Emergency
Transfer of Drugs Form for the drug needed in duplicate, one for the borrower and one for the
lender (see attached).
(3) Arrangements shall be made for a Pharmacy courier to obtain the drug from the
hospital.
(4) When the drug arrives at the Pharmacy Department at UHB, it shall be given to a
pharmacist to dispense to the appropriate Nursing unit and credit the inventory with the supply
received.
(5) The Material’s Manager shall make suitable arrangements to purchase a supply of the
drug within twenty hours (24) hours.
149
(6) When the ordered supply is received, the Material’s Manager shall dispatch a Pharmacy
courier to return the drug to the hospital from which it was borrowed.
1. Loaning to Local Hospitals:
(1) Upon receipt of a call from a local hospital in need of a drug, the Material’s Manager
shall determine if existing supplies shall permit lending of the drug.
(2) If the supplies permit, the borrowing hospital shall dispatch courier to pick up the drug
at UHB’s Pharmacy and provide the Pharmacy Material’s Manager at UHB’s Pharmacy with a
copy of the Emergency Transfer of Drugs Form.
(3) The Material’s Manager shall insure that the borrowed drugs are promptly retrieved
within one (1) week.
(4) The Material’s Manager shall debit the inventory of drugs loaned to another institution.

XLV. Changes in regulatory or statutory laws or standards
XLVI. System failures/ changes
XLVII. Institutional/operational changes
XLVIII. Attachments: Emergency Transfer of Medication or Supplies Form
One)
Yes No
150
No: ___CH. 14 Sect D
Subject: Drug Return Policy Page ____1__ of ___21__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish guidelines for Pharmacy staff for the disposition of medications returned from
patient care areas to the Pharmacy..
III. Policy: Drugs which have been sent to in-patient Nursing Units or Clinic Nursing Stations shall be
returned to stock only if they are retrieved in unopened unit dose packaging, unopened single use
packaging, or robotics bar coded packaging.
IV. Responsibilities: It is the responsibility of Pharmacy Aides to sort out an inspect all drug returns to
the Pharmacy to determine whether the drug can be used or, if not, disposed of in a appropriate
manner (that is returned for credit or exchange).
(1) All drugs returned to the Pharmacy shall be inspected by the Pharmacy Aides for closure,
integrity, and storage requirements.
(2) Drugs in unopened unit dose packaging, unopened single dose packaging, or robotics bar
coded packaging shall be re-inventoried and placed into stock.
(3) Drugs that are not reusable shall be screened for worthiness of return to the manufacturer.
(4) All unusable drugs shall be discarded in the regulated medical waste container in the Main
Pharmacy. These include:
(A) Oral liquids
(B) Oral solids
( C) Topical ointments, creams, lotions in opened multi-dose packaging
(D) Bedside self-medications
(E) Out-patient medications returned by a patient
(F) Opened multi-dose injections
(G) Compounded IV Solutions (Note: Oncology drugs are eliminated via the Cyto-toxic
Waste Containers)
151
(5) The regulated chemical waste container shall be sealed when full and Environmental Services
shall be called at extension 2997 to remove the container or removed by Pharmacy personnel to the
chemical waste store room of the hospital.
(6) Drugs that can be returned for credit/exchange from the manufacturer or prime vendor shall be
processed as such utilizing an external returns goods processor, e.g. Reverse Management System,
Easy Returns, Quick Return Solutions, EXP, Inc., etc.

One)
Yes No
152
No: ___CH. 14 Sect. E
Subject: Sales Representatives Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures for identifying pharmaceutical representatives with a SUNY-DMC

limited access ID card and to prevent intrusion into patient care areas. .
III. Policy: Sales representatives shall obtain a SUNY Downstate I.D. Card from the FSA Office before
conducting business at UHB’s Pharmacy and are forbidden to enter patient care areas.
(1) Sales representative shall be seen on Tuesday and Thursday afternoons by the Pharmacy
unless an appointment was previously made.
(2) If a sales representative is assigned to this hospital (SUNY-Downstate) on a regular basis,

he/she shall obtain an I.D. card from the FSA Office to proceed to any other area other than the
Pharmacy.
(3) No sales representative shall enter any patient care area unless they have an appointment with
a physician in that area. If this is the case, the representative shall wear their I.D. tag and go to that
appointment area only.
(4) No sales representative shall interrupt any physician on rounds, while giving lectures,
conducting ambulatory patient services, or without a appointment.
(5) Non-formulary drugs or samples shall not be given out unless a physician requests them for
personal private office use. These sample shall not be used within the hospital unless under the direct
control and storage by the Pharmacy Department or the control of the requesting physician/service
(refer to Chapter 28 for procedures)
(6) No sales representative shall enter the dispensing or compounding areas of the Pharmacy, its
satellites, or labs.
153
(7) If a sales representative wishes to present an in-service lecture or literature to the Pharmacy
staff, they shall coordinate this effort through the Pharmacy Associate Director’s office, extension
3158.
(8) If any sales representative is found in an unauthorized area of the Pharmacy or the hospital, at
any time, Public Safety shall be notified and the sales representative shall be asked to leave and have
their privileges of calling on staff at SUNY-Downstate property revoked.
(9) The Pharmacy shall coordinate with sales representatives any and all displays in public areas,
e.g., hospital lobby, or their drug products.
(10) Any correspondence demonstrations, or in-service lectures for Nursing, shall be arranged with
the Nursing Administration/Education office or the Institute of Continuous Learning at SUNY-
Downstate.

XLIX. Changes in regulatory or statutory laws or standards
L. System failures/ changes
LI. Institutional/operational changes
VII. Attachments: ID card request form
One)
Yes No
154
No: ___CH. 14 Sect. F
Subject: Inventory and Purchasing Controls Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures for testing the integrity of the Pharmacy inventory so that diversion, loss,
and waste of drugs can be avoided.
III. Policy: The Pharmacy inventory, defined as the quantity of medications, goods, or materials on hand
that is purchased and brought into the Pharmacy’s storage spaces and controlled until it is dispensed
to a patient or a user department, shall be maintained accurately in a perpetual inventory accounting
system with predetermined minimums and maximums required for re-ordering and for providing
appropriate pharmaceutical patient care.
IV. Responsibilities: The Material’s Manager is responsible for initiating a purchase requisition to a
recommended vendor for all inventory supplies and required commodities. The Director of Pharmacy
is responsible for reviewing all purchase requisitions Support Services is responsible for reviewing
and co-signing the purchase requisition before it is sent to Procurement Services is responsible for
placing the purchase order with the appropriate vendor that meets the required pharmaceutical
standards (refer Chap. 14. Sect. A) and the New York State Manager to receive all supplies delivered
from the Receiving Department, sign the Receiving Department’s receipt, open and reconcile the
contents of the delivery against the packing invoice, and post receipts in the appropriate computer
mainframe inventory account code (321336 for in-patient supplies and 321306 for out-patient supplies)
on the same day of receipt. It is the responsibility of the Material’s Manager, the Director of Pharmacy,
or the Associate Director of Pharmacy to sign-off on invoices for payment by Accounts Payable to the
vendor.
Finally, it is the responsibility of the Director of Pharmacy to maintain an accurate accounting of all
inventory assets purchased for the Pharmacy Department and insure that an independent official
inventory is taken annually of all Pharmacy inventory supplies and commodities stored in all
Pharmacy Service areas.
(1) All medications shall be issued upon written orders in the form of a prescription, floor
stock requisition, or grant request. Controlled substance sub-stocks shall be issued to a
Nursing care area on a verbal request from an Assistant Director of Nursing or authorized
representative for the respective unit.
(2) All procedures outlined in Chap. 4 (IPD Dispensing), Chap. 5 (Controlled Substances),
and Ch. 23 (OPD Dispensing) shall be followed with the proper subsequent charging through
the Rxobot® computer database or computer mainframe (THOMIS OR EAGLE) to the respective
patient or user unit.
155
(3) Daily inventory reports shall be generated by the Computer Center and delivered to the
Director of Pharmacy (PHARMINV Report).
(4) Monthly drug usage reports shall be generated by the Computer Center and delivered
to the Director of Pharmacy (PHARMAVG Report)
(5) Daily re-order level reports shall be generated by the Computer Center and delivered to
the Director of Pharmacy (PHARMREOR Report).
(6) The Director of Pharmacy shall review the PHARMAVG Report monthly and choose a
minimum of 3 drug items to be spot checked by the Material’s variances shall be investigated
by the Material’s Manager and the appropriate corrections/reconciliation shall be reported to
the Director of Pharmacy.
(7) A complete physical inventory of all Pharmacy storage and dispensing areas shall be
conducted annually in December by an external inventory accounting firm and a written,
attested document shall be provided to the Director of Pharmacy. The itemized pricing of the
inventory accounting firm and a written, attested document shall be provided to the Director of
Pharmacy. The itemized pricing of the inventory shall be done with the current computer value
for the particular items.
(8) The Director of Pharmacy shall review this document and compare the information to
the computer mainframe inventory. Any variances shall be investigated by the Material’s
Manager and the appropriate correction/resolution shall be completed by the Material’s
Manager and reported to the Director of Pharmacy.
(9) The Director of Pharmacy shall annually provide a report with supporting
documentation to the Chief Financial Officer or his/her designee of SUNY-Downstate Medical
Center after the inventory process is completed.

One)
Yes No
156
No: __CH. 15 Sect. A
Subject: Handling of Crash Carts Page: 1 of 3
Original Issue Date: 8/1/98

NICHOLAS GALEOTA, M.S., R.Ph
Prepared SETH MANOACH, M.D. Implementation Date: 1/1/02
by:
LEONARD KLEBANOV, M.S.,
TERESA CHAN, PHARM.D. Distribution:
 Administrative Manual
 Department Manual
Reviewed WILLIAM GERDES  Patient Care Manual
by:
 AOD Manual
Approved
by:
CONSTANCE SHAMES, M.D.
________________________________________________________________________________________
I. Purpose: To establish a controlled system for the re-conciliation and distribution of crash
carts within the hospital.
III. Policy: Upon completion of a cardiac/respiratory arrest code requiring intervention of a

crash cart, the charge nurse from the Nursing station shall immediately call the Pharmacy
at 2854 or 2856 and inform Pharmacy personnel that a replacement cart is required.
Pharmacy staff shall immediately transport a sealed, completed code cart from the
Pharmacy and remove the used cart from the nursing station, collect the appropriate and
completed documentation from the nursing supervisor, and replace it with a new cart. This
can be accomplished 24-hours a day through all tours.
Nursing
● It is the responsibility of the nurse to notify Pharmacy that a new crash cart is
needed and/or an equipment malfunction was noted during a routine inspection or
during resuscitation.
● It is the responsibility of nursing supervisor to complete the appropriate
documentation and take the Crash Cart completely out of service until a pharmacy
personnel replaces it with a new one.
Pharmacist
● It is the responsibility of the registered pharmacist to check the crash cart trays for
appropriateness after restocking by the Pharmacy Aide.
Pharmacy Aide
● It is the responsibility of the Pharmacy Aide to bring the used crash cart back to the
Pharmacy for re-stocking of the used trays and seal the tray in a tamper evident bag
after a pharmacist has checked the tray. The Pharmacy Aide shall replace the
sealed and completed drug trays into the crash cart before the cart is locked.
● The Pharmacy Aide should also notify SMIC of any equipment malfunction on the
crash carts when informed by the nursing supervisor.
SMIC
● Upon being notified of any equipment malfunction on the crash cart, it is the
responsibility of SMIC to respond to any service notification. The SMIC engineer
will determine whether the equipment must be brought back to the SMIC lab if more
extensive repairs are needed.
Central Sterile Supply (CSS)
● It is the responsibility of the CSS staff to replenish any supplies/equipments needed

in the crash carts and sign off when complete. Once complete, CSS shall transport
the crash cart to Pharmacy for restocking of appropriate medications.
(1) All crash carts opened for resuscitation purposes or emergency event regardless
of equipment use shall warrant a Code Critique to be generated.
(2) If a crash cart is opened for no apparent reason or an equipment malfunction

discovered during routine inspections, then an Incident Report alone must be filed.
(3) If an equipment failure occurred during the resuscitation process the nursing
supervisor shall complete BOTH the Code Critique and an Incident Report.
(4) A Pharmacy Technician shall remove all drugs from the used cart and transport
the used cart to CSS where used equipment trays shall be replaced. The Pharmacy
Aide shall then transport this cart to the Pharmacy for restocking with
medications.
(5) If the Pharmacy Aide has been notified that any equipment is defective, he/she
shall remove the Crash Cart immediately from service, notify SMIC of the problem
by submitting a copy of the incident report to SMIC, and document the date, time,
and SMIC engineer to whom it was reported to in the Pharmacy Code Cart Log.
The SMIC engineer will intervene, sign and document his or her intervention on the
Pharmacy Code Cart Log before the crash cart is put back into service. A
response/investigation letter will serve as documentation on the SMIC service
record that the intervention had taken place and a copy of it shall be submitted to
the CPR Committee record.
(6) A Pharmacy Aide shall replenish each tray with the correct ACLS approved drugs
and quantities as set forth by the CPR Committee for the respective cart and
drawer configuration within the Main Pharmacy (Room ALL1-469). The Pharmacy
Aide will sign-off on the re-stocked code cart and lock it with a numbered lock.
He/she shall then document on the appropriate crash cart records the lock number
used to lock each crash cart along with the expiration dates. The carts shall be
stored in the Pharmacy until needed following a subsequent code.
(7) A pharmacist shall check the assembled tray before the Pharmacy Aide seals the
tray in a tamper evident poly bag and dates the tray with the date of the most
recent expiring drug. These trays are stored in the Main Pharmacy (Room ALL1-
469) until such time that they are used to replenish a crash cart. A numbered lock
shall be used when sealing a completed cart and the number recorded in the
Pharmacy log.
(8) A Pharmacy Aide shall deliver a completed and sealed crash cart on demand and
sign the Pharmacy log verifying the seal number.
(9) On the Nursing Unit, the Nursing staff shall complete a supply checklist, insuring
that the external supplies (defibrillator, oxygen tanks, and suction equipment) on
the new cart are fully operational. Nursing shall notify Pharmacy of any
malfunction in external supplies or equipments and complete an incident report
stating such. Pharmacy shall then contact the relevant departments, e.g., SMIC or
Respiratory as needed, to replace or service external equipment and the cart shall
be immediately taken out of service.
(10)Pharmacy Administration shall forward the code critiques and incident reports to
the CPR Committee for review. All drugs provided for the replacement of crash
cart supplies shall be charged to the respective nursing station.

(1) Changes in regulatory or statutory laws or standards
(2) System failures/ changes
(3) Institutional/operational changes
One)
4/15/08 Yes No Nicholas Galeota, M.S., R.Ph.
5/14/08 Yes No Teresa Chan, Pharm.D.
Subject: Control and Security of Emergency Page ____1__ of ____2__

Medications In the Crash Carts

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide a mechanism to insure security of emergency medications contained in the

crash carts throughout the hospital.
III. Policy:
(1) All crash carts shall be secured at all times with tamper evident numbers, security
locks supplies by the Pharmacy.
(2) The Pharmacy shall control the distribution of tamper evident crash carts numbered
locks through the crash cart exchange system for crash carts.
(3) Nurses shall inspect the crash cart seals on every shift. The seal represents not only
completeness but also the security to insure that the contents have not been tampered.
(4) A crash cart seal is only to be broken in response to a code and monthly during
Nursing inspections. If a code cart is opened for any reason, a code critique must be filed and
Pharmacy notified. If the cart is opened and a code is not called, an incident report must be
filed. If the CPR Committee determines that the cart was used inappropriately, it shall
recommend that administrative action be taken.
IV. Responsibilities: It is the responsibility of a pharmacist to acquire, distribute, and maintain records for
the distribution of tamper evident numbered crash cart locks provided to the Nursing staff.
(1) A pharmacist at UHB shall supply the Nursing stations with one (1) crash cart tamper
evident numbered lock locked to the cart.
(2) An additional tamper evident numbered lock is provided to Nursing only during
Nursing’s monthly inspection of the cart.
(3) A tamper evident numbered lock shall be placed on the crash cart when the cart is
secured.
159
LV. Changes in regulatory or statutory laws or standards
LVI. System failures/ changes
LVII. Institutional/operational changes
One)
Yes No
160
Subject: Crash Cart Inspections Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish a procedure for checking the expiration dates assigned to crash carts
throughout the hospital.
III. Policy: The Pharmacy shall inspect all CPR Committee approved crash carts throughout the hospital
for an expiration date during the monthly inspection for each Nursing care area.
IV. Responsibilities: It is the responsibility of a pharmacist to inspect the crash cart monthly and insure
that an appropriate expiration date is present, insure that only CPR Committee approved drugs are
present, and that the sealed trays of drugs have not been opened. Carts expiring within one month of the
inspection date shall be removed by a pharmacist or Pharmacy Assistant and replaced with a new cart.
(1) During the monthly nursing station inspections, a pharmacist shall inspect the crash
cart assigned to the nursing station or clinic.
(2) The pharmacist shall check the cart is sealed and bears and expiration date that has
not been reached as yet.
(3) The pharmacist shall check all drugs contained in the crash cart trays for expiration
dates before any drugs are placed in the tray by a Pharmacy Aide in the Main Pharmacy.
Therefore, a check of each drug contained in the crash cart Is not required when conducting a
monthly Nursing station inspection.
(4) If the expiration date is approaching before the next Nursing station inspection, the
pharmacist shall order a new crash cart for the unit.

161
One)
Yes No
162
No: ___CH. 15 Sect. D
Subject: Drugs Maintained on Crash Carts Page ____1__ of ____1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To standardized the list of drugs maintained in crash carts that were approved by the CPR
Committee.
III. Policy: A pharmacist shall utilize the list of CPR Committee approved crash cart drugs when checking
exchange trays for crash carts in Nursing station or clinic crash cart (see attached list).
IV. Responsibilities: The pharmacist is responsible to insure that only the drugs listed on the CPR
Committee approved crash cart list are present on the exchange tray for crash carts in the proper
quantities and that weight based standardized dosing charts are also attached to all crash carts.
(1) The pharmacist shall utilize the list of CPR Committee approved crash cart drugs when
checking exchange trays for crash carts in Nursing station or clinic crash cart (see attached
list).

LVIII. Changes in regulatory or statutory laws or standards
LIX. System failures/ changes
LX. Institutional/operational changes
VII. Attachments: Broeslow Neonatal-Pediatric Crash Cart List; Adult and Pediatric Combination Crash
Cart List; Adult Crash Cart List; Pediatric Emergency Drug Dosing Chart; Adult Emergency Drug
Dosing Chart
X. References: none
One)
Yes No
163
Subject: Crash Cart Distribution in UHB Page ____1__ of ____1__
Approved by: CONSTANCE SHAME, M.D. Distribution: Administrative Manual

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: The following attached distribution record is a distribution and assignment list of the
Resuscitation Crash Carts approved by the CPR Committee at UHB that shall be inspected by the
Pharmacy on a monthly basis (see attachment):
III. Policy: N/A

LXI. Changes in regulatory or statutory laws or standards
LXII. System failures/ changes
LXIII. Institutional/operational changes
VII. Attachments: Distribution Record
One)
Yes No
164
Subject: Pharmacy’s Disaster Carts Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures for the maintenance of Pharmacy Disaster carts used during an
internal or external disaster response by Pharmacy personnel to 4-4-4- alarm bells.
III. Policy: The Pharmacy Department shall maintain emergency drug supplies on a cart in the Main
Pharmacy (Room ALL1-469) dispensing area for the pose of responding to a disaster signal (4-4-4)
within the hospital as the hospital’s disaster response plan.
IV. Responsibilities: It is the responsibility of the Pharmacy Director to insure the availability of
emergency drugs for response to a disaster signal within the hospital. It is the responsibility of a
Pharmacy Assistant to inspect the disaster cart monthly.
(1) The cart of emergency drugs (see attached list) for disasters shall be maintained in a
designated area outside of room ALL1-473 within the Main Pharmacy dispensing area.
(2) A Pharmacy Assistant shall inspect this cart monthly for integrity, quantities of drugs, and
record the date of inspection on the inspection maintenance record on the cart. The Pharmacy
Assistant will remove all drugs expiring within one month of the inspection and replace the drugs
before locking the cart.
(3) The drug inventory for this cart shall be maintained by a Pharmacy Assistant according to the
List of Selected Disaster Drugs (see attached).
(4) The Pharmacy Assistant shall maintain on the cart a list of drug companies as sources for
drugs, if necessary, during the disaster.
(5) The Pharmacy Assistant shall ask a pharmacist to unlock the cart prior to inspection and lock
the cart after the inspection is completed.
NOTE: Keys to the cart are maintained in the IPD Controlled Drug Safe and access to this safe is
restricted to pharmacists only. The carts can also be opened via the keypad code respective to each
cart.
165
LXIV. Changes in regulatory or statutory laws or standards
LXV. System failures/ changes
LXVI. Institutional/operational changes
VII. Attachments: Disaster Cart Content List
One)
Yes No
166
No: ___CH. 15 Sect. G
Subject: Pharmacy’s Disaster Plan Including Infant Page ____1__ of ____2__

Plan Response

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide for an organized system to mobilize (re-call) Pharmacy staff and initiate
Pharmacy’s role in the hospital’s disaster plan.
III. Policy: The Director of Pharmacy shall mobilize the staff and activate disaster response measures in
response to an activation of a disaster signal (3 sequences of 4 bells) within the hospital. In the event
that the Director of Pharmacy is not available, the Pharmacy staff shall respond to this disaster bell
code immediately.
IV. Responsibilities: It is the responsibility of the Director of Pharmacy to mobilize all Pharmacy services
and personnel in the event of an activation of a disaster signal. It is the responsibility of a pharmacist
to respond to the disaster signal by taking the Pharmacy disaster cart to the triage area at the
Emergency Room.
(1) In response to activation of a disaster signal, a pharmacist shall take the Pharmacy disaster
cart to the triage area at the Emergency room located on the first floor.
(2) The medical triage command post officer shall direct the pharmacist to proceed to a
designated area and open the cart and the pharmacist shall prepare for dispensing the drugs to the
medical staff.
(3) The Director of Pharmacy and the Associate Director during daily working hours, shall review
staffing and call in additional staff as needed (see attached cascade plan).
(4) The Associate Director shall proceed with the daily assignment sheet to the Personnel
Command post in Conference Room 1 & 2 or the Executive Director’s Office to provide information on
the distribution of Pharmacy personnel throughout the hospital.
(5) The most senior TH Senior Pharmacy shall report to the Pharmacy Director’s Office and
assume command for supply lines to the Emergency Room in response to consumption of drug
supplies used during the disaster.
167
(6) As the recalled staff arrives at the hospital, the Director of Pharmacy shall assign personnel in
response to the hospital’s pharmaceutical needs for responding to the disaster.
(7) During hours when the Director, Associate Director and the most senior TH Senior Pharmacist
are not present, Hospital Administration shall notify them at home to report to the hospital’s
pharmaceutical needs for responding to the disaster.
(8) The dispensing pharmacist in the Emergency Room shall return with the disaster cart upon
activation of the all clear signal (4 sequences of 1 bell)
(9) A pharmacist shall immediately review the emergency cart and replace all drugs used during
the disaster.
(10) A pharmacist shall lock the cart.

LXVII. Changes in regulatory or statutory laws or standards
LXVIII. System failures/ changes
LXIX. Institutional/operational changes
VII. Attachments: Notification Cascade for the Department of Pharmacy; Pharmacy Staff Directory; Infant
Adduction Plan
One)
Yes No
168
NOTIFICATION CASCADE FOR THE DEPARTMENT OF PHARMACY SERVICES IN THE
EVENT OF INTERNAL OR EXTERNAL DISASTER
Hospital Operator
↓
Nicholas Galeota
(Director of Pharmacy Services)
HOME # (718) 356-2168
Page: 760-0013
Office: 270-3115
↓
Donald Caracciola
(Associate Director of Pharmacy)
HOME # (516) 541-7398
Page: 760-1953
Office: 270-3158
↓
Mahammad Ali Elizabeth Iroku Lawrence Melisi

(Supervisor) (Supervisor) (Materials Manager)
1. Roy Mustard 1. Ira Dinerman 1. Leon Gantt

2. Irina Kuleshova 2. Digna Roberts 2. Alva Watson
3. Morvette Spencer 3. Rosa Aburto 3. Sandra
4. Olga Rivera 4. Sung Kew Jung Cunningham
5. Joan Watson 5. Eveline Dorval 4. Raquel
6. Reynaldo Rivera 6. Samia Youssef Ferguson
7. Mohammad Edreis 7. Helen Pruski
8. Joyce Wilson-Savage 8. Jihan Hanna
9. Jacqueline Fleming 9. Miyoung Hahn
10. Jaihro Tabocloan 10. Tseng Hsiang-Wei
11. Noah Silver 11. Claire Defour-Bazelais
12. Ancey Philip 12. LilyAnn Jeu
13. Marina Rafilova 13. Alan Hui
14. Anisa Davis 14. Elena Shak
15. Maureen McColl
16. Marc Silbergleit
17. Bichlien Truong
18. Teresa Chan
19. Laurie Ferguson
20. Thanikachalam Arunagiri
21. Ancillary Pharm. D. Staff:
a) Roopali Sharma
b) Motria Mishko
c) Rani Patel
Rev. 8/24/07
169
No: ___CH. 15 Sect. H
Subject: Emergency Drug Supplies Provided to the Page ____1__ of ____2__

Emergency Room

Department Manual
Patient Care Manual
AOD Manual

______________________________________________________________________________________
I. Purpose: See policy below.
III. Policy: The Pharmacy Department shall supply and maintain the emergency drug supplies within the
Emergency Room.
IV. Responsibilities: It is the responsibility of the Pharmacy Department’s staff (pharmacists and
Pharmacy Assistants) to provide for the emergency drug supplies required by the ER in its daily
activities of treating patients.
(1) A pharmacist shall have a replacement box when the ER’s myocardial infarction box (MI Box)
has been used to treat a patient in the ER.
(2) The pharmacist shall immediately restock the box with the necessary drugs and seal the box
with a tamper evident lock and store two (2) of these boxes within the Main Pharmacy, Room ALL1-
469, until required by the Emergency Room.
(3) A pharmacist shall supply a replacement box when the ER’s Poison Treatment Box has been
used to treat a patient in the ER.
(4) The pharmacist shall immediately restock the box with the necessary drugs and seal the box
with a tamper evident seal and store one (1) of these boxes in the Main Pharmacy, Room ALL1-469,
until required by the ER.
(5) The Pharmacy Department shall maintain the ER’s crash carts according to Chapter 15,
Sections A through D.

LXX. Changes in regulatory or statutory laws or standards
LXXI. System failures/ changes
LXXII. Institutional/operational changes
170
One)
Yes No
171
No: ___CH. 16
Subject: Handling of Multi-dose Vials of Injectable, Page ____1__ of ____2__

Inhalation, And Ocular Medications

__8/10/01__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures that insure the proper handling of multi-dose vials to prevent
microbiological contamination.
II. Definition(s): A multi-dose vials defined as one that contains a preservative by its manufacturer to
prevent contamination so that it can be used more than once
III. Policy:
(1) All medication packaged in ampoules is intended for one time use only, handled aseptically,
and the un-used portion shall be discarded once opened.
(2) All vials intended for multiple use contain preservatives and are labeled by the manufacturer as
multi-dose or multiple use vial. All vials without preservatives or not indicated as multiple use by the
manufacturer must be handled aseptically and discarded after one time use even if only a fraction of
the vial’s volume is withdrawn.
(3) If medication vials require the addition of fluid for reconstitution, such as lyophilized powders,
the person re-constituting the vial shall place the date and time of reconstitution on the vial’s label.
After reconstitution, proper storage and length of storage time after reconstitution shall be according
to manufacturer’s recommendations, e.g., penicillin G sodium is stable for 7 days after reconstitution if
refrigerated.
(4) All multi-dose vials of medication shall be dated with the date of expiration by the nurse
responsible for medications on Tour I. The expiration date shall be calculated as twenty-eight (28) days
from the date of opening by the nurse or clinician. The vials shall be discarded on that date. Once
opened, vials shall be stored in an enclosed clean area. Storage is to be at the manufacturer’s
recommended storage temperature for the drug.
(5) Multi-dose eye drop containers shall be dated when opened and kept no longer than twenty-
eight (28) days and used exclusively for one patient when ordered on a prescription basis.
(6) Multiple dose containers shall be used one at a time and assessed for integrity before use
including visual inspection. When the vial can no longer be used, it shall be discarded and another
vial started. It is a poor practice to maintain many partially used multiple dose vials.
172
IV. Responsibilities: It is the responsibility of a pharmacist during the monthly Nursing station or clinic
area inspections to remove undated multiple dose vials of medication as well as determine that
appropriateness of storage and integrity of all opened multiple dose vials or containers. The
pharmacist and/or staff nurse are responsible to remove all opened vials or containers if the integrity
of the drug is questionable.

LXXIII. Changes in regulatory or statutory laws or standards
LXXIV. System failures/ changes
LXXV. Institutional/operational changes
12/17/04 Yes No NICHOLAS GALEOTA M.S, RPH

1/10/06 Yes No NICHOLAS GALEOTA, M.S., RPh.
10/5/07 Yes No NICHOLAS GALEOTA, M.S., R.Ph.
173
No: ___CH. 17
Subject: Storage of Pharmaceuticals Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
_______________________________________________________________________________________
I. Purpose: To establish guidelines for the storage of pharmaceuticals to insure the integrity of the drug,
prevent theft, and to prevent mis-identification that may cause a medication error.
III. Policy: The Pharmacy Department shall maintain adequate space, facilities, and equipment for the
storage of drug supplies that are supervised by the Director of Pharmacy or his designee and
according to the manufacturer’s, current USP-NF, USP DI, or FDA approved storage conditions.
IV. Responsibilities: It is the responsibility of the Director of Pharmacy to provide for the proper storage
of all pharmaceuticals purchased and stored within the Pharmacy so that the potency, stability, and
integrity of the drugs is maintained in order to prevent adverse patient outcomes caused by
deteriorated or sub-potent drugs.
(1) Upon receipt of drugs from a manufacturer/vendor, the Material’s Manager shall place all drugs
into the appropriate storage areas under the manufacturer’s/FDA approved requirements for
temperature, light, moisture, ventilation, sanitation, segregation, if any, and security. Those drugs
placed in the Main Store Room will be arranged generically.
(2) A pharmacist or Pharmacy Assistant shall inspect all Pharmacy storage and dispensing areas
monthly using the “Main and Satellite Pharmacy Inspection Findings” record (see attached).
(3) The inspecting pharmacist or the Pharmacy Assistant shall remove all drugs expiring within
one (1) month of the inspection date (Note: the pharmacist shall check the daily log of drugs received
created by the Material’s Manager when inspecting the ‘
(4) The Material’s Manager shall place all supplies of absolute or 95% alcohol and any other bulk
supply of flammable/combustible drugs within the Pharmacy’s designated volatile storage area (Room
ALL 1-468) and into the fire rated yellow cabinets.
(5) Upon receipt of controlled substances, the Material’s Manager shall give the drug supplies to
the TH Senior pharmacist or one of the Pharmacy administrator’s in charge of controlled substances
to store in the Main Controlled Substance Safe.
174
(6) The Material’s Manager shall place all bulk supplies of drugs packed in cartons on pallets
sealed to the floor or on shelving 18” inches off the floor to allow for cleaning under the shelving.
(7) The Pharmacy Aides shall store all drug supplies within the appropriate storage areas 18”
inches down from any ceiling or sprinkler system.
(8) The Pharmacy Aides shall rotate stock in the storage areas to insure that drug supplies are
used according to the appropriate manufacturer’s expiration dates.
(9) A pharmacist shall store all investigational drugs in the locked investigational storage cabinet
or in the locked investigational refrigerator.
(10) Pharmacy Administration shall call Facilities, Management, and Development (x1212) to
report problems with the Pharmacy’s physical plant, e.g., lighting, plumbing, refrigeration, etc. and
arrange prompt correction of any deficiencies that would inhibit or create an unsafe condition for the
dispensing, storage, or compounding of medications.
(11) In order to prevent look-alike errors, Pharmacy storage bins for drugs where
appropriate shall be marked with a red sticker for look-alike drugs and a green
sticker for drugs that are available in multiple strengths.
(12) Pharmacy technicians shall record temperatures in a log of the Main Pharmacy,
all refrigerators, and all freezers storing medication on a daily basis. It the
temperature is out of range in these storage areas, the temperature shall be re-
checked in one (1) hour. If the temperature has returned to normal, the technician
shall enter the corrected temperature in the log and circle the corrected
temperature. If the temperature does return to normal range, a technician or
pharmacist shall report it to the Control Room at X 2810 and make arrangements
to remove the drugs for proper temperature storage.

LXXVI. Changes in regulatory or statutory laws or standards
LXXVII. System failures/ changes
LXXVIII. Institutional/operational changes
VII. Attachments: Medication Usage Quality Control Inspection Record

One)
Yes No
175
Chapter 17 SECTION A
Subject:
of
LOOK-ALIKE/SOUND-ALIKE DRUGS Page 1 3
Prepared by: Original Issue

LilyAnn Jeu, Pharm.D., BCPS date: 10/06
Reviewed by: Nicholas Galeota, M.S., R.Ph. Supersedes: 10/06
Approval date:
Approved by: Constances Shames, MD Distribution: Administrative Manual
Department Manual
Patient Care Manual
AOD Manual
I. Purpose:
To define the organization’s process for identifying and compiling the look-alike/sound-alike drug list.
To define preventive measures implemented by the institution to prevent look-alike/sound-alike

medication errors.
II. Definition(s):
Look-alike/sound-alike drug names are names that are similar in appearance or pronunciation, or
have the potential to be confused with other medication names due to these similarities. Confusion
between such agents may lead to potentially harmful medication errors.
III. Policy:
The Department of Pharmacy will identify and annually review the list of look-alike/sound-alike drugs
used in the organization. The Department will implement measures to prevent errors involving
interchange of these drugs.
The organization’s list will consist of a minimum of 10 sets of look-alike/sound-alike drug names
based on The Joint Commission’s recommendations.
Pharmacist: The Department of Pharmacy will update the organization’s list of look-alike/sound-
alike drugs and disseminate the updated list to Prescribers and Nursing personnel through the
Pharmacy & Therapeutics Committee. Preventive strategies to reduce medication errors with such
176
drugs will be disseminated via the same venue. Pharmacists shall follow preventive strategies to
reduce these medication errors.
Prescribers: Medication orders shall be complete with drug names clearly and correctly spelled.
When applicable, the indication for use of look-alike/sound-alike medications shall be included on
the medication order.
Nursing: Nurses shall obtain and transcribe only complete, clear medication orders to reduce the
risk of medication errors with look-alike/sound-alike drugs. Nurses shall practice and/or participate
in preventive strategies to reduce such types of medication errors.
1. On an annual basis, the Department of Pharmacy will review the Joint Commission
recommendations for updating the organization’s list of look-alike/sound-alike drugs.
2. The following preventive strategies will be employed to reduce potential and actual medication
errors with look-alike/sound-alike drug names in medication storage and/or patient care areas:
a. Physical separation of agents with similar names.
b. Use of different drug delivery devices to distinguish drugs with similar names (e.g., NovoLog
FlexPen vs Novolin R vials).
c. Use of brand and generic names on unit-dose packaging, in medication storage areas, and/or
medication orders whenever possible.
d. Inclusion of prompts for nurses to specify indication for use when medication is retrieved from
the automated dispensing cabinet (Pyxis).
e. Inclusion of dosing limits for medications with similar names but different dosage ranges.
f. Placement of “Look-Alike, Sound-Alike” auxiliary alerts on medication storage bins.
g. Use of tall man lettering for medication names in storage areas (e.g., shelf labels and bins,
automated dispensing cabinets) and in electronic ordering systems.
h. Abbreviations of drug names are not acceptable.
i. Remove drugs with potentially problematic names from formulary, whenever possible.
3. Guidelines outlined in the policy for Verbal and Telephone Orders shall be followed to prevent
medication errors when look-alike/sound-alike drugs are named.
4. The updated list of look-alike/sound-alike drugs shall be made available in nursing stations, within
the Department of Pharmacy, and in medication storage areas.
5. If at any time a nurse or pharmacist is unclear about the drug name, the health-care professional
shall contact the prescriber to clarify the medication order.
XI. Reasons for Revision:

System failures/changes
x Institutional/operational changes
VII. Attachments:
Top 10 Sound-Alike & Look-Alike Drugs
VIII. References:
JCAHO 2007 National Patient Safety Goal 3C
Look-alike/sound-alike drug tables (2006-2007) available at web site www.jcaho.org
177
Date Revision Required (Check One) Responsible Staff Name and Title
Reviewed
12/07 Yes X No P&T Committee
Yes No
178
Department of Pharmacy Services
Potential Problematic Drug Names in Red
BRAND (and generic) NAMES
Potential Errors and Consequences
 INSULIN PRODUCTS  ULTRAM (tramadol)
NOVOLIN (human insulin products) DESYREL (trazodone)
NOVOLOG (human insulin apart) KETOROLAC (toradol)
NOVOLIN 70/30 (70% isophane insulin [NPH] and Drugs with similar generic names. Mix-ups may result in a
30% insulin regular) decline in pain control, change in psychiatric symptoms, or
Similar names, strengths and concentration ratios have other serious adverse events.
contributed to medication errors. Mix-ups may result in
hypoglycemia or poor diabetes control.  VISTARIL, ATARAX (hydroxyzine)
APRESOLINE (hydralazine)
 CATAPRESS (clonidine) HYDRODIURIL (hydrochlorothiazide)
KLONOPIN (clonazepam) Drugs with similar names and dosage strengths. Mix-ups
The generic name of clonidine can easily be confused as may result in sedation, hypotension, or other serious
the trade or generic name of clonazepam. Mix-ups may adverse drug events.
result in hypotension, loss of seizure control, or other
serious adverse events.  COUMADIN (warfarin)
AVANDIA (rosiglitazone)
 AMBISOME (amphotericin B liposomal) CARDURA (doxazosin)
ABELCET (amphotericin B lipid complex) Poorly handwritten orders for Avandia (used for type II
AMPHOCIN, FUNGIZONE (amphotericin B diabetes) or Cardura (used for blood pressure or urinary
desoxycholate, conventional amphotericin B) symptoms) have been misread for Coumadin (an
Doses of lipid-based products are usually higher than anticoagulant), or vice versa.
conventional products. Doses also vary from product to
product. Confusion between products may result in
respiratory arrest, renal failure and sometimes fatal
 DILAUDID (hydromorphone) injection
ASTRAMORPH, DURAMORPH, INFUMORPH
adverse events. (morphine) injection
Hydromorphone is 4-8 times more potent than morphine.
 GLUCOPHAGE (metformin) Fatal errors have occurred due to the false belief that
FLAGYL (metronidazole) hydromorphone is the generic equivalent of morphine.
Drugs with similar names and dosage strengths may be
confused with poorly handwritten orders. Mix-ups may
result in hypoglycemia or untreated infection.
 CELEBREX (celecoxib)
CEREBYX (fosphenytoin)
CELEXA (citalopram)
 VELBAN (vinblastine) Drugs with similar brand names may be confused with
ONCOVIN (vincristine) poorly handwritten orders. Mix-ups may result in decline
Fatal errors have occurred, often due to name similarity, in mental status, lack of pain or seizure control, or other
when patients were given vincristine at a vinblastine dose. serious adverse events.
Strategies to Prevent Look-Alike/Sound-Alike Errors Examples

 Avoid abbreviations of drug names.  All drugs
 Physically separate agents in storage areas and automated dispensing  Insulin products
cabinets (Pyxis®).
 Use novel dosage delivery devices to distinguish products with similar  NovoLog FlexPen®
names.
 Print generic and brand names on unit-dose packaging, when possible.
 Use TALL MAN lettering to emphasize the spelling of drug names in Pyxis®  traMADOL,
and medication storage areas. trAZODONE
 Include prompts for nurses to specify indication for use when medication is  Hydroxyzine,
removed from Pyxis. hydralazine
 Include dosing limits for medications with similar indications.  Tramadol, toradol
 Place “Look Alike, Sound Alike” auxiliary alerts on medication storage bins.
 Remove drugs with potentially problematic names from formulary, whenever
possible.
Department of Pharmacy, Revised 2007
179
Subject: Antibiotic Surveillance/Control/Review Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish policies and procedures that would prevent nosocomial infections and reduce
the incidences of antibiotic resistance.
III. Policy: In order to assure appropriate and quality utilization of antimicrobial agents, a concurrent
Antibiotic/Review/Surveillance Program has been implemented by the University Hospital Pharmacy &
Therapeutics Committee and approved for implementation by the Executive Committee.
The objectives of the program are:

(1) To prevent the development of resistant microorganisms, thus prolonging the useful like of
potent new anti-microbial agents.
(2) To improve patient care by providing for a consult (usually by telephone) with an Infectious
Disease Division physician at the time that initial treatment decisions are made on patients who are
suspected of having serious infections.
(3) To prevent unnecessary expenditures for anti-microbial agents. On a periodic basis,

implementation mechanisms of control of certain antibiotics shall be designated by the Pharmacy &
Therapeutics Committee as “for use only after consultation with Infectious Disease Division”. A list of
presently designated antibiotics is appended. The Committee shall review the list of designated drugs
periodically. Most new antibiotics added to the formulary shall be so designated. Drugs may also be
dropped from the designated list when so warranted.
IV. Responsibilities: It is the responsibility of the house-staff physician in charge of the patient to page
the IDD Fellow to obtain approval to use the controlled antibiotic. It is the responsibility of the IDD
Fellow to call the Pharmacy to authorize release of the antibiotic.
(1) When a patient is considered to be in need of a designated antibiotic, the house-staff
physician responsible for the patient’s care shall page the Infectious Disease Division Fellow
on-call for University Hospital.
A brief discussion of the patient shall ensue. The Infectious Disease Divisions physician may
offer suggestions as to additional diagnostic procedures or alternative anti-microbial agents
(or both). An attending physician in the Infectious Disease Division shall always be available if
180
additional consultation is required. The Infectious Disease Division physician may ask to see
the patient if he/she feels that firsthand evaluation is needed. There shall be no consultation
fee unless the physician responsible for the patient’s specifically requested a formal
consultation.
(2) The Infectious Disease Division physician shall call the Pharmacy indicating that the
designated antibiotic should be released. Dosage and duration of treatment shall be specified
if so indicated. The name of the Infectious Disease Division physician shall be recorded.
(a) If the house-staff physician does not page the IDD Fellow and the prescription
comes to the Pharmacy, then the prescriber shall be called (name taken) and time recorded.
The prescriber is told that the prescription is for a controlled antibiotic; he/she shall be
informed to contact the IDD fellow responsible for the respective time period to obtain approval
for the use of the antibiotic.
(3) Designated antibiotics which have been released but which are not administered to the
patient, for whom they are approved, shall be returned by Nursing to the Pharmacy.

LXXIX. Changes in regulatory or statutory laws or standards
LXXX. System failures/ changes
LXXXI. Institutional/operational changes
VII. Attachments: Adult Restricted Antibiotic Order Form
One)
Yes No
181
Subject: Approved Controlled Antibiotic List at UHB Page ____1__ of ____2__
Reviewed by: WILLIAM GERDES Supersedes Date: __10/17/01__
Approval Date: 10/05

Department Manual
Patient Care Manual
AOD Manual
Issued by: Pharmacy and Therapeutics

Committee
______________________________________________________________________________________
PARENTERAL AGENTS ORAL AGENTS

Generic Name Type Trade Name Generic Name Type Trade Name
Acyclovir Injection Zovirax® All anti-retroviral agents
Amphotericin Injection Fungizone® Atovaquone Suspension Mepron®
Caspofungin Injection Cancidas® Flucytosine Capsule Ancobon®
Flucanozole Injection Diflucan® Rifabutin Capsule Mycobutin®
Ganciclovir Injection Cytovene®
Cefipime Injection Maxipine® All non-formulary Oral dosage
forms
Linezolid Injection Zyvox®
Meropenum Injection Merrum®
Gatifloxacin Injection Tequin®
Pentamidine Injection Pentam®

Azetreonam Injection Neutrexin
Valgancyclovir Injection Valcyte®
Vancomycin Injection Vancocin®
Voriconozole Injection V-fend®
Cidofovir Injection Vistide®
All non-formulary Injection
APPROVAL IS TO BE OBTAINED BY THE PRESCRIBING PHYSICIAN FROM THE INFECTIOUS DISEASE

DIVISION PRIOR TO PRESCRIBING THE ABOVE ANTIBIOTICS INCLUDING ANY REQUEST FOR A NON-
FORMULARY ANTIBIOTIC, revised 12/04.
One)
182
Yes No
Subject: Pharmacy Antibiotic Monitoring Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide advice to the Infectious Disease Division faculty on the use, patterns, and
volume of antibiotic usage within the hospital.
III. Policy: The Pharmacy Department shall review monthly the usage of all antibiotics used for in-patient
care for the purpose of therapeutic drug utilization review and cost containment analyses.
IV. Responsibilities: It is the responsibility of the Director of Pharmacy or the Associate Director of
Pharmacy to monitor all antibiotic usage patterns for in-patient care and resolve all usage questions
with the Infectious Disease Division, the originating service, or the Pharmacy & Therapeutics
Committee for the purpose of improving patient care and monitoring prescribing trends of the medical
staff.
(1) The Computer Center shall provide on the first of each month a printed report
(PHARANTI) of all antibiotic usage for in-patient care from the previous month. This report
shall indicate usage for individual Nursing care units and a cumulative house-wide tally.
(2) The Director of Pharmacy or Associate Director Pharmacy shall review the report for
usage patterns.
(3) Controlled antibiotics shall be separated from non-controlled antibiotics and price
calculations for dollar value shall be calculated.
(4) Any excessive or unusual usage patterns shall be identified.
(5) These patterns shall be brought to the attention of the Infectious Disease Division
Department for clarification at extension 1330. If the discrepancy cannot be resolved, the
service in question shall be contacted for clarification.
(6) The Director of Pharmacy shall create a DUE study for review by physician experts for
drugs that have unresolved questions concerning usage and prescribing excesses.
183
(7) Upon completed review by the physician, the DUE shall be forwarded to the hospital
Q/M Case Management Department for Manual shall be followed). The results shall be
presented at a P&T meeting for corrective action, if any.
(8) A computer file and graph depiction of usage patterns can be created in the Pharmacy
Director’s Office for the year with monthly entries posted during the first week of each month.

One)
Yes No
184
Subject: Drug Information to Hospital Services Page ____1__ of ____1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To give direction to pharmacists for providing drug information to healthcare professionals.
III. Policy: A Pharmacist shall provide drug information to any hospital service requesting assistance by
using current books, journals, magazines, or periodicals and, if necessary, through computer search
through the Health Science Education Library, Med-Line ®, Micro-Medex® Drug-Dex, Dolphin® MSDS,
Micro-Medex® Patient Leaflets, or Micro-Medex® Altern-Dex.
The Director of Pharmacy shall co-chair the standing Nursing/Pharmacy Committee for the purpose of
disseminating drug information, policies on the use and handling of drugs, e.g., parenteral, orals, etc.,
as well as resolving Nursing and patient issues associated with Pharmacy operations.
IV. Responsibilities: It is the responsibility of a pharmacist to answer any and all requests for drug
information posed by the Hospital Services at UHB using current literature. It is the responsibility of
the Director of Pharmacy to share this information with all services and committees.
(1) Upon receipt of a request for drug information, a pharmacist shall search through the
titles of books and other publications in the Pharmacy Library for the appropriate information
to expeditiously answer the question. (see attached listing)
(2) The Pharmacist shall document the request and the information provided on the Drug
Information Request Form or the Drug Information Form for Unofficial Medication Use (see
attached). These requests will be filed in the corresponding file
maintained in the Pharmacy Director’s office or in the Non-FDA Approved use File,
respectively.
185
(3) The Director of Pharmacy shall present these drug information questions and answers
at the monthly Pharmacy Staff meeting and Pharmacy/Nursing Committee, or in the Pharmacy
newsletter publication, which is circulated hospital-wide.

VII. Attachments: Drug Information Form; Library of Pharmacy Text References
One)
Yes No
186
Subject: Drug Information to Discharge and Ambulatory Page ____1__ of ____2__

OPD Patients

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide for pharmacist counseling expertise to discharge and/or ambulatory care
patients.
III. Policy: Upon request by a nurse conducting a discharge interview or by an OPD Ambulatory patient, a
pharmacist shall provide drug information in language understandable by the patient and distribute
any drug information literature applicable.
IV. Responsibilities: It is the responsibility of a pharmacist to provide drug information in understandable

language to all patients requesting assistance and to provide pharmaceutical expertise and to any of
the medical services at UHB.
(1) A pharmacist shall assist a nurse conducting a discharge interview with a patient by
either participating in the interview, by providing written drug information, or printing patient
information leaflets from the Micro-Medex® database to the nurse to use during the interview.
(2) A pharmacist shall provide information to ambulatory OPD patients at the OPD
Pharmacy window so that any question concerning the drug, its use, its dose, its toxicity, if
any, warnings, adverse effects, and possible drug – drug, or drug – food interactions, or
warnings are clearly understood by the patient.
(3) Drug information printed from the Opus® Ambulatory Pharmacy Management System
shall be given to the patient to assist in reinforcing the education of the patient concerning the
medication that the patient is taking when an ambulatory prescription is dispensed.
(4) Any follow-up telephone calls for further assistance from a nurse or a patient shall be
answered professionally, courteously, and intelligibly.
(5) Cross reference shall also be made to Chapter 23 Titles Pharmaceutical Education for
Patients and Family Members.
187
One)
Yes No
188
Subject: Patient Medication Profile System Page ____1__ of ____1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures to maintain a patient’s drug profile for use and evaluation by
pharmacists and other healthcare professionals.
III. Policy: In order to capture, use, and communicate patient medication information throughout the
hospital community responsible for evaluating the effects of medication modalities in the care of the
patient, making patient care decisions, and improving organizational performance concerning the use
of medications, the Pharmacy shall maintain a patient medication profile system through the Robot
Automated Dispensing System. This system shall be supported by both the patient’s medical record
information and the documents of Pharmacy.
IV. Responsibilities: It is the responsibility of the Admitting office to assign a computer number to the
patient, enter this number in to the computer mainframe which creates the patient’s medication profile,
and, in conjunction with the Nursing station clerical staff to enter the admitting patient demographics
into the patient’s medication profile. It is the responsibility of the pharmacist staff to enter medication
orders and maintain the completeness and accuracy of the medication profile.
(1) Upon admission to the hospital, a patient medication profile shall be created in the
computer mainframe through entries made by the Admitting Office and the Nursing station
clerical staff (The EAGLE System). The initial profile shall contain the following patient
demographics (this information is interfaced with the Robot Automated Dispensing System):
• Patient name, age, sex, location, medical record number, and computer number
• The patient’s weight (in pounds and kilograms), height (in inches and centimeters), all
known allergies, OTC and herbal medications taken prior to admission, pregnancy and
lactation states for female patients
• The patient’s admitting diagnosis
(2) As physicians prescribe medications for the patient in the patient’s medical record, the
medication orders written shall be computerized by the pharmacist staff within the Main
189
Pharmacy. These computerized orders are added to the patient’s medication profile in
chronological order and comprise the body of a multi-page profile.
NOTE: The physician’s orders computerized include new, renewal, discontinuation, and floor
sock medication orders used in the patient care while in the hospital.
(3) Improperly/incorrectly written prescriptions shall be corrected by a pharmacist

contacting the prescriber at the Nursing station, a discontinuation order written for the
incorrect order, and a new corrected order written by the prescriber.
(4) Clinicians hall have access to the information contained in this profile in all patient care
areas in hard copy form provided by the Pharmacy during the daily medication drug cassette
exchange and as needed.
(5) For the OR area serviced by a satellite Pharmacy, the Pharmacy shall maintain a written
patient profile system of drugs administered pre-operatively and intra-operatively. These
documents are available for review by the clinical staff of the hospital in this location.
(6) Lab test requests and lab test results shall be obtained by entering the appropriate
menu choice on the computer screen at the Nursing stations. This is accessible to all
clinicians in Nursing care areas and in the Main Pharmacy also through the patient’s computer
number.
(7) The patient medication profile system shall also be available for ambulatory OPD
patients. This profile can be accessed by clinicians utilizing the patient’s outpatient computer
number immediately followed by the letter “p” and pressing ENTER in the THOMIS system.
(8) The outpatient Pharmacy department shall also maintain a free standing computerized
patient profile system (OPUS®) which is available for review by the clinical staff.

One)
Yes No
190
Subject: Continuing Education of the Pharmacy Staff Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide for the continuing education and competency of professional and para-
professional staff within the Pharmacy.
III. Policy: Pharmacy Administration shall provide for continuing in-service education to the entire
Pharmacy staff on current additions to the hospital formulary, changes in therapeutic usages/doses of
pharmaceuticals, pertinent drug information specific to professional practice, e.g., pharmakinetics,
pharmacology, age-specific dosing and competency, etc, and new medication modalities. Pharmacy
Administration shall encourage all staff to attend external continuing education programs, participate
in literature continuing education opportunities and maintain documentation of attendance or credit
accumulation.
IV. Responsibilities: It is the responsibility of Pharmacy Administration to provide for the in-service
continuing education of the Pharmacy staff on an on-going basis so that the pharmaceutical expertise
of the staff external to the UHB Pharmacy.
(1) On an as needed basis, the Associate Director of Pharmacy shall schedule an in-
service education session for all of the Pharmacy staff. The presentations shall be conducted
by pharmaceutical company representatives on recent additions of drugs to the formulary or
changes in existing drugs or dosage forms on the formulary.
(2) A post-test shall be given to the staff to ascertain competency and learning potential
for the session.
(3) A record of attendance shall be taken and maintained in the Pharmacy Associate
Director’s office.
(4) Pharmacy Administration shall attached all continuing education programs to the files
for staff members attending those sessions or educational programs participated in or
attended by the staff external to the UHB Pharmacy.
191
One)
Yes No
192
Subject: Pharmacy Staff Meetings Page ____1__ of ____1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide for forum to communicate with the Pharmacy staff by Pharmacy Administration
concerning administrative, clinical, and operational issues.
III. Policy: Pharmacy Administration shall conduct monthly or as needed Pharmacy Staff meetings for the
entire Pharmacy staff.
IV. Responsibilities: It is the responsibility of the Director of Pharmacy to schedule and conduct monthly
staff meetings for the purpose of efficient communication to the entire staff of subject matter effects
Pharmacy operations, systems improvement, legal matters relating to hospital Pharmacy practice, and
patient care and safety. It is the responsibility of the Director of Pharmacy to publish official minutes
of all staff meetings for the entire staff.
(1) On a monthly basis, a general staff meeting shall be scheduled and conducted in the
Main Pharmacy Room (ALL 1-469)
(2) Attendance by all staff members is mandatory and shall be taken.
(3) Minutes shall be compiled or recorded, including handout, and distributed before the
next staff meeting. An official copy of the minutes shall be maintained in the Pharmacy
Director’s office.
(4) Agenda material shall include:
(a) Policies & Procedures

(b) Operational problems and information
(c) Changes in legalities concerning hospital Pharmacy practice or hospital
operations
(d) P&T Updates
(e) Q/A – PI projects, committee formations, follow-ups, and updates
(f) Medication Errors and Adverse Drug Reaction incidents
(g) Changes in hospital information systems
(h) Update on investigational drug protocols
(i) Controlled substance problems
193
(j) Personnel and Labor Relations subjects
(k) Infection Control
(l) Education and instruction
(m) Drug Re-Calls
(n) Good & Welfare of the staff
(o) Regulatory agency information, e.g., JCAHO, NYS DOH
(p) Information technology upgrades and training
(q) High-risk drug advisories and “black box warnings”
(5) Any staff unable to attend shall be briefed on the subject matter of the meeting, e.g.,
sick leave, vacation, operational coverage assignment.
(6) All staff members shall receive a copy of the minutes.

One)
Yes No
194
No: ___CH. 20
Subject: Prescription Transmission to the Pharmacy Page ____1__ of ____2__

Via Fax Machine

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Establish procedures for the faxing of medication orders to the Pharmacy.
III. Policy: In-patient prescription orders can be transmitted to the Pharmacy department via a facsimile
telephone transmission device (FAX machine). The faxed prescription shall be the authority by which
a pharmacist shall verify the prescriber’s orders, and thereafter dispense the prescribed medication to
the Nursing station for administration by a nurse to the patient.
IV. Responsibilities: The physician is responsible to initiate the order process. The nurse is responsible
to place the order into the transmittal cycle to the Pharmacy. The Nursing station clerk is responsible
to fax the order to the Pharmacy. The pharmacist is responsible to check all prescription orders faxed
or otherwise, and then release the completed medication order for delivery to the Nursing station.
(1) After a nurse picks up a new medication order and signs the medication order, the
prescription order shall be given to the Nursing station clerk.
(2) The clerk shall then FAX the order to the Pharmacy at x2855.
(3) The pharmacist shall review the order for accuracy and completeness. (Note: follow
Chapter 4, Section G)
(4) Upon confirmation, the pharmacist shall enter the medication order in to the patient’s
profile database and release the first dose of medication for delivery to the Nursing station. All
subsequent doses shall be delivered in the daily cassette exchange.
(5) The original medication order shall be delivered to the Pharmacy at a later time,
matched checked against the Faxed copy by a pharmacist, and filed with the Faxed copy by a
pharmacist, and filed with the Faxed copy.
195
(6) If the Faxed copy is vague, obscured, or otherwise questionable to read, the pharmacist
shall contact the Nursing station to clarify the order before dispensing.

One)
Yes No
196
Subject: The Pharmacy Department’s Patient Page ____1__ of ____2__

Confidentiality and Data Security

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To insure that patient confidentiality is maintained at all times during the provision of
pharmaceutical care.
III. Policy: All Pharmacy employees shall maintain hospital and patient confidentiality relating to all of
their daily activities as it relates to the pharmaceutical and medical care of the patient.
IV. Responsibilities: It is the responsibility of Pharmacy Administration to provide for the in-service
continuing education of the Pharmacy staff on an on-going basis so that the pharmaceutical expertise
of the staff external to the UHB Pharmacy.
Each employee shall:
(A) Uphold the patient’s right to privacy in the disclosure of personally identifiable medical
social information as stated in the Patient’s Bill of Rights.
(B) Disclose to no one but proper authorities any evidence of conduct or practice revealed
in medical reports or observed conduct that has indicated possible violation of established
rules and regulations of the hospital or a professional’s practice.
(C ) Preserve the confidential nature of professional determinations made by official

committees of the Medical Staff or health and health-service organizations.
(D) Preserve patient confidentiality by securing all computer data, programs, files, and
graphs after use.
(E) At the time of commencing employment personnel responsible for handling

confidential patient information shall be required to sign the following statement:
“I understand and agree that in the performance of my duties as an employee of University

Hospital/SUNY HSCB, I must hold medical information in confidence.
Further I understand that intentional or involuntary violation of the Hospital’s or Patient’s
confidentiality may result in punitive action. I hereby attest my acceptance of this
responsibility by my signature.”
197
(F) At the time of the annual employee evaluation and re-appointment, each Pharmacy
employee shall sign the Staff Confidentiality of Protected Health Information document.

VII. Attachments: Staff Confidentiality of Protected Health Information document

One)
Yes No
198
Subject: Administrative Table of Organization for the Page ____1__ of ____2__

Department of Nursing Services

Department Manual
Patient Care Manual
AOD Manual

______________________________________________________________________________________
I. Purpose: The following table of organization represents the reporting lines for the Department of
Nursing Services:
III. Policy: N/A

LXXXII. Changes in regulatory or statutory laws or standards
LXXXIII. System failures/ changes
LXXXIV. Institutional/operational changes
VII. Attachments: Table of Organization Patient Care/Nursing Administration
One)
Yes No
199
Subject: Drug Weight Conversion Chart on Nursing Page ____1__ of ____2__

Care Areas

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide a tool for the safe conversion of metric weights of drugs to apothecary weights
and vice versa.
III. Policy: During the monthly Nursing care area inspection, a pharmacist shall check for the presence of
a drug weight conversion chart (apothecary-metric conversion) and replace any missing any charts.
IV. Responsibilities: It is the responsibility of the prescribing physician to write medication orders using
the metric system unless the manufacturer’s labeling expresses the concentration or strength of the
drug in the apothecary system. It is the responsibility of a pharmacist to insure the presence of a
conversion chart when questions arise concerning metric-apothecary conversions.
(1) A pharmacist shall inspect each Nursing care area monthly.
(2) A pharmacist shall check for the presence of a drug weight conversion chart posted on
the unit.
(3) If the chart is missing, a pharmacist shall affix a drug weight conversion chart to an
area in the medication preparation room in the Nursing station area.
(4) Any nurse responsible for administering medication shall refer to this chart if a
question concerning metric/apothecary weight conversion occurs or telephone the Pharmacy
at extension 2854 or 2856 to obtain a pharmacist’s assistance.

LXXXV. Changes in regulatory or statutory laws or standards
LXXXVI. System failures/ changes
LXXXVII. Institutional/operational changes
VII. Attachments: Drug Weight Conversion Chart
200
One)
Yes No
201
Subject: Medication Orders for Discharge Patients Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To prevent adverse medication events associated with inpatient medication if given to a
patient upon discharge.
III. Policy: Any medication labeled for an in-patient from a Nursing station shall not be given by a nurse or
other medical professional to a patient upon discharge.
IV. Responsibilities: It is the responsibility of an authorized practitioner responsible for the patient to
write ambulatory prescriptions for the patient upon discharge. It is the responsibility of the nurse
responsible for the patient to return all unused in-patient labeled medication to the Pharmacy upon
discharge of the patient.
(1) Upon discharge of an in-patient, the attending physician or a house-staff physician

shall write the necessary prescriptions for the patient on an out-patient prescription blank
including all of the mandated legal information (see attached).
(2) The patient can have the prescription filled at their neighborhood Pharmacy if it is
written by a practitioner with prescriptive authority in the State.
(3) If the prescription is to be filled at the UHB outpatient Pharmacy due to financial
burdens on the patient, a pharmacist shall dispense the medication according to legal
requirements, properly label for ambulatory patients, and in a child proof container where
applicable.
(4) The nurse responsible for the patient shall return all unused inpatient labeled
medication to the Pharmacy.
LXXXVIII. Changes in regulatory or statutory laws or standards
LXXXIX. System failures/ changes
XC. Institutional/operational changes
VII. Attachments: OPD Prescription Blank
202
One)
Yes No
203
Subject: Medication Storage Areas Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To insure that medications are stored safely to insure their integrity when stored in patient
care areas.
III. Policy: Medication received by Nursing Care area nurses shall only be stored according to the
manufacturers and/or Pharmacy labeled storage requirements for the drug in the officially designated
Nursing station locked medication storage areas and/or medication carts.
IV. Responsibilities: It is the responsibility of the Assistant Director of Nursing for the respective unit to
insure that all drugs are properly stored upon receipt from the Pharmacy. It is the responsibility of the
monthly inspecting pharmacist to insure that all drugs are stored under the appropriate storage
conditions.
(A) A nurse shall store medication supplies only in the official nursing station medication
storage areas and/or medication carts under locked conditions, which include:
• Medication Preparation Areas (including crash carts)

• Controlled Substance Cabinets
• Cassette Exchange Carts
• Medication Refrigerators
(B) A nurse shall segregate internal medication storage from external medical storage.
(C ) The nurse and the monthly inspecting pharmacist shall insure that drugs are stored
under the proper storage temperatures according to USP-NF or USP DI Official storage
temperatures that is: (see attached).
(D) The monthly inspecting pharmacist shall inspect for proper operation of the medication
refrigerators and insure that a thermometer is present.
(E) If a medication is suspected of being improperly stored, the nurse or pharmacist shall
remove the suspected drug from the Nursing unit and the replacement medication is to be
placed under the proper storage conditions.
204
XCI. Changes in regulatory or statutory laws or standards
XCII. System failures/ changes
XCIII. Institutional/operational changes
VII. Attachments: Storage Temperature Sheets
One)
Yes No
205
Subject: Medication Orders for Heparin Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures for the safe prescribing of the high-risk drug heparin.
III. Policy: Heparin medication orders shall be written in terms expressing strength and dosage in U.S.P
units.
IV. Responsibilities: It is the responsibility of the prescribing practitioner to write all orders for heparin in
terms of units or units/ml. It is the responsibility of the nurse to refer to all heparin orders not written
in terms of units or units/ml back to the physician for correction.
(1) A prescribing practitioner shall indicate on the prescription the strength of the
appropriate dosage form of heparin in terms of units/ml.
(2) The dosage and administration rate of an infusion for heparin shall be written by the
prescriber in terms of units/ml or units/hour, respectively.
(3) A Nurse receiving medication orders for heparin in terms other than units shall refer
the order back to the prescriber for corrections.
4. A pharmacist shall only fill heparin orders expressed in terms of units or units/m
5. No medication order shall be filled if the symbol “U” is used to express “UNITS”. The
term “UNITS” must be spelled out.

XCIV. Changes in regulatory or statutory laws or standards
XCV. System failures/ changes
XCVI. Institutional/operational changes

206
One)
Yes No
207
Subject: Dispensing Concentrated Sodium Chloride Page ____1__ of ____2__

(23.4%) for Sputum Induction

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To control the distribution of the high-risk concentrated 23.4% sodium chloride solution
when it required for sputum induction by the Respiratory Therapy Department.
III. Policy: Upon receipt of a faxed copy of a respiratory therapy order written by an authorized prescriber,
a pharmacist shall dispense concentrated sodium chloride (23.4%) to a Nurse for use by a respiratory
therapist for sputum induction.
IV. Responsibilities: It is the responsibility of an authorized prescriber order to order concentrated

sodium chloride (23.4%) for sputum induction. It is Nurse’s responsibility to pick up the Prescription
for Respiratory Care and send the order to the Pharmacy. It is the responsibility of the pharmacist to
dispense and properly label this medication for safe use in sputum induction.
(1) Upon receipt of a copy of the Prescription Form for Respiratory care (UH 198-A) (see
attached) signed by an authorized prescriber indication the type of therapy, a pharmacist shall
obtain a vial of concentrated sodium chloride (23.4%) from the Pharmacy stock room.
(2) Using a syringe, the pharmacist shall withdraw the contents of the vial and place this
solution into an amber prescription bottle, number the bottles according to the prescribed
treatment regimen, and indicate the volume of solution contained therein according to the
Prescription for Respiratory Care.
(3) The pharmacist shall label this bottle according to correct format for in-patient labels
and add an auxiliary label stating “For Sputum Induction Use Only”.
(4) This medication shall be dispensed to a Nurse for his/her patient’s therapy.
(5) The Nurse shall give this medication to a respiratory therapist for use in the sputum
induction procedure.
(6) The respiratory therapist shall discard any unused portion of this medication after the
completing of each treatment.
208
XCVII. Changes in regulatory or statutory laws or standards
XCVIII. System failures/ changes
XCIX. Institutional/operational changes
VII. Attachments: Respiratory Therapy Sheet
One)
Yes No
209
Subject: Medication Dispensing on Prescription Orders Page ____1__ of ____1__

For Ambulatory Care

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: The Pharmacy Department does not maintain an ambulatory care Pharmacy Division,
however, in the event Hospital Administration through the Social Work Department authorizes the
dispensing of medication to a discharge/ambulatory care patient, the following procedures apply.
III. Policy: A licensed pharmacist shall dispense ambulatory care medication (clinic or discharge)
properly labeled to patients pursuant to a written prescription issued by a licensed/registered
medical/dental practitioner or by a post-graduate medical house-staff resident under the supervision
of a licensed supervising or attending physician.
IV. Responsibilities: It is the responsibility of a pharmacist to dispense medication and properly label all
medications pursuant to a written prescription for ambulatory care or discharge patients before the
patient receives the medication. It is the responsibility of a pharmacist to provide drug information
and counseling to the patient prior to releasing the medication to an ambulatory care or discharge
patient.
(1) Upon receipt of a prescription written by a licensed/registered practitioner or a post graduate

medical resident for use within the hospital, pharmacist or Pharmacy assistant shall gather the
medication to satisfy the practitioner’s order.
(2) A pharmacist shall verify the identity, license/registry number, and signature of the prescribing
practitioner.
(3) The prescription shall be stamped with the appropriate prescription number, that is:
(A) The pharmacist shall review the prescription for completeness and propriety (Refer
Chapter 4, Section G, Procedures).
(5) A pharmacist or Pharmacy assistant shall create a label to be affixed to the immediate
container of the medication.
(6) A pharmacist shall insure that the label bears the following information:
(A) Name, address, telephone number of the hospital Pharmacy
210
(B) Date and identifying prescription number of the prescription
(C ) Full name and address of the patient
(D) Drug name, strength, and quantity of the drug
(E) Directions to the patient in language understandable
(F) Name of prescribing physician
(G) Name or initials of dispensing pharmacist
(H) Any pertinent accessory or advisory/cautionary labels or DEA cautionary labeling
(7) A pharmacist shall insure that the drug container is a child-proof container, unless the drug is
exempt, e.g. nitroglycerin, before it is dispensed to the patient. If the patient desires a non-child-proof
container, the patient must sign and date the back of each prescription accompanied by a statement
indicating their desire and knowledge that the container is not child-proof.
(8) A pharmacist or Pharmacy assistant shall verify the identity of the patient by requesting either
a clinic identification card or other appropriate identification, e.g., health insurance card, driver’s
license, before the medication is dispensed to the patient.
(9) A pharmacist shall provide to the patient or family member information and patient counseling
concerning the use of the prescribed medication. (Refer also to Chapter 14, Section B and Chapter
32).
(10) All business transactions shall be completed according to Chapter 23, Sections D, E, F,
whichever applies, before the medication is dispensed.
(11) All business transactions shall be completed according to Chapter 33, Sections D, E, F,
whichever applies, before the medication is dispensed.
(12) The completed prescription form is to be filed in the appropriate prescription file according to
legal requirements by a pharmacist or pharmacy assistant.

C. Changes in regulatory or statutory laws or standards
CI. System failures/ changes
CII. Institutional/operational changes
VII. Attachments: Sample Label
One)
Yes No
211
Subject: Verification of Practitioner’s Name, License / Page ____1__ of ____2__

Registration, and Signature on Ambulatory
Care/Discharge Prescriptions

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To direct pharmacists to verify the identity of an authorized prescriber..
III. Policy: A pharmacist preparing OPD Pharmacy prescriptions for dispensing to ambulatory care or
discharge patients shall verify the prescribing practitioner’s name, license/registration number, and
signature before dispensing the prescription medications.
IV. Responsibilities: It is the responsibility of a pharmacist to verify all practitioner information contained
on ambulatory care/discharge prescriptions presented for filling at the OPD Pharmacy prior to
dispensing to the patient.
(1) Upon receipt of a written prescription at the OPD Pharmacy Service Area for an ambulatory
care/discharge patient, a pharmacist shall ascertain that the following information is contained in the
prescribing practitioner’s field on the prescription:
(A) Practitioner’s signature

(B) Stamp/imprint of the practitioner’s name
(C) License/registration number of the practitioner’
(2) In any information in Procedure #1 is missing or unreadable, the patient shall be referred back
to the prescribing practitioner for clarification or correction.
(3) In the information is present and complete, a pharmacist or Pharmacy assistant shall verify the
authenticity of the information against the medical/dental/resident/PA CNP practitioner files in the OPD
Pharmacy dispensing area.
(4) If the information is correct, the pharmacist shall proceed to fill and dispense the prescription
medication.
(5) If the information cannot be verified, the pharmacist or Pharmacy assistant shall notify the
Associate Director of Pharmacy, extension 3158, who shall contact the originating service for
clarification.
212
CIII. Changes in regulatory or statutory laws or standards
CIV. System failures/ changes
CV. Institutional/operational changes
One)
Yes No
213
Subject: Weekend and Holiday Dispensing of Page ____1__ of ____2__

Ambulatory Care Prescriptions

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures for filling an ambulatory/discharge prescription after authorization

is received from Hospital Administration and/or Social Work Department.
III. Policy: The pharmacist on-duty for weekend and holiday tours in the Main Pharmacy shall fill and
dispense prescriptions for discharge or clinic ambulatory care patients in financial burden presenting
written prescriptions signed by the administrator on-duty for medications not readily obtainable in
local pharmacies, e.g., heparin, chemotherapy medication, etc., in response to an emergency, or in
circumstances when an ambulatory patient cannot have their prescriptions filled in a community
Pharmacy. The OPD Pharmacy services shall otherwise be closed on weekends and holidays.
IV. Responsibilities: It is the responsibility of a pharmacist to dispense and label medication pursuant to
a written prescription by a licensed/registered practitioner and signed by the administrator-on-duty for
medications not readily obtainable in local pharmacies, e.g., heparin, chemotherapy medication, etc.,
in response to an emergency, or in circumstances when an ambulatory patient cannot have their
prescriptions filled in a community Pharmacy. The OPD Pharmacy service shall otherwise be closed
on weekends and holidays.
(1) Upon presentation of written discharge prescriptions or clinic ambulatory care prescriptions
from a licensed/registered practitioner for medications not readily obtainable in local pharmacies, the
pharmacist shall proceed to fill and dispense the prescription according to Chapter 23, Section A,
Procedures 1 through 11, inclusive.
(2) All business policies and procedures shall be followed as described in Chapter 23, Sections D,
E, and F, whichever applies.

CVI. Changes in regulatory or statutory laws or standards
CVII. System failures/ changes
CVIII. Institutional/operational changes
214
One)
Yes No
215
Subject: Prescription Pricing Policy for Ambulatory Page ____1__ of ____1__

Care Prescriptions

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish financial guidelines for pharmacists to follow when Hospital Administration
and/or the Social Work Department authorizes dispensing of ambulatory care medications.
III. Policy: Upon presentation, a pharmacist or Pharmacy assistant shall price the ambulatory care
prescription according to the hospital approved mark-up schedule programmed into the OPD (OPUS
FORTE) Pharmacy management system.
IV. Responsibilities: It is the responsibility of a pharmacist or Pharmacy assistant to price all

prescriptions according to the hospital approved policy and collect all charges for the subsequent
dispensing of the medication.
(1) Employees, students, and private patients who wish to pay by cash or check for out-patient
prescription services, shall be charged for out-patient prescription services according to the following
formula: AVERAGE WHOLESALE PRICE + A MARKUP = PRICE CHARGED
(2) The markup schedule to be followed is:
(a) If the average wholesale price falls between &0.01 and $10.00, inclusive, a markup of
$3.00 shall be added
(b) If the average wholesale price is greater than $10.00, a 30% markup shall be added.
(3) Licensed/registered practitioners purchasing drugs for their private practice, shall pay only the
average wholesale price of the drug without a mark-up. The drugs included for physician practice are
vaccinations, injectable oncologicals, injectable anti-inflammatory steroid agents, and any infection
that a physician requires and is justified for his/her practice.
(4) Third-party payor prescriptions shall be priced according to the regulations of the payor and
the appropriate co-pay shall be collected. The following third party payor plans are accepted for
prescription services:
216
(a) Medicaid
(b) PAID Prescriptions
(c ) National Prescription Administrators
(d) GHI
(e) EPIC
(f) ADAP
(g) PCS RECAP
(h) DPS
(i) VALUE Rx
(j) Caremark

One)
Yes No
217
Subject: Cash Transactions Involving Ambulatory Care Page ____1__ of ____1__

Prescriptions

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures for the deposit of funds received in the Pharmacy from OPD
transactions, manufacturer rebates, or medication returns. It should be noted that the Pharmacy does
not provide general ambulatory care Pharmacy services.
III. Policy: Collection of payments for OPD prescription services at the OPD Pharmacy Department shall
follow an organized and verifiable system to accept case, checks, and money orders, and subsequent
deposits of receipts at the Hospital Business Office.
IV. Responsibilities: It is the responsibility of a pharmacist to collect, enter sales in the register, and
issue receipts to patients for prescription services in the OPD Pharmacy. It is the responsibility of the
Director of Pharmacy to prove out the register, reconcile receipts against the receipt book, and make
deposits of all receipts at the Hospital Business Office. The Director of Pharmacy is responsible for
investigation all discrepancies and taking corrective measures to resolve any discrepancies.
(A) RECEIPTS:
(1) All case received for prescription services at the OPD Pharmacy Department
shall be entered into the cash register by the pharmacist assigned the register
responsibility in the OPD Pharmacy.
(2) A pre-numbered written receipt and a register receipt shall be given to the
patient.
(3) The second copy of the written receipt shall go to the Business Office daily and
the third copy shall remain in the Pharmacy in the receipt book.
2. All checks received for payment shall be stamped FOR DEPOSIT ONLY, JP Morgan
Chase Bank/SUNY-DMC.
3. All third party checks received in the mail shall be recorded by the Director of
Pharmacy in the annual check receipt log and stamped as in Procedure #4 for
deposit with the Business Office.
218
(B) PROVING OF THE REGISTER:
(1) At the end of the day, the Director of Pharmacy shall reconcile the receipt book
with the register tape.
(2) The total receipts for the day shall be recorded and verified by Director of
Pharmacy.
(3) The receipts shall be placed in the safe until it is deposited at the Hospital
Business Office.
(C) DEPOSITS:
(1) The Director of Pharmacy shall prepare deposit for the Business Office
breaking down the deposit total into cash, patient checks, and third party
insurance checks.
(2) The Director of Pharmacy deposits all receipts from the day daily.
(3) The Assistant Patient Account’s Manager or other authorized Hospital Business
Office employee shall count and verify the deposit.
(4) The Hospital Business Office shall issue a receipt for the Pharmacy receipts to
the Director of Pharmacy.
(D) ERRORS AND VOIDS:
(1) Any error or void in ringing the sale in to the register, shall be presented to a
manager with the register receipt and written receipt.
(2) A manager shall sign the void transaction and write a VOID RECEIPT and attach
this to the original transaction receipts. This is placed into the register and the
correct transaction shall be entered by the pharmacist.
(3) Any discrepancies between the register tape, the actual deposit, and the written
receipts shall be reported to the Business Office by the Director of Pharmacy.
(4) The Director of Pharmacy shall proceed to investigate the discrepancy, tale
corrective actions, and report to the Business Office any corrections or action
taken. A file of discrepancies shall be maintained in the Director’s Office.

VI. Attachments: Sample Receipts, Deposit stamp

VII. References: none
One)
Yes No
219
Subject: Collection Procedures for OPD Pharmacy Page ____1__ of ____2__

Services

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures for providing medication to the indigent/un-insured patient and to
insure proper collection procedures for dispensing activities..
III. Policy: The Out-Patient Pharmacy Department shall provide medication initially without charge to
those patients who have been approved by the respective financial screener and hospital
administrator provided that the patient has initiated appropriate insurance/assistance applications to
cover the medication charges incurred.
IV. Responsibilities: It is the responsibility of a pharmacist to direct those patients who do not have the
means to pay for prescription services to the appropriate financial screener and/or the Social Work
Department for review.
(1) All procedures described in Chapter 23, Section D & E, are to be followed, EXCEPT, in
those situations where the patient does not have the ability to pay for pharmaceutical services or does not
have appropriate insurance coverage.
(2) In the case of inability to pay, the pharmacist shall follow the Hospital’s Procedure for
Collection for Out-patient Pharmacy Services using the attached form.

VII. Attachments: Outpatient Pharmacy Prescription Financial Questionnaire
220
One)
Yes No
221
Subject: General Safety Page ____1__ of ____4__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish general safety and safety response procedures in the physical environment
within the Pharmacy.
III. Policy: Pharmacy Administration shall educate the entire Pharmacy staff to be aware of safety
measures required in their practice and to maintain safety standards in all Pharmacy environments.
NOTE: Refer to specific Policies * Procedures for extensive procedures for each section.
IV. Responsibilities: It is the responsibility of the Director of Pharmacy and Pharmacy Management to
insure that a safe environment is maintained for the professional activities of the staff. It is the
responsibility of the Pharmacy Management to educate the staff on an on-going basis safety policies
and practices both within the Pharmacy and in response and provide assistance.
(A) Access to Pharmacy Areas:
1. Only authorized Pharmacy personnel are permitted in all Pharmacy areas (Main
Pharmacy, Room ALL1-469, Satellite Pharmacies and Laboratories)
2. I.D. cards shall be worn at all times
3. Sterile compounding areas are restricted to pharmacists unless supervisory

arrangements are made for support staff.
(B) Pharmacy Environment:
1. Dispensing and Compounding areas shall be cleaned daily
2. Refuse shall not to be thrown on the floor
3. Smoking shall not be permitted in an y area of the Pharmacy
4. No food shall be brought into the compounding, dispensing, or storage areas
222
5. Food or drinks shall not be stored in drug storage refrigerators
6. White Lab coats shall be worn at all times when on duty
7. Trash is collected, floors swept daily and waxed once a week by Environmental
Services
8. A first aid kit shall be maintained in the event of injury or accident (in the Main
Pharmacy, RM ALL1-469).
C) Drug Storage Areas and Shelves:
1. Drug containers shall be kept in an orderly manner on shelving and removed if labeling
is unreadable
2. There shall be a minimal number of drug containers on work area shelving
3. External preparations shall be kept separate from internal preparations.
4. Alcohol and other flammable substances are to be stored in the alcohol storage room
or in designated fire rated yellow cabinets (AB-468)
5. The walk-in refrigerator shall be kept orderly and free of boxes on the floor
6. Expiration dates shall be checked monthly from the log of expiration dates
7. Expired drugs shall be stored for return outside the Main Pharmacy dispensing area in
the designated location
8. All refrigerators shall contain a thermometer and these are checked for accuracy daily.
9. Glassware shall be cleaned immediately after use
10. All containers shall be clearly marked with contents otherwise the container shall be
discarded
11. Cyto-toxic drugs shall be stored on shelving marked accordingly in the main
stockroom (ALL 1-427) or dispensing area and segregated from the general drug inventory
12. Flammable liquids shall not be kept in refrigerators
(D) Sterile Preparation Areas (TPN Lab and IV Addictive Preparation
1. Only trained personnel shall work in these areas
2. No food or smoking shall be permitted in these areas
3. Laminar airflow hoods shall be turned on one (1) hour prior to use
4. Logs of lot numbers and manufacturers of drugs products used shall be kept
5. All personnel working under the hoods shall wash with a bactericidal agent, e.g.,
Hibiclens
6. All completed IV bags shall be clearly labeled with name of patient, location, content,
expiration date, etc.
7. Intravenous tubing and intravenous bags shall be discarded in the regulated medical
waste (red bag) containers
8. Messengers shall sign for the completed solutions
223
9. Nurses shall sign a receipt form to be returned to the Pharmacy when they accept an
IV solution delivery
10. Delivery boxes shall be marked with the Nursing station number and a red label marked
REFRIGERATE is placed on the outside of the box
11. Pharmacists shall initial completed labels before adhering the label to the IV bag
12. A first aid kit shall be maintained in the event of injury or accident
13. Parenteral preparation hoods shall be inspected and certified semi-annually and the
inspection certificate affixed to the hood
(E) Emergency Preparedness and Fire Plans:
1. Staff shall be appraised of locations of fire exits, fire extinguishers, alarm signal code
directions, fire alarms, and proper use of fire doors.
2. Fire Wardens and Fire Captains shall insure that all staff is safely evacuated
3. Staff shall attend fire safety lectures given by hospital administration through
Environmental Safety
4. All boxes and packaging shall be kept away from sprinklers a minimum of eighteen (18)
inches
5. IF a disaster is called (bell signal of 4-4-4), the Pharmacy shall respond by bringing the
disaster cart to the Emergency Room and be prepared to give assistance with triage and patient care (refer
Chapter 15, Section G, Procedures 1-10)
6. The Pharmacy disaster cart shall be maintained, accuracy and expiration dates shall be
checked monthly
7. All bulk supplies of flammable substances shall be stored in hazardous materials room
8. Upon sounding of the fire alarm system, the OPD Pharmacy window shall be closed as
well as all fire doors and not re-opened until the all clear signal is sounded (1-1-1)
9. The fire alarm boxes located within the closest proximity to the Pharmacy are:
• Stairway 6 (6-6-1-1), Stairway 8 (6-1-1-1), and Stairway 5 (6-5-1-1)
10. In the event that a fire alarm does not activate a verbal alarm of “Code Red” shall be
called out and all fire procedures shall be followed
(F) Repackaging Areas:
1. All drugs repackaging shall be assigned by a pharmacist
2. Equipment for repackaging shall be cleaned before use
3. New labels shall be used when re-packing
4. All paperwork with drug information shall be presented with the re-packaged item
5. A pharmacist shall check the re-packaged drug, the label made for the container, and
check randomly a sample of repackaging procedure
(G) Electrical Equipment:
1. All electrical equipment shall be certified safe by SMI, tagged, and inspected annually.
UL certification shall also be required
224
2. All IV hoods shall be certified at least once every six (6) months and the certificate
displayed
3. All personnel shall report an y defective equipment and frayed wires immediately to a
supervisor
4. Only grounded hospital grade equipment and outlets shall be used
5. Only vital equipment shall be plugged into emergency outlets
6. No extension cords shall be used (Exception: power surge cords on computer

equipment in offices)
(H) Hazardous Materials and Wastes:
1. All expired drugs which cannot be returned for credit shall be discarded in the
regulated medical chemical waste container (white and yellow bag)
2. All cytotoxic drugs shall be placed in Winfield containers when discarded
3. All IV tubings and bags shall be discarded in regulated medical waster (red bag)
containers
4. Used needles and syringes used in compounding shall be placed in sharps containers
or in sealed Winfield containers for syringes
5. Material Safety Data sheets shall be available to the staff in the Director’s office, in the
IPD compounding/investigational drug area, and on-line as the Dolphin MSDS program.
(I) Miscellaneous:
1. In the even of a cardiac arrest, the hospital’s overhead page system shall sound a Code
99 or Code Blue
2. In the event of an infant or child abduction, the hospital’s overhead page system shall
sound Code Pink (See Infant Abduction Policy and Procedure, Chapter 15, Section I).

CIX. Changes in regulatory or statutory laws or standards
CX. System failures/ changes
CXI. Institutional/operational changes
One)
Yes No
225
Subject: Pharmacy Key Control Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To control the distribution of keys to Pharmacy Service areas.
III. Policy: The Director of Pharmacy shall only issue a key for the Pharmacy service areas to
pharmacists.
IV. Responsibilities: It is the responsibility of the Director of Pharmacy to provide for key security to all
Pharmacy service areas.
(1) The Director of Pharmacy provides keys to the pharmacist that have been cut and coded by
UHB’s FM&D’s locksmith shop and are not keyed to the hospital master or sub-master keys.
(2) The pharmacist receiving the key shall sign and date a receipt for the key.
(3) The Director of Pharmacy shall provide an entry key to the Public Safety Security Office (A1-
339) to be used in an emergency.
(4) Combinations to controlled substance work safes are only given to the pharmacists.
(5) Combinations to the Main Stock Controlled Substance safe is given only to Pharmacy
Administration and the TH Senior pharmacists responsible for controlled substances.
(6) When a pharmacist leaves UHB service, the issue key shall be returned and the pharmacist
shall sign and date that the key was returned

226
One)
Yes No
227
Subject: Power Failure Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures to follow in the event of a power failure and/or non-activation of
emergency power so that medication integrity will not be compromised .
III. Policy: In the event of a power failure, a pharmacist shall be dispatched to all drug areas within the
hospital to determine the effects of the power failure on the storage provisions for drugs stored under
refrigeration and provide for interim alternate storage provisions during failure.
IV. Responsibilities: It is the responsibility of a pharmacist to inspect all nursing care/clinic areas to
insure proper storage requirements of drugs under refrigeration. It is the responsibility of the Director
of Pharmacy to provide for the operational needs of all Pharmacy services during a power failure
emergency.
(A) Nursing Care/Clinic Areas:
1. A pharmacist shall proceed to the Emergency Power Failure Box and break the seal.
2. A pharmacist shall remove a flashlight and the list of Nursing care/clinic areas where
medication is stored.
3. A pharmacist shall proceed to the Nursing care/clinic areas where drugs are stored and
ascertain the viability of the refrigerator storage for drugs.
4. If the refrigerator is operational (on emergency power) the pharmacist shall notify the
Assistant Director of Nursing for that unit that the refrigerator storage is viable.
5. If the refrigerator is not operational, the pharmacist shall inform the Assistant Director
of Nursing for the unit of this fact, and proceed to collect the refrigerated drugs, and store these drugs
in the Main Walk-In Refrigerator in the Main Pharmacy (ALL1-469) until the emergency is over.
228
6. After the power is restored, a pharmacist shall secure the Emergency Power Failure
Box.
(B) Intra-departmental:
1. Emergency overhead lights in the IPD Dispensing areas, the Pharmacy Director’s office
and the Drug Receiving area will go one once the power has failed.
2. All refrigerators and freezers in the Main Pharmacy and Satellite are on emergency
power.
3. All IV Lamina Airflow Hoods and Vertical Flow Class B Bio Safety Hoods are on
emergency power.
4. All Pharmacy personnel shall remain in or return to their assigned areas for
deployment as needed to assist during the power failure.
5. Pharmacists shall write all prescription labels as required.
6. The Director of Pharmacy shall create a command post for the emergency in his/her
office and if required, re-call staff members to address the needs of the hospital during the emergency.
7. The emergency light power packs shall immediately be energized at the entrance to the
Main Dispensing area, the OPD Dispensing area, and the Floor Stock Room areas.

CXII. Changes in regulatory or statutory laws or standards
CXIII. System failures/ changes
CXIV. Institutional/operational changes
One)
Yes No
229
No: ___CH. 24 SECT. F___
Subject: Authorized Signatures and Computer Page ____1__ of ____1__

Security

8/21/01

Department Manual
Patient Care Manual
AOD Manual
____________________________________________________________________________________
II. Purpose: See policy below.
III. Policy: A) Only the following signatures shall be authorized to execute or approve the specified
transactions:
Policy and Procedure Approval:

Nicholas Galeota
Donald Caracciola
Overtime Authorization and Payment:

Nicholas Galeota
Donald Caracciola
On Call/Recall Authorization and Payment:

Nicholas Galeota
Donald Caracciola
Personnel Transactions excluding promotions, salary upgrades, appointment renewal, or non-

renewal:
Nicholas Galeota
Donald Caracciola
Personnel Transactions including promotions, salary upgrades, appointment renewal or non-renewal

or non-renewal:
Nicholas Galeota
Donald Caracciola
Purchase Requisitions:
Nicholas Galeota
Donald Caracciola
Receiving Department Receipts:

Nicholas Galeota
Donald Caracciola
230
Larry Melisi
Authorization for Invoice Payment:

Nicholas Galeota
Donald Caracciola
Class I and II Controlled Substance DEA Order Form 222:

Nicholas Galeota
Donald Caracciola
Pharmacy and Therapeutic Committee Minutes and Agendas:

Nicholas Galeota
Donald Caracciola
Telephone Access Level Changes:

Nicholas Galeota
Donald Caracciola
Prescriptions and Dispensing Records:

All pharmacists (see Pharmacist Signature File)
B) Computer Security:
The following computer screens are only accessible to the authorized individuals indicated using their
personal ID numbers or codes and authorization access granted by the Director of Pharmacy:
All Pharmacy Screens:

Nicholas Galeota
Donald Caracciola
All Pharmacy Screens excluding AZ, A3, A5, BI, OO, 53, BQ
None
All other Pharmacy Screens included in THOMIS and Eagle, the Rxobot database (level access to be assigned
by the Director of Pharmacy), the free standing TPN, Oncology, and drug information pc’s:
Pharmacy Staff
IV. Responsibilities: It is the responsibility of the Director of Pharmacy to authorize use of an official
signature for Pharmacy transactions. It is the responsibility of the Director of Pharmacy to provide authority
level user ID’s into the Pharmacy computer system with an associated level of security.

CXV. Changes in regulatory or statutory laws or standards
CXVI. System failures/ changes
CXVII. Institutional/operational changes
231
One)
Yes No
Yes No
232
No: ___CH. 25
Subject: Infection Control Page ____1__ of ____4__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To prevent contamination of pharmaceuticals at the point of dispensing..
III. Policy: The Pharmacy Department functions as the starting point for the dispensing of medication in
the hospital and therefore plays a part in infection control in the hospital. To that end, all pharmacists
and Pharmacy staff will maintain all Pharmacy service areas in a manner consistent with infection
control as directed by legal authorities, advisory councils, and the hospital’s Infection Control Policy
and Procedure Manual under the authority of the Infection Control and Epidemiology service and the
Medical Staff’s Infection Control Committee.
IV. Responsibilities: It is the responsibility of the Director of Pharmacy to provide for key security to all
Pharmacy service areas.
(A) General housekeeping guidelines for maintaining cleanliness in all Pharmacy service areas:
1. The housekeeping department shall wipe down shelves each with disinfectant
detergent.
2. The lavatory shall be cleaned each day.
3. The Pharmacy shall be swept each day.
4. Garbage collection and disposal shall be carried out daily.
5. The entire Pharmacy shall be mopped with a cleansing solution and waxed at least
once a week.
6. Regular visits from the exterminators shall be carried out.
(B) Pharmacy Guidelines for Pharmacy staff:
1. Universal precautions shall be practices whenever the situation warrants.
2. All medication personnel shall wash their hands before handling medication.
233
3. Whenever possible, unit dose medication shall be provided, especially for injectable
solutions.
4. All equipment and glassware shall be cleaned before and after use.
5. All refrigerators shall be kept clean and under proper refrigeration temperatures.
6. Garbage pails shall be kept clean
7. Pharmacy counters shall be wiped down each day.
8. Expired drugs shall be removed from shelves and sent back to the manufacturer for
credit and segregated from the general inventory.
9. Oral medications returned form Nursing stations shall be discarded if not in unit dose
packaging.
10. Sterile distilled water for reconstituting oral suspensions shall be obtained from single
use containers.
11. All reconstituted oral antibiotic liquids shall contain an expiration date.
12. Any questions on infection control shall be answered by referring to the hospital’s
Infection Control Manual or by calling the Infection Control and Epidemiology Department at extension
1940.
(C) Sterile Compounding of Pharmaceuticals:
All hyper-alimentation fluids and cardioplegia solutions shall be prepared under a laminar flow
hood utilizing the following procedures:
1. The laminar flow workbench shall be located in an area which is clean, orderly, and free
from strong air currents. The filter shall be tested for integrity and wind velocity at least semi-annually
and whenever the hood is moved. A “DoP” smoke detector system shall be used to test for filter
integrity.
2. At the beginning of each workday, the beginning of each shift, and when spillage
occurs, the workbench surface shall be wiped thoroughly with a clean, lintless sponge dampened with
a suitable disinfectant such as 70% ethyl alcohol, isopropyl alcohol, or Chlorox® solution.
3. The blower shall be turned on each morning and operated continuously until the day’s
orders are filled.
4. Traffic in the area of the workbench shall be minimized and controlled.
5. Supplies entering the buffer area shall be isolated until they can be decontaminated by
removing the outer packaging. Outer cartons and packaging materials shall not be brought near the
workbench.
6. All supply items shall be examined for defects prior to being introduced into the aseptic
work area.
7. All supply items shall be examined for defects prior to being introduced into the aseptic
work area.
8. Personnel may enter the buffer area with street clothes or daily uniforms but shall not
approach the workbench. Before approaching the workbench, personnel shall thoroughly scrub
hands and arms and Hibliclens® or equivalent. A face mask shall be worn if the operator has facial
hair or an upper respiratory condition that promotes sneezing and coughing.
234
9. After proper introduction of supply items into the aseptic workbench, they shall be
arranged in a manner such that operations can take full advantage of the direction of laminar airflow.
Supply items within the workbench shall be limited to minimize clutter of the work area and provide
adequate space for critical operations. A clean path of HEPA filtered air shall be provided directly
from the filter to the critical work site. Therefore no objects shall be placed behind the critical work
site in a horizontal flow workbench such as outs. Also, all work shall be performed at least six (6)
inches within the hood to avoid drawing in contamination from the outside, and arms shall not be
moved in and out of the work area any more than shall be absolutely necessary.
10. All supply items shall be arranged so that the work flow will provide maximum
efficiency and order.
11. It shall be noted that the hands are antiseptically clean but sterile. Therefore, all
procedures are performed in a manner to minimize the risk of contact contaminated. For example, the
outside barrel of a syringe may be touched with the hands since it does not come in contact with the
solution, but the plunger or needed shall not be touched.
12. All rubber stoppers of vials and bottles and the neck of ampoules shall be cleaned with
70% alcohol and a non-linting sponge, prior to the introduction of the needle for removal or addition of
drugs.
13. Spraying of solutions on the workbench screen and filter shall be avoided. This may
cause cracking of the filter material or otherwise generate holes.
14. Medication orders shall be worked on one (1) at a time.\
15. After every admixture, the contents of the container shall be thoroughly mixed and then
shall be inspected for the presence of particulate matter of evidence of an incompatibility, e.g.,
precipitation.
16. If possible to minimize coring, use needles 22 gauge or smaller for making transfer of
additive.
17. Filtration of solutions to remove particulate matter is frequently necessary, particularly

where admixtures have been prepared. A small volume of solution may be filtered by attaching an
appropriate membrane filter to the end of a syringe, using the plunger force the liquid through the
filter. Note: To avoid rupture of the membrane, force shall be applied in one direction only through
the filter, unless the membrane is adequately supported on both sides.
18. The porosity of the appropriate membrane filter shall be determined by the objective of
the filtration. To remove particulate matter, a 1 micron porosity filter should be satisfactory. To
sterilize a solution, a 0.2 micron filter shall be required.
19. The complete preparation shall be provided with an appropriate tamper proof cap or
closure to assure the user that the integrity of the container has been maintained until the time of use.
20. Parenteral nutrition solutions shall be refrigerated at 4 Celsius and used within a 72-
hour period following preparation. No infusion bag shall hang for more than 24 hours.

VII. Attachments: Blood and Other Potentially Infectious Materials Exposure Control Plan; OSHA
Occupational Exposure to Blood borne Pathogens; IC Manual excerpt The Pharmacy Department and Its Role
in Infection Control
235
One)
Yes No
236
No: ___CH. 26___
Subject: The Pharmacy and Therapeutics Committee Page ____1__ of ____1__
Reviewed by: WILLIAM GERDES Implementation Date: __8/22/01___

Department Manual
Patient Care Manual
AOD Manual
____________________________________________________________________________________
III. Purpose: The Primary purposes of the Pharmacy and Therapeutics Committee are:
1. Advisory: The Committee recommends the adoption of, or assists in the formulation of,
policies regarding evaluation, selection, and therapeutic use of drugs in the hospital.
2. Educational: The Committee recommends the adoption of, or assists in the formulation of,
programs designed to meet the needs of the professional staff (physician, nurse, pharmacists, and
other healthcare-care practitioners) for complete current knowledge on matters related to drugs and
drug use).
3. Quality of Care Assessment: The Committee reviews adverse drug reaction reports and
incidents involving medication to determine if reaction reports and incidents involving medication to
determine if corrective actions or recommendations are necessary to a particular medical service or
other professional staff so as to improve patient care.
III. Policy: The Director of the Pharmacy shall sit as the Secretary of the Pharmacy & Therapeutics
Committee and, as such, shall prepare agendas, compile minutes, provide reviews of adverse drug
reactions or incident reports involving medication, present policies & procedures involving the use of
medications within the hospital review, addition, or revision, present proposals for drug utilizations
evaluations, reviews, investigational drug protocols, and present any information that affects the
distribution, storage, handling, administration, or clinical use of medication within the hospital.
Philosophy: The multiplicity of drugs available and the complexities surrounding their safe and
effective use make it necessary for hospitals to have an organized, sound program for maximizing
rational drugs use. The Pharmacy and Therapeutics Committee, is the organizational keystone and
standardization committee of this program. In making its decision on formulary additions the
Committee shall consider not only safety and efficacy of the drugs but also the drug’s potential to
cause adverse events, its addiction potential, and its involvement or potential involvement in sentinel
events
The Pharmacy and Therapeutic Committee is an advisory committee of the Medical Staff and serves as
the organizational line of communication between the Medical Staff and Pharmacy Department. This
committee is composed of physicians, pharmacists, and other healthcare professionals as well as
representatives from Hospital Administration, Risk Management and Hospital Quality Management and
237
Nursing, selected with the guidance of the Medical Staff. It is a policy-recommending body to the
Medical Staff and the administration of the hospital on matters related to the therapeutic use of drugs.
IV. Responsibilities: It is the responsibility of the Director of Pharmacy to coordinate the activities of the
Pharmacy and Therapeutics Committee through agendas, minutes, and official communications
representing the actions to be taken as follow-ups of recommended or directed determinations by the
Director of Pharmacy to provide minutes that include recommendations of the Pharmacy and
Therapeutics Committee to the Medical Board office for inclusion as items for action, if necessary, at
the Executive Committee of the Medical Board meeting held monthly.
(A) Organization and Operation:
The following shall apply:
(1) The Pharmacy and Therapeutics committee shall be composed of at least three physicians, a
pharmacist, a nurse, and an administrator. Committee members are appointed by the governing unit
or elected official of the Executive Committee of the Medical Staff. Members to the P&T Committee
sub-committees shall be appointed by the Chairperson of the P&T Committee (see attached).
(2) A chairperson from among the physician representatives shall be appointed. The Pharmacy
Director of UHB shall be designated as secretary.
(3) The Committee shall meet regularly at a minimum, ten times per year, and more often when
necessary.
(4) The Committee shall invite to its meetings persons within or outside the hospital who can
contribute specialize or unique knowledge.
(5) An agenda and supplementary materials (including minutes of the previous meeting) shall be
prepared by the secretary and submitted to the Committee members in sufficient time before
the meeting for them to review the material properly.
(6) Minutes of the Committee meetings shall be prepared by the secretary and maintained in the
permanent records of the hospital and the Pharmacy Department.
(7) Recommendations of the Committee shall presented to Medical Staff or its appropriate
committee for adoption or recommendation.
(8) Liaison with other hospital committees concerned with drug use, e.g., Infection Control, IRB,
shall be maintained.
(B) Function and Scope:
The basic organization of the hospital and Medication Staff determine the functions and scope of the
Pharmacy and Therapeutics Committee. The following is a list of committee functions:
(1) The Pharmacy and Therapeutics Committee shall serve in an advisory capacity to the medical
staff and hospital administration in all matters pertaining to the use of drugs (including investigational drugs).
(2) The Pharmacy and Therapeutics Committee shall develop a formulary of drugs accepted for
use in the hospital and provide for its constant revision. The selection of items to be included in the
formulary is based on objective evaluation of their relative therapeutic merits, safety, and cost. The
Committee shall minimize duplication of the same basic drug type, drug entity, or drug product.
238
(3) The Pharmacy and Therapeutics Committee shall establish programs and procedures that help
insure cost-effective drug therapy.
(4) The Pharmacy and Therapeutic Committee shall establish or plan suitable educational
programs for the hospital’s professional staff on matters related to drug use.
(5) The Pharmacy and Therapeutics Committee shall participate in quality assessment and
improvement activities related to distribution, administration, and use of medications.
(6) The Pharmacy and Therapeutics Committee shall review adverse drug reactions and incidents
involving medications in the hospital.
(7) The Pharmacy and Therapeutics Committee shall initiate or direct (or both) drug use review
and drug utilization evaluation programs and studies and review the results of such activities.
(8) The Pharmacy and Therapeutics Committee shall advise the Pharmacy in the implementation
of effective drug distribution and control procedures.
(9) The Pharmacy and Therapeutics Committee shall make recommendations concerning drugs
shall be stocked in hospital patient-care areas.

System failures/ changes
Institutional/operational changes
VII. Attachments: Flow Chart of P&T Drug Approval and Evaluation Process
One)
Yes No
Yes No
239
Subject: Requesting an Addition of a Drug to the Page ____1__ of ____2__

Formulary

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures for healthcare practitioners to follow when proposing drugs for
addition to the formulary.
III. Policy: Only drugs recommended for addition to the formulary by the Pharmacy and Therapeutics
Committee and approved by the Executive Committee of the Medical Board for addition to the
formulary shall be used in University Hospital at Brooklyn for patient care, with the exception of
investigational drugs used in a n investigational protocol approved by the IRB accompanies by a
patient informed consent.
IV. Responsibilities: It is the responsibility of the requesting physician to complete a formulary addition
kit and attend the scheduled Pharmacy and Therapeutics Committee meeting addressing the request
for presentation. It is the responsibility of the Director of Pharmacy to notify the requesting physician
of the Pharmacy and Therapeutics Committee and Executive Committee’s determinations and provide
for the acquirement of the drug for Pharmacy stock, if approved.
(1) When a physician wished to sponsor a drug for addition to UHB formulary, he/she shall first
obtain a copy of a formulary addition kit (see attached) from the Pharmacy Director’s office, Room ALL
1-469, extension 3115.
(2) The physician is required to complete the Request for Addition to the Formulary Form and
have it signed by the Department Chairperson.
(3) The physician is required to write drug utilization guidelines for the requested drug and
address those questions contained in the DUG portion of the formulary addition kit.
(4) The physician is required to append to the kit and article from a mainstream medical journal
concerning the use, advantage, or comparisons to other agents of the requested drug.
(5) The completed kit is submitted to the Director of Pharmacy, Room ALL 1-469, Box 36.
240
(6) The Director of Pharmacy shall schedule a review of the request at the next available Pharmacy
and Therapeutics Committee meeting, provided all of the required documentation is complete.
(7) The Director of Pharmacy shall call the requesting physician to invite him/her to the scheduled
meeting addressing the new request. At the meeting the physician shall present his/her case for
addition of the drug, defend their position against questioning from Pharmacy and Therapeutics
Committee members, and answer any questions addressed to the request.
(8) After presentation, the requesting physician shall leave and a vote and/or discussion shall
ensue concerning the request. (Note: a vote will not be taken unless a quorum of physicians is
present.)
(9) The Director of Pharmacy shall notify the requesting physician of the committee’s
determination in writing.
(10) Non-formulary requests for drugs shall be acquired following the procedures in Chapter 10,
Procedure C.
(11) If approved for addition by the Executive Committee meeting of the Medical Board.
(12) If approved for addition by the Executive Committee of the Medical Board, the Director of
Pharmacy shall make arrangements to obtain the drug for stock in the Pharmacy.

CXVIII. Changes in regulatory or statutory laws or standards
CXIX. System failures/ changes
CXX. Institutional/operational changes
VII. Attachments: Request for Addition to the Formulary Form, Drug Utilization Guidelines Format
One)
Yes No
241
No: ___CH. 27
Subject: Administration of Drugs in University Hospital Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To define classes of healthcare practitioners who may administer drugs within the hospital.
III. Policy: Only medically qualified and legally licensed/registered individuals shall administer drugs
pursuant to a valid written order from a practitioner within the hospital according to hospital policies
and procedures, interdisciplinary protocols and manufacturers/FDA guidelines. Further, only
medication labeled by the hospital Pharmacy shall be administered. The medications administered
shall be charted only by the licensed individual who prepares the medication for administration this
insuring patient safety and fostering quality patient care.
IV. Responsibilities: Department of Nursing has authority over the Nursing staff, i.e., RN’s and LPN’s, to
insure that all licensed Nursing personnel who administer medications have met all legal, training, and
competency requirements. The Executive Committee and Medical Board through the Rules and
Regulations of the Medical and Dental Staff have responsibility for physician activities relating to
patient care. The patient is the responsibility of the attending physician or his designee.
1. NURSING:
(A) Registered Nurses:
(1) Registered nursed may add the following types of parenteral medications to infusions
as ordered: antibiotics, electrolytes, vitamins, etc.
(2) Registered nurses may add oxytocin to infusions for ante-partum Obstetrics in
designated areas
(3) Registered nurses may add narcotics or barbiturates to infusions to control chronic
uncontrollable pain as ordered by an M.D.
(4) All RN’s shall be responsible for administering parenteral and non-parenteral
medications.
(5) RN's with credentialing or an I.V. team member may start an infusion.
242
(B) Licensed Practical Nurse:
(1) LPN’s may administer heparin via heparin lock and “IV” piggyback medications only
after required training has been completed.
2. MEDICAL STAFF:
(1) Physicians with clinical privileges, including authorized house staff, may administer all
medications, parenteral and non-parenteral dosage forms.
(2) Physicians may titrate I.V. solutions of oxytocics, narcotics, and barbiturates.
(3) Physicians may administer investigational drugs.
(4) Physicians may administer IV push drugs and intrathecal injections.
(5) Physicians may start I.V. infusions.
3. PATIENT POPULATIONS ONLY SUBSEQUENT TP PHYSICIAN’S ORDER:
(1) Follow Chapter 4, Section J, “Policy on Self Medication by Patients”.
(2) Only patients deemed competent shall self administer drugs on units such as NS 82
where an active self medication program exists, under present rules, under strict procedures, and using the
proper infusion device, e.g., PCA pump.
(3) A patient may self-administer I.V. medications at rates prescribed by the physician
programmed into the infusion pump by the registered nurse.

CXXI. Changes in regulatory or statutory laws or standards
CXXII. System failures/ changes
CXXIII. Institutional/operational changes
VII. Attachments: None
One)
Yes No
243
No: CH. 27 Sect. A
Subject: Medication Administration Schedule Page ____1__ of ____1__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
III. Policy: Medication shall be administered on scheduled times for routine medications or on a schedule
prescribed by an authorized practitioner.
IV. Responsibilities: It is the responsibility of a pharmacist to dispense medication only if defined dosing
schedules (frequency) and durations are indicated by the prescriber. It is the responsibility of the
nurse to administer medication to patients based on the prescriber directions and according to the
Department of Nursing’s approved schedule.
(1) Upon written prescription order, the scheduled times for administration medications of drugs
shall follow these intervals:
b.i.d Twice a day 10 A.M. – 6P.M.
h.s. Bedtime 10P.M.
Daily Every day 10A.M.
q.h. Every hour
q.i.d Four times a day 10 A.M. – 2P.M. – 6P.M. – 10P.M.
Every other day Every other day 10 A.M.
q2h Every two hours 10 A.M. – 12 Noon – 2P.M.

4 P.M. – 6P.M. – 8:P.M.
10 P.M. – 12 A.M. – 2A.M.
4 A.M. – 6A.M. – 8A.M.
q4h Every four hours 10 A.M. – 2P.M. – 6P.M.

10 P.M. – 2A.M. – 6A.M.
q6h Every six hours 6P.M. – 12 Noon
244
6P.M. – 12 A.M.
q8h Every eight hours 6 A.M. – 2 P.M. – 10P.M.
q12h Every twelve hours 10 A.M. – 10 P.M.
t.i.d. Three times a day 10 A.M. – 2P.M. – 6P.M.
a.c. Half hour before meal Depends on meal schedule
p.c. Half hour after meal Depends on meal schedule
Subject to change by specific order of the physician.
IT SHOULD BE NOTED THAT ANY ORDER CONTAINING AN ABBREVIATION FROM THE HOSPITAL’S LIST OF
UNACCEPTABLE ABBREVIATIONS SHOULD NOT BE PICKED UP BY NURSING PERSONNEL (See attached).

CXXIV. Changes in regulatory or statutory laws or standards
CXXV. System failures/ changes
CXXVI. Institutional/operational changes
VII. Attachments: Unacceptable Abbreviation and Symbol List
One)
Yes No
245
No: CH. 28
Subject: Drug Samples on University Hospital at Page ____1__ of ____2__

Brooklyn Property

__12/5/07
Supersedes : 8/28/01_

Department Manual
Patient Care Manual
AOD Manual
_____________________________________________________________________________
_________
I. Purpose: To control the integrity of any medication utilized in patient care in the
IPD or OPD care areas.
III. Policy: The use and distribution by drug company representatives as well as the
dispensing and administration by the professional staff at UHB of drug samples
and complimentary packages of medication is not permitted on UHB property for
patient use. The use of paper vouchers is allowed.
IV. Responsibilities: The pharmacist shall dispense only Executive Committee

approved drugs or IRB approved investigational drugs for in-patient or out-patient
use. Sales representatives shall not distribute drug samples within the hospital.
Physicians shall not dispense or administer drug samples to patients within the
hospital’s patient care areas.
(1) All drugs to be used within UHB shall be sponsored by a physician for inclusion to
the formulary at a Pharmacy and Therapeutics Committee meetings. Applications for
formulary addition can be obtained from the Director of Pharmacy in Room ALL1-469.
Once the application is complete with all attachments, the Director of Pharmacy shall
place the request on a P&T agenda. The P&T Committee shall hear the sponsor’s
presentation and review supporting documentation. If the Committee determines that the
drug warrants addition to the formulary (Due to its benefit to UHB patients, its
effectiveness and superiority to other agents on formulary, its safety recommended for
addition to the formulary to the Executive Committee and, if approved, shall be purchased
and stocked by the Pharmacy. The Pharmacy shall dispense only those drugs
recommended by the P&T Committee and approved by the Executive Committee or
investigational drugs approved by the IRB for use within UHB.

VII. Attachments: Letter to Pharmaceutical Manufacturing Industry
One)
12/5/07 Yes No
Yes No
TO: All Our Colleagues Representing the Pharmaceutical
Manufacturing Industry
FROM: Nicholas Galeota, M.S., R.Ph.

Director of Pharmacy
RE: Drug Samples within University Hospital of Brooklyn
DATE: December 5, 2007
This memo is being given to you to seek your help and assistance
to insure the safety of our patients. We recognize your tireless
efforts to keep our healthcare community well informed about new
drugs and research for the same. We also recognize that without
your pharmaceutical products, the work of our medical staff would
not be as successful as it has been.
Because of safety and regulatory concerns,

Downstate has banned the distribution of
pharmaceutical samples. We seek your support and
assistance in this regard, and request that you do not
distribute pharmaceutical samples on our property.
Your cooperation will be greatly appreciated
We also respectfully suggest that you utilize a voucher system to
provide access to initial supplies of your product line. In this way
there is no question about the integrity of the drug and the patient
can take this voucher to their community Pharmacy to process the
drug without charge.
If your company does not provide this type of service, I would urge
you to discuss it with your leadership as a strong effort on your part
to support all hospitals’ mission of medication safety.
Your compliance with this request is sincerely appreciated.

No: CH. 29 Sect. A
Subject: Policy Statement on the Compounding of Page ____1__ of ____2__

Sterile Parenteral Admixtures

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
III. Policy: The Pharmacy Department at UHB compounds and dispenses parenteral admixtures by
licensed pharmacists in response to physician orders under aseptic techniques and conditions to
prevent exposure of the patient population to hospital-acquired infections from contaminated
solutions to sub-therapeutic or toxic therapies from physical incompatibilities or combinations, and to
outdated or improperly stored products.
The labeling of parenteral admixtures prepared by the Pharmacy Department shall meet all JCAHO,
NYS DOH, NYS Education Department and ASHP Practice Standards so as to clearly inform the
healthcare professional administering the preparation as to the correct demographics and prescribed
requirements for the patient to insure safety and quality patient care.
The professional staff of the Pharmacy Department provides the following sterile parenteral
preparations.
 Irrigation solutions with additive, e.g., cardioplegia

 Central and peripheral parenteral nutrition solutions
 Chemotherapy solutions utilizing cyto-toxic drug admixtures
 Potassium Chloride infusions in mini-bags or LVP’s
 Peritoneal dialysis solution mixtures
 PCA narcotic infusions
 Epidural infusions
 Anti-fungal infusions, e.g., liposomal amphotericin B
 TPA injection for catheter clearance
 Through the Pharmacy’s Parenteral Admixture Lab (Rm ALL1-516) any and all parenteral drugs
shall be admixed, compounded, labeled, and dispensed by a pharmacist
 IV. Responsibilities: It is the responsibility of a pharmacist to mix parenteral drugs for use
by Nursing when treating patients.
248
One)
Yes No
249
No: CH. 29 Sect. B
Subject: Staffing Responsibilities and Supervision in Page ____1__ of ____2__

The Parenteral Compounding Laboratories

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide for adequate, competent staffing and supervision within the Pharmacy’s sterile
compounding labs.
III. Policy: The sterile parenteral nutrition compounding labs are supervised by TH Senior Pharmacists
who report to the Associate Director of Pharmacy. The lab is staffed by full-time pharmacists and
pharmacy assistants, Monday thru Fridays, inclusive, from 8:30A.M. to 5:00P.M. The Parenteral
Admixture Lab is operational from 7:00 A.M. to 6 :00 P.M. Mondays through Fridays. The sterile
compounding areas are located within the Main Pharmacy, at Rm All1-516, Rm ALL1-514A, Rm A6-401,
and Rm A2-481.
IV. Responsibilities: The responsibilities of the supervisory staff are:
• Education and professional certification of staff

• Maintenance of all records and statistics
• Supervision of all staff activities relating to technique, infection control, labeling, storage,
distribution, housekeeping, and removal of waste after each procedure
• Maintenance of adequate supplies of drugs, compounding equipment, and infection control
materials
• Maintenance of lamina flow hood certification every 6 months
• Maintenance of computer compounding equipment, programs, an auxiliary compounding
equipment, e.g., Auto-Mix®, Micro-Mix®
• Supervision and instruction of undergraduate students
• Supervising the sterility testing of solutions by the Microbiology lab and quantitative testing of
neonate preparations by the Chemistry Lab
• Maintain quality assessment measures and procedures for all practices in the lab
• Report directly to the Director of Pharmacy concerning problems, opportunities to improve, or
patient incidents involving the laboratory, including quantitative errors and microbiological
contamination problems.
The responsibility of the pharmacist is to compound and label the solution accurately according to
the specific stages for each respective component procedure involved in the compounding
procedure.
The responsibilities of the Pharmacy assistants are:
• Stock the lab with all necessary drugs, solutions, and equipment daily
250
• Turn hoods on one (1) hour prior to commencement of the compounding procedure and
replace unused drugs on storage shelves
• Assist the pharmacist in non-compounding procedure
• Remove all regulated medical waste at the end of the day’s activities for housekeeping
disposal
• Deliver preparations to the respective nursing unite, as needed
• Assist in maintaining all files for each procedure

One)
Yes No
251
No: CH. 29 Sect. C 1
Subject: Working under the Lamina Air-Flow Hood Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide guidance for Pharmacy staff in the utility of sterile lamina flow compounding
hoods so as to maintain a sterile field for compounding and sterile techniques when compounding.
III. Policy: All procedures to prepare intravenous parenteral nutrition solutions shall be conducted under
a lamina vertical air-flow hood using aseptic techniques.
(1) All staff members shall scrub up to the elbows with Hibliclens® or equivalent germicidal cleaner and
utilize a hand/nail scrub brush.
(2) All staff members working under the lamina air-flow hood shall wear cover-up gowns over their street
clothes and cover their hair with a cap. Gloves shall be worn when handling ampoules or when the
compounder feels that an extra measure of asepsis is necessary. NOTE: the protective garments shall not be
worn outside the lab and shall be discarded in the appropriate receptacle. Rings and jewelry shall not be
worn while working under the hood.
(3) All interior surfaces of the lamina air-flow shall be cleaned before each procedure with 70% isopropyl
alcohol and a final wash shall be done at the end of the day. Wipe downs shall be conducted in the event of a
spill or breakage.
(4) The staff shall turn on the lamina air-flow hood one (1) hour prior to the commencement of the day’s
work.
(5) The staff shall wear masks in the event of respiratory problems, such as allergies, which might cause
particle contamination from a sneeze or cough.
(6) The staff shall wash down all bottles, vials, ampoules, and bags with 70% isopropyl alcohol prior to
manipulation.
252
(7) All work done under the lamina air-flow hood shall be performed six (6) inches in front of the rear
HEPA filter.
(8) Large bottles or IV bags shall not be placed next to the Hepa filter so that sufficient air flow and
exchange can be maintained.
(9) Removal of hands outside the lamina air flow hood, the staff shall be a minimal, if at all, so as to avoid
any compromise to the sterile field.
(10) When working under the lamina air-flow hood, the staff shall utilize a smooth technique so that no
disruption of air-flow shall be created.
(11) The staff shall not be permitted to eat or drink within any sterile parenteral admixture lab.

One)
Yes No
253
Subject: Syringe Manipulations Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide guidance for Pharmacy staff when utilizing syringes to introduce medications
into parenteral drug delivery containers.
III. Policy: Syringes shall be utilized only by the pharmacist staff to introduce medication into base
parenteral solutions in an aseptic fashion, with regard to patient safety, and disposed of according to
accepted practices for regulated medical waste.
IV. Responsibilities: It is the responsibility of the compounding pharmacist to utilize syringes in a safe,
aseptic manner to insure the safety of the patient and to dispose of the used syringes in a fashion to
insure the safety of housekeeping staff and in accordance with all Federal, State, City, OSHA, EPA,
and CDC regulations and/or recommendations on medical waste disposal.
(1) Inspect the outer packaging of the syringe to ascertain that the package ha snot been broken
resulting in a breach of sterility
(2) Choose the appropriate size-volume syringe to complete the medication transfer correctly.
(3) Remove the syringe from the outer packaging, place in the lamina air-flow hood, but leave the
hub cover on until it is necessary to place a needle on the syringe.
(4) Choose a needle with the appropriate bore so as to minimize coring if a vial medication must
be accessed.
(5) Remove the outer wrapping of the needle and attach the needle to the hub of the syringe
leaving the needle sheath over the needle until the syringe shall be used.
(6) Swab the neck of the vial, ampoule, or IV bag/bottle with 70% isopropyl alcohol before inserting
the needle and syringe.
(7) Remove the needle sheath on the needle and pull the plunger back without
touching the inside of the plunger to the desired volume mark of the solution to be withdrawn.
(8) Insert the needle into a vial at a 45 degree angle and slowly push the needle through rubber
stopper. When withdrawing solution is injected into the base solution.
254
(10) Withdraw a volume slightly greater than desired, invert the syringe and cover the needle with a
sterile gauge pad. Slowly depress the plunger to expel any air or excess solution.
(11) The withdrawn solution shall be immediately introduced into the base solution and then the
base solution shall be shaken to insure homogeneity and the presence of evidence of physical
incompatibilities
(12) If the withdrawn solution cannot be added immediately label the syringe and leave it in the
lamina air-flow hood.
(13) When the syringe is no longer needed, dispose of the needle and syringe in its entirety in the
appropriate regulated medical waste container (hard plastic molded covered sharps container).

One)
Yes No
255
Subject: Reconstitution and Transfer of a Drug to a Page ____1__ of ____2__

Parenteral Solution
Approved by: CONSTANCE SHAMES, M.D Distribution: Administrative Manual

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide guidance for the sterile transfer of medications into parenteral solutions.
III. Policy: All drugs in sterile, powder/crystal non-preservative form requiring reconstitution with a sterile
diluent shall be diluted aseptically and immediately added to the base parenteral solution.
IV. Responsibilities: It is the responsibility of the compounding pharmacist to reconstitute drugs required
for the parenteral admixture according to the manufacturer’s recommendations and introduce the drug
in an aseptic manner into the base solution.
(1) Follow all steps for syringe manipulation as stated in Chapter 29., Sect. C, Sub-section 2, Procedures 1
through 13, inclusive.
(2) Inject the diluent into the medication vial/ampoule.
(3) Hold the vial/ampoule in an upright position between the palms of the hands and rotate the
vial/ampoule until all of the powder/crystals has been dissolved.
(4) Wipe the top of the vial with an alcohol swab before attempting
(5) Inject the same volume of air as the volume of drug that is desired to be withdrawn. This step is not
necessary when withdrawing reconstituting drug from an ampoule.
(6) Do not touch the inside of the plunger as it is pushed out of the vial as the drug fills the syringe.
(7) Remove the syringe from the vial and cover the needle with a sterile gauze while expelling air or
excess drug from the syringe.
(8) Immediately introduce the drug into the base solution and mix the solution so as to insure
homogeneity and to observe for physical incompatibilities

256
One)
Yes No
257
No: CH. 29 Sect. D
Subject: Preparation of the Sterile Parenteral Admixture Page ____1__ of ____3__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish sterile technique procedures used by pharmacists when compounding

parenteral admixtures.
III. Policy: All sterile parenteral admixtures shall be compounded only by licensed pharmacists trained
and annually in-serviced in the appropriate techniques required to safely prepare the prescribed
admixture.
IV. Responsibilities: It is the responsibility of a pharmacist to compound the parenteral solution. It is the
responsibility of the Pharmacy assistant to assist the pharmacist in all non-compounding activities. It
is the responsibility of a messenger or Pharmacy staff member to deliver the product to the Nursing
Station. It is the responsibility of a registered Nurse to receive the parenteral products.
(1) Mondays through Fridays, inclusive, a pharmacist shall collect all parenteral drug orders from the
Pediatric and Neonatal Nursing stations in the morning before 10:00A.M. Adult orders will be sent directly to
the TPN lab after the Parenteral Nutrition Service physician evaluates the patient’s needs. Cyto-toxic drug
admixture orders and general parenteral drug admixtures are sent directly to these labs or faxed to this lab.
(2) The pharmacist shall review the prescribed order before leaving the Nursing station or review received
orders before compounding procedures are started so that any ambiguities or errors can be corrected by the
prescribing physician.
(3) The pharmacist shall bring the NCR copy of the order to the TPN laboratory for processing.
(4) The pharmacist shall first compare the order against the patient’s allergy profile, secondly, check
dosage propriety and physical compatibility of the prescribed ingredients, and thirdly, check that the route of
administration is appropriate for the concentrations prescribed by the physician.
(5) The pharmacist shall make all dosage calculations based on the parenteral bag volume size or syringe
volume size prescribed by the physician.
(6) The Pharmacy assistant shall gather all ingredients requested by the pharmacists for the respective
preparation and prepare a log sheet for the procedure (see attached).
258
(7) The demographic data on the patient is then entered in to the computer based patient profile system in
the lab by a pharmacist or by a Pharmacy assistant checked by the pharmacist.
(8) The volumes of drugs required to satisfy the physician’s order are programmed into the Auto-Mix ®
machine or the Micro-Mix® machine only by a pharmacist when preparing parenteral nutrition admixtures.
(9) The Pharmacy assistant shall create the IV procedure log sheet recording the product used, the
manufacturer of the product, and the lot number of the product used, the manufacturer of the product, the
volume of the drug used in the procedure, and the lot number of the product used. The expiration dates of the
products used in the preparation shall be maintained by the Material’s Manager.
(10) After the admixture is completed by the pharmacist, the Pharmacy assistant shall initiate a print order
to the computer to generate a label for the respective preparation in the TPN lab.
(11) The label for all parenteral admixtures shall contain the following information: (see attached sample)
• Patient’s name and location
• Bag or bottle prescription number
• Name and amount of drugs added
• Flow rate of administration
• Name and volume of basic parenteral solutions
• Date and time of the additions
• Name, initials, or identifying code of the pharmacist who prepared the mixture
• Supplemental instructions
• Expiration date of the compounded solution NOTE: The expiration data of all solutions shall not
exceed 72 hours unless stability data is available to substantiate a longer expiration. Products stable
for less than 72 hours will be marked according to the product information or manufacturer’s
recommendations.
(12) The final label shall be checked by a pharmacist before affixing to the bag or bottle (if bottle or bag is
prepared, invert the label). Auxiliary labels shall be affixed at this time.
(13) The finished parenteral nutrition products shall be placed paper bag or box and cyto-toxic drug
admixture shall be placed in an appropriately labeled bag and then into a delivery container clearly labeled
with the Nursing station destination and a red label to refrigerate for parenteral nutrition admixtures.
(14) A nurse’s receipt shall be made indicating the Nursing Station, the patients’ names, date, and the
number of products for each patient. For cyto-toxic drug admixtures, a delivery log is created for the Nurse to
sign upon delivery of preparation.
(15) The Pharmacy assistant shall prepare a pickup entry in the messenger pick-up book for parenteral
nutrition admixtures indicating date, Nursing Station, and number of bottles or bags to be picked up.
(16) The Pharmacy assistant shall call the floor messenger for a pickup. Cyto-toxic drug admixtures shall
only be delivered by Pharmacy personnel.
(17) The messenger shall sign the pickup book before receiving the products of parenteral nutrition
admixtures.
(18) The messenger or Pharmacy staff member shall deliver the products to the appropriate Nursing
Station and only a registered nurse shall sign for the delivery and place the products immediately into the
refrigerator, if required.
(19) The messenger shall return the Nurse’s receipt to the TPN laboratory and the Pharmacy staff member
shall return the delivery log to the Oncology Admixture Lab.
• Reasons for Revision:

259
VII. Attachments: Hyperalimentation Log Sheet; Sample Labels
One)
Yes No
260
No: ___CH. 29 SECT. E___
Subject: Discontinued Parenteral Preparations Page ____1__ of ____1__
Reviewed by: WILLIAM GERDES Implementation Date: __8/3/01___

Department Manual
Patient Care Manual
AOD Manual
____________________________________________________________________________________
IV. Purpose: To establish procedures for the safe disposal of discontinued/expired parenteral solutions.
III. Policy: All parenteral preparations prepared by the Pharmacy that are discontinued by a physician’s
order shall be removed from the Nursing Station and returned to the Main Pharmacy for proper
destruction or disposition.
IV. Responsibilities: It is the responsibility of a pharmacist or Pharmacy assistant/aide to remove and

destroy all un-used or discontinued IV solutions. It is the responsibility of a registered Nurse to inform
the admixture labs of discontinuation orders from a physician or changes in orders that may influence
the number of preparations to be made by the Pharmacy, e.g., change in flow rates.
(1) During the daily rounds to pick-up new orders or discontinued drugs, the pharmacist or
Pharmacy assistant /aide shall check the IV solution refrigerator or the drug return bin on the
Nursing station for un-used or discontinued preparations and remove them for return to the
Main Pharmacy.
(2) During the course of the day if a nurse calls the admixture labs to inform the lab that a
order has been discontinued by a physician, a Pharmacy assistant/aide shall be dispatched to
the Nursing Station to retrieve all unused preparations.
(3) The returned products shall be destroyed according to regulated medication waste
procedures or cyto-toxic waste procedures.
(4) The patient’s account shall be credited for all un-used products.
(5) The patient’s computer profile shall be updated accordingly.
261
(6) During the monthly Nursing station inspections, the inspecting pharmacist shall double
check the parenteral solutions overlooked.

One)
Yes No
Yes No
262
No: CH. 29 Sect. F
Subject: Sterility and Quantitative Testing of Parenteral Page ____1__ of ____3__

Solutions

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures to verify the qualitative and quantitative testing of parenteral
admixtures.
III. Policy: The Associate Director of Pharmacy shall implement, collect data, evaluate results, and take
corrective actions if necessary in procedures, personnel training, or equipment
maintenance/upgrading based on regularly schedule sterility and quantitative testing on compounded
parenteral solutions.
IV. Responsibilities: It is the responsibility of the Director of Pharmacy to maintain and evaluate results of
the microbiological sterility and quantitative testing program for parenteral solutions compounded by
pharmacists and take appropriate corrective actions as required. It is the responsibility of the
compounding pharmacist to maintain sterile technique and care in the preparation of these solutions
so as to insure the safety and care in the preparation of these solutions so as to insure the safety of all
parenteral solutions compounded for patients at UHB.
Sterility Testing:
(1) Random sterility testing on compounded solutions shall be conducted on a weekly
basis.
(2) The sample shall be obtained by puncturing the entry port of the solution with a needle
attached to a Vacutainer ® collection tube. A minimum of a 5ml sample is required.
(3) The Vacutainer® collection tube label shall contain the following information:
(a) The name of the compounding pharmacist

(b) The date of the sample was taken
(c) The name of the patient for which the solution was prescribed
(d) The prescription number of the solution from which the sample was
obtained
(4) The information contained on the Vacutainer® collection tube label shall be recorded in
the TPN Sterility Sample Log Book.
263
(5) The sample shall be sent to the hospital’s Clinical Laboratory for microbiology sterility
testing.
(6) The Director of Pharmacy receives the lab result slip and after review gives the lab slip
to a pharmacist who records the results in the TPN Sterility Sample Log Book.
(7) The pharmacist files the lab result slip in a chronological file for 1 year.
(8) If the results indicate the presence of micro-organisms, the Director of Pharmacy shall
conduct an investigation to determine the Director of Pharmacy shall conduct an investigation
to determine the source of the contamination, immediately recover all un-used solutions from
the Nursing stations, inform the physician responsible for the patient, and inform the Hospital
Epidemiologist of the steps taken to find the source of the contamination and the results of
his/her investigation.
(9) The Director of Pharmacy shall instruct a pharmacist to immediately prepare a new
solution and dispatch a Pharmacy assistant to the Nursing station to replace the patient’s
solution.
(10) If the source of the contamination is attributed to pharmacist technique, the Associate
Director shall remove the pharmacist from the lab rotation schedule and provide an in-service
to re-affirm the proper procedures for infection control and sterile technique.
(11) Pharmacists identified as sources of microbiological contamination, shall have their

techniques and solutions re-evaluated on a weekly basis for a period of 1 month after the
inservicing has been completed.
(12) The Director of Pharmacy shall conduct appropriate Quality Assessment studies on all
procedures in the lab on a annual basis.
Quantitative Testing:
(1) Quantitative testing of all preparations mixed for the pediatric and neonatal Nursing
units shall be tested for Na+, K”, and glucose.
(2) The compounding pharmacist shall take a sample of the TPN preparation.
(3) The sample shall be sent to the Clinical Labs along with a completed Hyperalimentation
Solution Quality Control Form at 3:00p.m. (see attached form).
(4) The Clinical labs shall perform the necessary tests to insure that a safe and accurate
quantity of these agents is present in the preparation. This form will be signed by the lab
technician and his/her supervisor indicating that a safe an accurate level of these agents is
present. If the solution doesn’t test safe and accurate, this shall be indicated on the form.
(5) The form shall be sent back to the TPN lab where, if ascertained as safe and accurate, a
pharmacist shall sign the form to indicate that he has reviewed the results and take form to
indicate that he has reviewed the results and take responsibility for releasing the preparation
to the Nursing unit.
(6) NOTE WELL: If the sample solution tests unsafe or inaccurate, the TPN pharmacist
shall re-mix the solution and submit samples for testing as outlined in steps 1 through 5,
inclusive, of the Quantitative Testing section of this procedure. No preparation shall be
released until it has passed these testing procedures.
(7) Records of these test trials shall be maintained in the Pharmacy’s TPN lab for a period
of one (1) year.

264
VII. Attachments: Hyperalimentation Solution Quality Control Form; Acceptable Ranges of Analytes
One)
Yes No
265
No: ___CH. 29 Sect. G
Subject: Procedures and Addendums for the Operation Page ____1__ of ____1__
Of the Auto-mix®, Micro-mix®, and Laboratory
Computer Systems

Department Manual
Patient Care Manual
AOD Manual

______________________________________________________________________________________
I. Purpose: Provide for technical instructions for Pharmacy staff for the operation of automated
compounding equipment within the TPN Lab.
III. Policy: All pharmacists with responsibilities for compounding parenteral admixture solutions shall be
trained by the Associate Director of Pharmacy in the use of automated technology used to mix,
compound, and preserve data in the parenteral admixture compounding laboratories.
IV. Responsibilities: It is the responsibility of the Associate Director of Pharmacy to train and maintain a
safe and effective level of education in the use of automated technology for all pharmacists
responsible for compounding parenteral admixture solutions.
V. Procedures/Guidelines: See the appended procedural instructions.

CXXVII. Changes in regulatory or statutory laws or standards
CXXVIII. System failures/ changes
CXXIX. Institutional/operational changes
VII. Attachments: Automix 3+3 addendums 1 &2; TPN Laboratory Computer Procedures
One)
Yes No
266
No: ___CH. 29 Sect. H
Subject: Physician Order Forms for Parenteral Page ____1__ of ____2__

Admixture Solutions

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Identify approved forms that prescribers may use to order TPN solutions.
III. Policy: Physicians requesting parenteral nutrition or cyto-toxic drug admixture solutions for patients
shall order the appropriate solutions using the service approved physician order form for Pediatrics
and Neonatology or the P&T Committee/Medical Records Committee form for adult parenteral nutrition
preparations or cyto-toxic drug admixtures.
IV. Responsibilities: It is the responsibility of the prescribing physician to use only the approved order
forms to request these solutions and provide the required information to direct the pharmacist in
compounding and labeling and the Nurse in administration of the solution. It is the responsibility of
the Nurse to sing (pick-up) the order form in the patient’s chart. It is the responsibility of the
pharmacist to maintain all records according to legal requirements.
(1) The attached form shall be used by the appropriate service of the origin and completed
in their entirety.
(2) The Nurse responsible for the patient shall sign for the order before releasing it for
compounding to the parenteral admixture lab.
(3) All completed orders shall be maintained by the Pharmacy for a period of 5 years.

CXXX. Changes in regulatory or statutory laws or standards
CXXXI. System failures/ changes
CXXXII. Institutional/operational changes
VII. Attachments: Neonate, Pediatric, Adult TPN Order Forms
267
One)
Yes No
268
No: ___CH. 29 Sect. I
Subject: Cyto-toxic Drug Admixtures Page ____1__ of ____6__

__8/30/01__

Department
Manual
Patient Care
Manual
AOD Manual
_____________________________________________________________________________
_________
I. Purpose: To establish safe procedures for the admixing/handling of the high-risk

cyotoxic (chemotherapy) drugs including safe waste management.
III. Policy: Any medication labeled for an in-patient from a Nursing station shall not be
given by a nurse or other medical professional to a patient upon discharge.
(1) The accuracy and appropriateness of the drug and dose.

(2) The sterility of the parenteral agents.
(3) The safety of personnel preparing the chemotherapy.
(4) The proper disposal of chemotherapy waste with increasing awareness of
environmental health hazards.
IV. Responsibilities: It is the responsibility of an authorized practitioner responsible

for the patient to write ambulatory prescriptions for the patient upon discharge. It
is the responsibility of the nurse responsible for the patient to return all unused in-
patient labeled medication to the Pharmacy upon discharge of the patient.
V. Procedures/Guidelines: The procedural steps to comply with the policy are broken
down into specific subjects as follows:
(1) All professional staff shall receive training before working with anti-
neoplastic agents and pass a certification exam.
(2) Access to the compounding lab and hood shall be limited to
authorized and trained personnel.
(3) Personnel shall be rotate through the area on an as needed basis to

minimize exposure.
(4) Personnel working with these agents shall be observed on a regular

basis by supervisory personnel to insure compliance with accepted safety
standards.
(5) Staff working with cytotoxic agents shall be identified to University

Hospital’s Heath Service.
(6) Staff working directly with mixing chemotherapeutic drugs shall

have an annual CBC, differential, and SMA-18 performed in addition to the
annual Health Service screening Physical examination and other lab test
shall be done if the Physical examination and other lab tests shall be done
if the Health Service physician feels these are indicated.
(7) According to OSHA guidelines, staff shall be fully informed of the

potential reproductive hazard, and, id they so request, staff members who
are pregnant, breast-feeding, attempting to conceive, have a history of
cancer or other condition that may be aggravated by or limit the staff
members ability to safely mix cyto-toxic drugs shall be transferred to
comparable duties that do not involve handling cyto-toxic drugs.
NOTE: On the basis of available evidence, it seems reasonable to assume

that if appropriate procedures are followed, and proper equipment and
protection are provided, reproductive hazards shall be reduced.
(8) Acute exposure must be documented in an official Employee

Accident Investigation Report and referred immediately to the Employee
Health Service for treatment.
ENVIRONMENTAL PROTECTION:
(1) The preparation of all cyto-toxic agents shall be done in a vertical

air flow Class II, Type B externally vented biological safety cabinet within
the negative pressure, self contained IV Admixture Lab (Room ALL1-516).
(2) The biological safety cabinet shall be certified by an independent

scientific medical instrumentation agency twice (2) annually or whenever
the cabinets are moved.
(3) The blower on the cabinet shall remain on at all times.
(4) The viewing screen of the cabinet shall be engaged at the

recommended opening during any preparation.
(5) Aseptic technique as stated in Chapter 29, Section C, Sub-sections

1 through 3, inclusive, shall be employed.
(6) No other admixtures are to be prepared in the safety cabinet

designated for chemo admixture.
OPERATOR PROTECTION:
(1) Disposable latex gloves shall be worn for procedures involving anti-
neoplastic agents.
(2) Double gloving is recommended, with the outside glove being

changed at least every hour.
a) When using “Chemo Safety” gloves it is not necessary to
double glove.
(3) In the event of a spill or if the gloves become wet due to leakage of
medication, both pairs of gloves shall be discarded and placed in the
chemotherapy waste container.
(4) Disposable protective barrier garments shall be worn during the

compounding procedure. These gowns shall have a closed front, long
sleeves and closed (elastic or knit) cuffs.
(5) Goggles and face masks shall be provided for operator protection.
(6) All contaminated or used garments and gloves shall be discarded in

the hazardous waste containers and must not be worn outside of the cyto-
toxic preparation area of the admixture lab.
(7) If the double glove method is used, the outer gloves shall be
changed hourly. Should the gloves or gowns become wet from
chemotherapeutic agents, they shall be changed immediately.
(8) A plastic backed absorbent drape (barrier field) shall be placed on

the work surface of the biological safety cabinet. This barrier field shall be
changed whenever spillage occurs and at the end of each production
sequence. The barrier shall be discarded in the hazardous waste
container.
(9) The pharmacist shall preplan the work area so that everything
needed for the complete procedure should be placed in the cabinet before
starting the procedure so that nothing passes in or out through the air
barrier until the procedure is completed.
(10) The materials needed for the procedure shall be arranged in a

logical manner, such that clean and contaminated materials are
segregated, preferably on opposite sides of the compounding pharmacist.
(11) When all of the materials needed for the procedure are in place
within the cabinet, the access door shall be shut. This restricted opening
is necessary for proper operation of the biological safety cabinet.
(12) The unit shall operate for at least 3 minutes after closing the access
door before proceeding to mix the drugs to allow purging of the air space.
(13) All procedures shall be performed on the solid work surface of the
cabinet and not on the screened surface.
(14) Only syringes and IV sets with luer-lock fittings shall be used in
preparing and dispensing chemotherapeutic admixtures.
(15) The pharmacist shall work as far as possible into the cabinet but
not less than six (6) inches behind the viewing screen.
(16) A no point in time shall the airflow be blocked in any fashion.
(17) Aseptic technique shall be used at all times.
(18) Using an alcohol swab, all bag ports, vial covers, and ampoule
necks shall be wiped down.
(19) A chemo-pin or a Cytogard ® shall be used with vials.
(20) A sterile alcohol soaked sponge shall be carefully wrapped around

the needle and vial top during withdrawal from the vial.
(21) When reconstitution of a vial is necessary, gently swirl the vial to

dissolve the medication.
(22) When using a syringe, always pull back the plunger before pushing
it forward when entering a vial. This will reduce aerosolization of vial
contents.
(23) When ejecting air bubbles from a syringe, use an alcohol soaked
sponge to cover the needle tip.
(24) External surfaces of syringes shall be rinsed or wiped clean of any

drug contamination.
(25) The filled needle less syringes shall be capped using syringe caps
and labeled.
(26) Before opening an ampoule, be sure that the top of the ampoule if
free of any liquid.
(27) Place a sterile alcohol soaked sponge around the neck of the
ampoule before opening. This shall contain aerosol produced and to
prevent fingers from being lacerated by broken glass.
(28) Use a filter straw or filter needle attached to a syringe to draw up

contents of an ampoule.
(29) The ampoule shall be discarded as cyto-toxic hazardous waste.
(30) Chemotherapeutic agents shall be dispensed in the following

dosage forms: pre-filled syringe, IV piggyback minibag for infusion, or
large volume parenteral for infusion.
(31) After preparation, the ports shall be wiped down with an alcohol
swab and the sides/tops of vials used in preparation are also to be wiped
down.
(32) Syringes and tubing’s shall be primed under the hood.
(33) All final labeled products shall be placed in a polyethylene, zip

locked bag and sealed. This shall be placed in a second, outer bag marked
“CHEMOTHERAPY DRUG, TOXIC, DISPOSE OF AS BIOHAZARD.”
(34) All doses shall be delivered to the Nursing care areas in a plastic
cooler container by Pharmacy Technicians
(35) A spill kit shall accompany the delivery at all times.
(36) All chemotherapeutic preparations in bags are to be primed with

naked solution using Baxter # 2C55015 tubing or equivalent.
LABELING OF CHEMOTHERAPEUTIC DRUGS:
Each label for IVPB and syringes shall contain the following information:
• Name of patient
• Location of patient
• Date
• Drug Name
• Dose (x mg in y ml)
• Date and time of the additions
• Name of base solution and total volume (based on Mfg. 5% overfill)
• Date, time, and route of administration
• Compounding pharmacists initials or identification
• Expiration date
• Prescribing physician
Labels on outer bags:

• Caution sticker and any other accessory labels.
• Nursing unit and name of patient.
Handling of Oncovin ® (vincristine):

• NOT FOR INTRATHECAL USE
• DO NOT REMOVE COVER UNTIL TIME OF INJECTION
PROFILING AND RECORDING:
(1) Upon receipt of a chemo order to be mixed, the pharmacist

responsible shall be notified.
(2) The pharmacist shall then prepare a patient profile.
(3) When patients receive medication for more than 1 day, this profile
shall serve as a daily work sheet and each profile shall be reviewed each
morning by the pharmacist for doses due each day.
(4) A separate log for each day’s preparations shall be maintained.
(5) When the preparations are delivered to the Nursing Station, a

registered nurse shall sign for the medication and indicate the time
received and the form or log shall be returned to the Pharmacy.
(6) The completed orders shall be charged to the patient account by a
pharmacy technician on a daily basis.
(7) All calculations of dosage shall be double calculated on the back of

the prescription and verified by another pharmacist.
(8) A sample label shall be affixed to the back of the prescription.
DISPOSAL:
(1) Contaminated needles and syringes shall be disposed of intact to

prevent aerosol generation from clipping needles. Special containers shall
be supplies for this waste.
(2) Contaminated gloves, paper, gowns, etc., shall be disposed in the

waste container marked “Hazardous Waste”.
(3) Anti-neoplastic drug waste shall be transported according to the

institutional procedures for contaminated waste.
(4) Needles shall NEVER be recapped.
CLEANING OF HOOD WORK SURFACE:
Utilizing the Surface Safe® product (comprised of two pads labeled #1, containing a 2%
hypochlorite solution, #2, containing a thiosulfate solution, the following procedure is
followed:
1) Use pad #1 to wipe down all surfaces of the hood, allowing

the solution to remain on the surfaces for thirty (30)
seconds
2) Use pad #2 (after waiting 30 seconds) to wipe down all
surfaces of the hood, allowing the solution to remain on the
surfaces for thirty (30) seconds
3) Use the solution labeled H20 orange to wipe down all
surfaces of the hood allowing the solution to remain on the
surface for three (3) minutes
4) Use the alcohol spray bottle on all surfaces of the hood and
wipe with gauze
SPILL CONTROL:
(1) In the event of a spill of a chemotherapeutic agent, the user

department shall contact the Housekeeping Service at ext. 2997.
(2) All participants shall use the items contained in the chemo spill kit
to contain and clean the spill.
(3) The area of the spill shall be mopped with Clorox® and rinsed with
water 3 times.
(4) All materials used shall be discarded in the hazardous waste

containers.
(5) Personnel shall wash hands with Betadine® scrub for at least three
(3) minutes.
(6) The lab shall be cleaned each night before closing.
MEDICAL STAFF:
(1) Only those physicians specifically authorized to prescribed

chemotherapeutic agents shall write for these medications.
(2) Physicians shall include body surface area on all orders to facilitate
ease of re-calculations for double-checking.
(3) Physicians shall indicate the order the patient’s age, diagnosis,
height, weight in kilograms, locations, and sex.
(4) Orders for chemotherapeutic agents shall be received in the

additive lab at least one (1) hour before administration time and no later
than 4:00P.M. on the scheduled day for administration.
(5) Medication to be administered before 9:00 a.m. requires receipt of

the orders in the Main Pharmacy by 9:00 P.M. on the day preceding the
scheduled administration day.
(6) Orders written for chemotherapeutic agents that are not received in
the additive lab by 4:00P.M. on the day scheduled for administration WILL
NOT be compounded by Pharmacy personnel.
(7) Agents whose stability is less than three (3) hours, e.g.,
mechlorethamine (15 minutes) and investigational agents whose stability is
unknown, shall not be compounded by Pharmacy personnel.
(8) On Saturdays and Sundays, if the product is stable and the patient
is on a continuation order, the product shall be mixed on Fridays and
delivered to the Nursing stations. If the drug is not stable, the physician
may mix the drug and can use the biological safety hood in the additive lab.
It is preferred that a pharmacist mix the drugs, however.
SPECIAL PRECAUTIONS:
(1) Eating, drinking, chewing gum or storage of food in, around or near
the hood is prohibited. Each of these are sources of ingestion of the
chemotherapeutic agent.
(2) Spills inside the hood shall be cleaned immediately with Clorox ®
and rinsed with copious amounts of water.
NEUPOGEN® ORDERS:
(1) Blood work (Complete Blood Counts) is done on Mondays and

Fridays.
(2) Neupogen® shall be sent to the Nursing units on the following

basis:
No: ___CH. 30
Subject: Dispensing of Albumin Solutions Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures to be followed by pharmacists for the safe storage and dispensing
of the blood derivative albumin.
III. Policy: All albumin products shall be dispensed from the Pharmacy service areas by a pharmacist on
the written prescription order of a physician or other legally licensed professional with prescriptive
authority.
IV. Responsibilities: It is the responsibility of a physician or other legally authorized professional to write
a medication order for albumin products. It is the responsibility of a pharmacist to dispense the medication
upon presentation of a complete prescription order and record all of the necessary information about the
product as required by NYS DOH laws.
(A) A physician or those individuals legally authorized to have prescription authority under
the NYS laws granted by the NYS Education Department shall write a complete prescription
order for albumin products in the physician’s medication order section of the patient’s medical
record.
(B) The Nurse assigned to the patient shall pick up the order and give the order to the
Nursing station clerk for subsequent delivery of the order via messenger or Pharmacy
Technician to the Main Pharmacy.
(C ) Upon receipt of the prescription, all procedures for dispensing medication according to
Chapter 4, Section A, Procedures e –1
(D) The Pharmacy shall record the following information required by the NYS DOH on the
Albumin Monitoring Log:
1) Date dispensed
2) Patient name
3) Location of patient
4) Signature of dispenser
5) Strength and volume of albumin dispensed
276
6) Manufacturer
7) Quantity dispensed
8) Lot number of the product
(E) For those requests for albumin from Cardio-Thoracic Surgery:
1) All albumin products shall be dispensed from the OR Satellite Pharmacy

directly to the physician or a member of the Perfusion Team.
2) The physician or a member of the perfusion team shall sign for these products
on an administration record given to him/her by the pharmacist.
3) The administration record and any unused albumin shall be returned to the OR
Satellite Pharmacy after the surgical procedure is completed by a member of the
perfusion team.

CXXXIII. Changes in regulatory or statutory laws or standards
CXXXIV. System failures/ changes
CXXXV. Institutional/operational changes
One)
Yes No
277
No: ___CH. 31
Subject: Dosing of Cardiac Medications: Nitrate and Page ____1__ of ____2__

Other Anti-Anginals

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures for utilizing anti-anginal drugs to insure a nitrate free period and at
the same time insuring that the patient is covered during this period..
III. Policy: In order to obtain the maximum therapeutic response and at the same time cover the patient
through 24 hour periods during his/her stay in the hospital, the prescribing physician shall prescribed
nitrates and other anti-anginal medications according to a rigid dosing schedule based on the
pharmacokinetic properties of the drug.
IV. Responsibilities: It is the responsibility of the prescribing physician to prescribe nitrates and other
anti-anginal medication according to specific dosing schedules for efficacy and safety. It is the
responsibility of the registered Nurse not to pick up incorrectly written orders for these classes of
drugs. It is the responsibility of a pharmacist not to fill incorrectly written orders for these classes of
drugs and contact the physician for correction if an order is received in the Pharmacy.
(1) A prescribing physician shall write prescriptions for nitrates and other anti-anginals
according to the following schedules for the respective pharmacologic class:
I. Nitrates:
A) Oral: In order to minimize the risks of increased susceptibility to ischemic
episodes and at the same time allow for a nitrate free interval to prevent
tolerance, it is recommended that oral nitrates shall be prescribed at with a
nitrate free interval of 10 to 12 hours, e.g. 8:00A.M., 2:00P.M., and 9:00P.M.
and the frequency of “TID” not be used. The frequency of q8 hours is
acceptable.
B) Topical Patches: with the same considerations in mind as stated in

Procedure #1-I, section A, nitrate patches shall be prescribed by the physician
to be applied at 8:00A.M. and removed at 10:00P.M. through a 24 hour period
during the patient’s stay in the hospital.
a) If extenuating circumstances exist that require the patch medication to remain on the
patient for 24 hours, the physician shall state on the comments sections of the medication order and
document these reasons in the progress notes of the patient’s medical record.
278
b) The nurse applying the patch to the patient shall write the date and time of application
on the patch before applying the patch.
II. Oral Anti-Anginals:

A) The prescribing physician shall prescribe oral anti-anginal medication,
e.g., Procardia ®, Cardizem®, on an equal dosing interval schedule, such as
q6 or q8 hours.
B) If another schedule is prescribed, the physician shall indicate on

the prescription the times, e.g., 8:00A.M., 2:00P.M., etc., in
frequency section of the medication order and document in the
comments section and in the progress notes the reason for this
schedule.
(2) The prescribing physician shall not use BID, TID, or QID to indicate a dosing frequency
on the medication order nor shall a Nurse pick up an order written in this fashion for nitrates
and other anti-anginal drugs.
(3) If a medication order is received by the Pharmacy that is written in a manner other than
as stated in this Procedure, Sections 1a. or 2a. and b., the pharmacist shall not dispense the
medication until the physician is contacted, the correct dosing scheduled is determined, and a
new medication order is written.
(4) A pharmacist shall label all medication orders for nitrates and other anti-anginal
medication according to these procedures.

CXXXVI. Changes in regulatory or statutory laws or standards
CXXXVII. System failures/ changes
CXXXVIII. Institutional/operational changes
One)
Yes No
279
No: ___CH. 32
Subject: Pharmaceutical Education for Patients and Page ____1__ of ____2__

Family Members

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To provide direction to pharmacists when providing medication counseling to patients or

family members.
III. Policy: The Pharmacy Department at UHB shall participate in the facilitation of the patient’s
understanding of his/her health care status by providing education to the patient and/or family
members concerning the safe and effective use of medication interventions prescribed by a qualified
practitioner.
IV. Responsibilities: It is the responsibility of the Pharmacy Department to provide approved printed
patient leaflets to the Nursing staff to be used at discharge counseling of patients. It is the
responsibility of a pharmacist to counsel all patient receiving outpatient prescription services at the
OPD Pharmacy.
(1) The Pharmacy Department provides to all Nursing stations a series of approved printed
patient drug information leaflets from the Micromedex® Patient Leaflet database reference
source. The information in these references provide the following information:
• The pharmacological class of the drug

• The trade and generic name of the drug
• The dosage forms and strengths of the drug
• An explanation of pharmacological effects
• An explanation of directions on how to take the drug with cautionary statements
• An explanation of how to recognize and how to respond to the side effects and adverse
reactions while taking the drug
• Directions on how to avoid drug-food interactions
(2) The references shall be distributed by the Nursing staff to patients and/or family
members during the discharge planning interview conducted for the patient.
280
NOTE: Language translations are available through the hospital contracted translator telephone line or
through a hospital translator.
(3) A Nursing staff member can contact the Main Pharmacy, ext. 2854 or ext. 2856, to
obtain the assistance of a pharmacist when counseling a discharge patient.
(4) When a discharge patient o ran ambulatory care patient presents prescriptions at the
OPD Pharmacy Department, the patient shall be counseled by a pharmacist concerning his/her
prescription medication.
(5) The patient will sign in the documents of Pharmacy that the counseling was conducted.
The patient has the right to refuse counseling and also indicates this by his/her signature.
(6) Upon receiving the completed prescription order, the patient also receives from
the pharmacist’s a computer printout concerning each medication received. This printout
contains written information and support for the patient concerning the proper use of the
medication, directions for use, indications of side effects and their management, drug-food
interactions, and how to optimize the therapeutic effect of the drug.

CXXXIX. Changes in regulatory or statutory laws or standards
CXL. System failures/ changes
CXLI. Institutional/operational changes
One)
Yes No
281
No: ___CH. 33
Subject: TPA Injection for Catheter Clearance Page ____1__ of ____2__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: To establish procedures for pharmacists to follow when compounding TPA for catheter
clearance when industrial shortages occur.
III. Policy: Due to the ongoing nation availability problems with urokinase injection, the Pharmacy
Department shall extemporaneously prepare, store, and dispense TPA injection for catheter clearance.
IV. Responsibilities: It is the responsibility of an authorized prescriber to write the medication order for
TPA catheter Clearance on the physician’s order form. It is the responsibility of a pharmacist to
prepare the alteplase syringe in the appropriate dosage concentration and to store the syringe in a
frozen state until dispensed. The pharmacist’s procedure shall yield 100 doses of this preparation. It
is the responsibility of the Nurse to thaw the syringe prior to installation into the catheter.
PHYSICIAN:
(1) The prescribing physician who determines that catheter Clearance, a pharmacist shall
dispense a pre-filled frozen syringe labeled as follows:
Alteplase 0.5mg/1ml
0.5mg alteplase = 30,000 units urokinase activity
Preparation Date:
Good for 1 month from Preparation Date in Freezer
(2) Preparation of this syringe shall be done by a pharmacist in the following manner:
a) The pharmacist shall reconstitute a 50mg alteplase (TPA) vial with 50ml of sterile
water.
b) The pharmacist shall let this solution set until the foaming has subsided.
c) The pharmacist shall take a 25oml sterile evacuated bottle and
d) The pharmacist shall remove the contents of the TPA vial from Step
e) The pharmacist shall then add an additional 50ml of sterile water for injection to
this container.
282
f) This final volume shall be 100ml and the dilution shall yield a final concentration of
0.5mg/1ml of alteplase.
g) The pharmacist shall withdraw 1ml (0.5mg) of this solution into a 3ml syringe and
seal the syringe with a sterile cap.
h) The pharmacist shall label the syringe as stated above and place the pre-filled
syringes into the freezer for storage.
NURSE:
(1) The Nurse shall thaw the syringe by leaving the syringe at room temperature. The
thawed syringe is stable for eight (8) hours.
(2) The syringe contents may be diluted with normal saline to a sufficient quantity to fill
the lumen of the catheter in which it shall be used.

CXLII. Changes in regulatory or statutory laws or standards
CXLIII. System failures/ changes
CXLIV. Institutional/operational changes
One)
Yes No
283
No: CH. 34
Subject: Management of the Pyxis® Medication Page ____1__ of ____1__

Dispensing Cabinets

HELEN PRUSKI
Reviewed by: WILLIAM GERDES Approval Date: 10/10/06
Supersedes: 1/2/02
____________________________
Approved by: CONSTANCE SHAMES, M.D. Department Manual
_____________________________ Patient Care Manual
AOD Manual
_____________________________
Issued by: P&T Committee
______________________________________________________________________________________
I. Purpose:
To describe staff responsibilities and to provide guidelines relating to the operation of the Automated
Medication Dispensing Machine.
II. Definition(s):
Pharmacy and Nursing Services may use the Automated Dispensing Machine System (henceforth known as
Station) as an administration and charging system for the following types of medications:
1) All Controlled Substances

2. Stat PAR level medications (medications required for first dose emergency
administration)
3. First doses and missing doses
4. All floor stocks in the PYXIS
The existing manual of controlled substance cabinet will be operational for storage and usage of
controlled substances that are not included in PYXIS.
III. Policy:
The Department’s of Pharmacy and Nursing shall work co-operatively to maintain, operate, and manage the
®
Pyxis medication dispensing cabinets
Pharmacist, pharmacy technicians, nursing, and physicians will have the responsibilities described below in
the procedure and guidelines.
284
i. Procedures/Guidelines:
AUTHORIZED ACCESS:
1. The Pharmacy department leadership establishes privileges for all non-temporary access (lasting > 1 day)
codes. These ID’s will be entered and maintained by the appropriate Pharmacy System Manager. It is
recommended that all passwords should be from 3 to 6 alphanumeric characters. The password may
contain both letters and numbers and should not be the same as the user ID. Any user with access to the
Station may change his/her password if needed.
2. All user ID’s will be issued with an initial temporary password. The user must immediately access the
Station and follow the prompts to change the temporary password to a confidential, permanent password.
Once the user has established his/her password, the user will be prompted at the station only to register
his/her Biometric ID (finger print). The user will register his/her Biometric ID by scanning one finger four
times. In the event that the Biometric ID system is down, the users will revert to using their passwords.
3. All requested additions, deletions or changes to permanent access ID’s must be (submitted in writing) and
implemented by the Pharmacy System Manager, or his/her designee. If a nurse is discharged from UHB,
a Unit Head Nurse, or their designee must notify (in writing) the Pharmacy system Manager within 24
hours of discharge so that their access privileges can be removed from the system. Periodic reports may
also be printed out by Pharmacy System Manager, or his/her designee as a second check to remove past
employees.
4. Short term Agency nurses, will be issued a temporary access ID and password by the Unit Head Nurse or
his/her designee. This temporary ID and password shall expire 14 hours after issuing. The nurse shall
follow the same procedure for registering his/her Biometric ID.
Long term Agency nurses, will have permanent Station privileges:
a. Station Login/Witness Function
b. Access to Non-Controlled Substances
c. Station System Report Access
5. All Staff Nurses, Nurse Managers, and Charge Nurses have the following Station privileges:
a. Station Login/Witness Function
c. Access to Controlled Substances
d. Station System Report Access and
e. Station Temporary User Privileges (This privilege is reserved to the nurse manager his/her designee)
6. Selected Physicians (Anesthesiologists) privileges:

a. Station login/Witness Function
c. Access to Selected Controlled Substances
d. Station System Report Access
MEDICATION REMOVAL FROM PYXIS
1. Medication is removed at the station by selecting the Remove Medications option on the main menu and
following the instructions on the screen.
2. The nurse must verify the inventory count when removing selected medication from the Station.
3. Upon completion of each transaction, a transaction slip can be generated and printed at the Station. This
slip is not a legal document. The nurse may use it for charting purposes or to verify a patient’s ID when
giving the medication. This transaction slip can be discarded.
4. The MedStation is intended for STAT doses, first doses, missing doses, controlled substances, as-needed
(PRN) doses and some floor stock medications. All orders shall be faxed to pharmacy for review. Before
removal of medication from the MedStation, a pharmacist reviews all prescriptions or medication orders
unless
a) a licensed independent practitioner controls the ordering, preparation, and administration of the
medication or
285
b) there is an urgent situation in which the resulting delay would harm the patient, including situations
in which the patient experiences a sudden change in clinical status (e.g., new onset of nausea).
5. For STAT orders, the nurse shall fax the medication order to the pharmacy for review. The nurse will then
call the pharmacy for a verbal verification of the order. If the order is verified as correct and complete, the
nurse will inform the pharmacist of the number of doses that will be taken from Pyxis (to prevent
dispensing a duplicate doses). The pharmacist shall then process the order, note the number of doses the
nurse plans to take, and provide subsequent doses of medication, if necessary.
6. For FIRST dose orders, the nurse shall fax the medication orders to pharmacy for review and processing.
If the dose is urgently needed, the nurse shall follow the procedure for a STAT order.
7. Orders for PRN doses of medications shall also be faxed to the pharmacy for review. The nurse may then
retrieve medications from Pyxis. If necessary, PRN medications shall be dispensed from the pharmacy.
8. Missing doses may be removed from Pyxis after review of medication orders by a pharmacist. However,
the Pyxis cabinet should not be used for routine retrieval of missing doses of medication.
9. If a dose is missing after more than one nursing shift from the time the order was acknowledged by a
nurse, the order should be faxed to the pharmacy. The nurse shall then call the pharmacist to review and
process the order or to identify unresolved problems with the order (e.g., medication error, non-formulary
medication, order not received in the pharmacy).
10. Orders for controlled substances shall be faxed to the pharmacy for review and profiling. The nurse may
then retrieve controlled substances from the Pyxis. For controlled substances not stored in Pyxis, see
procedure outlined under, “Obtaining Medications That Are Not in Pyxis.”
OBTAINING MEDICATIONS THAT ARE NOT IN PYXIS
1. If a medication order is written for a controlled substance that is not available in PYXIS (after 4pm,
weekend or holidays):
a. Assistant Director of Nursing/designee places the order with the Pharmacy that indicates the unit,
his/her name and title and name and title of RN picking up the order
b. Drugs are picked up by RN with identification badge after presenting the physician order and
completing the required Pharmacy records.
c. The drugs and narcotic sheets are returned to the unit and secured according to policy:
• Narcotics and controlled drugs are kept in a double locked cabinet at all times
• The keys to the cabinet are never to be taken off the unit /are kept in the possession of a UHB
licensed Registered Nurse (who has completed orientation at all time)
• The Assistant Director of Nursing /designee on each shift assigns a Registered Nurse and a relief
Registered Nurse responsibility for the narcotic keys
• Controlled drugs are counted at the beginning of each tour by the off-going and on-coming
assigned RN’s (12-hour shift-7a.m. and 7:30p.m., 8 hour shift-7:30am, 3:30pm., and 11:45 pm
Mixed shifts-7:30am. and 7:30p.m.)
• All nurses needing controlled drugs must confer with the RN assigned to carry keys. Removal and
documentation is done in the presence of the assigned RN.
• Wastage must be witnessed and countersigned by assigned RN
• All controlled drug discrepancies are reported to the Assistant Director of Nursing and investigated
immediately
d. Completed narcotic sheets should be returned back to pharmacy immediately
2. If a medication order is written for a non-controlled substance that is not available in PYXIS, pharmacy will
process the order and provide medication
3. Any additional medication (controlled or non-controlled) recommended for inclusion to the PYXIS machine
by a Nursing supervisor or the Medical Director of the ED shall be referred (in writing) to the Pharmacy
System Manager or his/her designee for implementation.
ADMINISTRATION OF MEDICATIONS OBTAINED FROM PYXIS
286
1. Nurse will check orders and compare to Physician Order Sheet and Medication Records prior to
administration
2. Administer Pharmacy approved medications after checking the following:

a. Patient’s allergy history (MAR/PYXIS)
b. Purpose/therapeutic action
c. Dosage
d. Side/adverse effects
e. Method and frequency
f. Storage
e. Resource information (Micromedex, Lexi-Comp)
ENTERING PATIENT INFORMATION

1. The patient’s name should appear on the Station census list. This information is obtained via an interface
with the UHB admission, discharge and transfer patient care system.
2. If the patient is in the unit but not listed on ADT, complete the following steps to add a new patient:
a. Select Add Patient (This patient stays in the system 6 hours)
b. Enter the patient’s last name, select Enter to go to the next field
c. Enter the patient’s first name, select Enter to go to the next field
d. Enter patient’s admission number
3. The patient ID field will automatically be assigned once the ADT has been received. After adding a new
patient to the station, the nurse can access the patient’s account by selecting Remove Meds.
RETURNING MEDICATIONS
1. A narcotic medication removed from the station in its original package and not administered to the patient
will be returned to the Station Return Bin. This allows the patient to be credited for the medication. To
return the medication to the return bin, select the Procedures option on the Main Menu and select the
Return option. Follow the instructions on the screen return the medication. Two nurses will be required to
witness and to document the return of a controlled substance
2. An unscheduled medication removed from the Station in its original package and not administered to the
patient will be returned to Station Return Bin. This allows the patient to be credited for the medication. To
return the medication, select the Procedures option on the Main Menu and select the Return option.
Follow the instructions on the screen to return the medication.
3. If the medication package is not intact and an un-used controlled substance for example in tubex form
follow the procedure below (WASTING MEDICATIONS) for wasting medications.
4. Items too large to fit in the Pyxis internal Return Bin will be placed in the external bins picked up by
pharmacy personnel. If the return is a narcotic, it should be credited by the patient’s name in the Pyxis
and returned to existing manual controlled substance cabinet. Two nurses will be required to witness and
document return of controlled substances.
WASTING MEDICATIONS
1. Medication wastes are defined as all or part of a medication that is not in its original sealed package and
not administered to a patient as well as un-used controlled substances.
2. If all or part of a controlled substance originally taken from the Station has been wasted, it will be
documented at the Station by using the Waste option under Procedures. Two nurses will be required to
witness and document waste of controlled substances.
3. Any part of wasted controlled substance can be documented at the time of removal from Pyxis, or after the
administration within 32 hours of transaction when patient entered via hospital admission or 6 hours if
entered manually
NARCOTIC INVENTORY
287
1. Controlled drugs are counted at the beginning of tour II by the off-going and on-coming assigned RN’s
Mondays, Wednesdays, and Fridays.
2. All controlled substance access will require mandatory blind count
3. If discrepancy is discovered, follow UHB policy on discrepancies
DISCREPANCIES
1. When the user’s entered count of medication at the Station differs from the displayed count for that
medication, a discrepancy exists. All narcotic (meds classified as II through V) discrepancies are logged
and can be printed out at the Station. All stock medication discrepancies are logged, but are then
automatically resolved and sent to the Console. Unresolved narcotic discrepancy information remains on
the Station for seven days.
2. Any narcotic discrepancy discovered should be reported immediately to the nurse in charge.
3. To ensure controlled substance discrepancies are resolved not later than at the end of each shift, the
charge nurse must print a discrepancy report. The charge nurse should notify all staff involved of any
unresolved discrepancies. The procedure for printing a discrepancy report is:
a. Select Report Menu from the Screen.
b. Select Discrepancies to print the report
4. A narcotic discrepancy should be resolved at the time of discovery or at the change of shift. A narcotic
discrepancy is resolved between the user changing the count and the user with previous access. The
charge nurse must print a discrepancy report at the end of each shift
5. Once resolution is established, the involved users will use the Resolve Discrepancy function from the
Procedures menu to attach an electronic explanation for the discrepancy. The procedure for resolving
discrepancies on the PYXIS is as follows:
a. Select Procedures
b. Select Resolve Discrepancy
c. Advance page to the discrepancy of the perspective nurses involved
d. Select the appropriate response from predefined list of resolutions if none of the reasons are
appropriate, select other and type in the reason for the discrepancy, a witness is necessary to
document resolution of the discrepancy, the witness will be prompted to enter user ID
6. If the discrepancy cannot be resolved, The Unit Head Nurse must be informed. The Charge Nurse should
notify all staff involved of any unresolved discrepancies. A University Hospital Brooklyn Patient Incident
Report (UH-025) will be filled out. The referral carbon copy shall be forwarded to Pharmacy.
7. Pharmacy will review the Discrepancy Report for valid explanations and any discrepancies that may need
further investigation. Pharmacy will follow-up with the Unit Head Nurse.
DOCUMENTATION
1. Electronic signature authorization has been approved by the State of New York. At the end of each shift it
is recommended that each nurse print an “Activity Report” and review it for verification of all activity during
his/her shift, to ensure accurate documentation.
2. To print the controlled substance Activity Report the nurse should:

a. Enter his/her ID and the Biometric ID in PYXIS
b. Choose Reports Menu
c. Choose My Activities
d. Press Next button until All Classes is highlighted
e. Choose print report
3. Discrepancies should be resolved as soon as they are discovered. In the event an unresolved discrepancy
is discovered during production of an activity report, the nurse should notify the Charge Nurse and resolve
the discrepancy.
288
STOCK REPLENISHMENT
1. The Pharmacy will be responsible for maintaining adequate inventory of all medications in the Station.
2. Inventory levels will be checked periodically. Pharmacy staff will refill the medications that are recorded as
low inventory.
3. Pharmacy personnel will empty the return bin.
4. The Pharmacy personnel will replenish the controlled substance stock. A nurse and pharmacy personnel
will do inventory on refilled controlled medications.
5. Pharmacist will verify Narcotic quantity removed from main pharmacy safe vs. what is refilled into Pyxis on
Nursing Stations.
STOCK AND INVENTORY LEVEL CHANGE
1. Any change to the stock or inventory levels will be requested in writing by the unit head nurse and
discussed with the Pharmacy System Manager.
EMPTYING THE RETURN BIN
1. Pharmacy personnel are responsible for emptying the return bin.
PROBLEM-SOLVING
1. If a problem arises that requires manual opening of MedStation in the back, an access key will be in the
possession of the Pharmacy System Manager or his or her designee. If the problem cannot be resolved by
referring to the Station Reference Guide the nurse may call the PYXIS 800 service number found on the
Station for additional assistance.
POWER OUTAGE/EMERGENCY PROCEDURES
1. The station is plugged into the emergency power system and should remain operational
2. If it becomes necessary to manually open the Station for medication access, the Pharmacist System
Manager or his/her designee will be notified. The Pharmacist System Manager or his/her designee will
have access to the keys. If it is necessary to have a Pyxis service representative available to repair the
Station, a pharmacist or Pharmacy personnel will remain with the repair person at the Station at all times.
3. PYXIS will be called in the event of a software or hardware problem and will plan and coordinate the
resolution to the problem. Pharmacy will make this call if the Pharmacy is unable to resolve the issue at
the Console. Nursing may also call if it appears to be hardware issue or a localized problem, but they
should notify the Pharmacist System Manager or his/her designee of the call.
4. In the event a controlled substance cannot be added to the PYXIS it should be placed in the controlled
substance cabinet on the unit and inventoried by manual system. The Pharmacist System Manager or
his/her designee will “Load” the new medication to the station as soon as the power outage/emergency is
resolved.
289
REPORTS
1. The Unit Head Nurse may request special reports from the Pharmacy manager. Examples of these reports
are:
a. Medication Removal-generates a report on the activities that have occurred for a specified medication
beyond 32 hours
b. Activities by Nurse- generates a report on the activities that a specific nurse has done beyond 32
hours
c. Activities by Witness-- generates a report on the activities of a specific witness has done beyond 32
hours
d. Discrepancies –generates report on any discrepancies that have occurred. Discrepancies can be
printed on the unit for 1 month period
2. The Station will store information for 32 hours. The Console will store information for 31 days. All data is
archived to a disk
3. Pharmacy will generate and distribute to Nursing Units “User modification Report- an effective security
assurance tool, ensures that all temporary users added were appropriate.
4. Pharmacy generates monthly report on:

a. Control Substance wastage variance
b. Medication error summary report
c. Monitoring Medication Safety in Dispensing with prompts to alert to potential problems
d. Outdate inventory report to verify that all controlled drugs that were outdated were logged (witness
signature necessary) in a binder
MAINTENACE OF REMOTE REFRIGERATION MONITORS
1. Refrigerator temperature is monitored by Smart Remote Managers (SRM) and has a LED readout outside
the refrigerator on the Nursing units that interfaces with the PYXIS console. The temperatures are set in
Fahrenheit measurement and each device is tested for accuracy on monthly basis using infrared
thermometer.
0 0
2. The temperature is maintained @ 36 F -46 F
3. If temperature falls outside the range, “Temperature out of range” icon appears on the MedStation,
Nursing will notify FM&D for repair and Main Pharmacy for relocation of medication for the period of
repairs.
4. The Main Pharmacy will get a remote notification “Temperature Warning” for out of range readings and will
notify Nursing units affected.
5. Main Pharmacy will get an automatic printout of the daily status of all refrigerators including interventions
implemented to correct malfunction
6. Nursing document in the temperature log sheet every shift
I. Reasons for Revision:

CXLV. Changes in regulatory or statutory laws or standards
CXLVI. System failures/ changes
CXLVII. Institutional/operational changes
III. Attachments: none

IV. References: none
290
One)
Yes No NICHOLAS GALEOTA MS, RPH
Yes No HELEN PRUSKI, RPH
9/06 Yes No LilyAnn Jeu, PharmD, BCPS
Helen Pruski, RPh
Nicholas Galeota, MS, RPh
291
No: ___CH. 35
Subject: High-Risk Electrolyte Injections Page ____1__ of ____2__
Reviewed by: WILLIAM GERDES Implementation Date: __NEW__

Department Manual
Patient Care Manual
AOD Manual
______________________________________________________________________________________
I. Purpose: Direct administration of undiluted parenteral potassium chloride can cause severe
hyperkalemia and possibly death. The JCAHO considers the use of concentrated KCL as a potential
sentinel event and suggest that “Health care organizations NOT make concentrated KCL available
outside the pharmacy unless appropriate specific safeguards are in place.” This position has been
extended to all parenteral electrolyte preparations.
III. Policy: Concentrated KCL vials and other high-risk electrolytes will no longer be dispensed and all
vials of Concentrated KCL will be removed from all patient care areas. All orders for potassium
chloride solutions or other high risk electrolyte solutions will be dispensed as pre-mixed IV solutions
by the Department of Pharmacy services. Pre-mixed KCL IV solutions (large volumes and K-riders)
will not be stocked on the floor, and will only be dispensed when a prescription is written for a patient.
Exceptions are the critical care units where pre-mixed KCL IV solutions (large volumes) will be
available as a floor-stock.
IV. Responsibilities: It is the responsibility of a pharmacist to provide a ready-to-use diluted dosage form
to a Nurse of any and all high risk electrolytes
(A) All orders for parenteral potassium/or other electrolyte must include the following:
1. Amount of drug per L in mEq’s

2. Name of Base Solution
3. Volume of Base Solution
4. Infusion rate in mEq/hr
5. Number of doses desired
(B) No standing orders for Intermittent Infusion of KCL will be accepted.
(C ) An EKG rhythm strip should be taken pre and post administration of an intermittent infusion of
KCL. EKG telemetry monitoring is required
292
(D) If multiple intermittent infusions of KCL are required, the physician should indicate this by
writing “X ____ doses’
(E) Volume controllers should be used on all patients receiving K solutions or other electrolytes.
(F) The recommended maximum rate of administration of Potassium Chloride Solutions in Adults
on continuous EKG monitoring is:
• 10mEq/hr in patients with a serum K>3
• 20mEq/hr in patients with a serum K<3
• 40 mEq/hr in patients only with life-threatening arrhythmias, or respiratory failure.
(G) Infusions of potassium chloride should be discontinued when the serum level of potassium is
3.5 or greater.
(H) The infusion of multiple simultaneous KCl solutions are not permitted (e.g, IV KCL being
infused at the same time as TPN).
(I) Orders for intermittent infusion of KCL (IV Piggy Back) are most expeditiously dispensed when
ordered for one of the following commercially available solutions:
KCL 10mEq in 100ml Sterile water for infusion

(J) Orders for large volume parenteral (LVP’s) potassium chloride solutions or other electrolyte
will be dispensed by the Department of Pharmacy services – using whatever possible commercially
available Pre-mixed solutions. The recommended maximum concentration of potassium chloride in a
large volume solution in 40mEq/L.
(K) No additional additives will be made to any Pre-Mixed solutions.
(L) Pediatric Patients.

The Pharmacy staff will prepare all potassium or other electrolyte solutions for patients in
these areas.

CXLVIII. Changes in regulatory or statutory laws or standards
CXLIX. System failures/ changes
CL. Institutional/operational changes
CLI.
One)
Yes No
293
Subject: Therapeutic Interchange Policy No: Chapter 36 Section: _______
Prepared by: Alan Hui, Pharm.D. Original Issue Date: 7/12/05
Reviewed by: Nicholas Galeota, MS, Rph Implementation Date: 9/1/05

Supersedes date: 3/06
Approved by: Constance Shames, MD
Distribution: ⁪ Administrative Manual
William Gerdes ⁪ Departmental Manual
⁪ Patient Care Manual
⁪ AOD Manual
Issued by: Pharmacy and Therapeutics Committee
I. Purpose:
To provide safety, improve cost-effectiveness, facilitate medication delivery, and streamline the medication
formulary at SUNY Downstate Medical Center.
II. Definitions:
Therapeutic interchange is the automatic substitution of therapeutically equivalent drugs as determined by the
Pharmacy and Therapeutics (P&T) Committee. Agents must demonstrate therapeutically equivalent efficacy
to be approved for substitution. Agents are only substituted during the patient’s inpatient hospital stay.
III. Policy:
The Pharmacy and Therapeutics Committee will determine the agent(s) of certain class of drugs to be on the
medication formulary at SUNY Downstate Medical Center. In appropriate situations, therapeutic interchange
will occur for non-formulary medications and will be substituted with the formulary agent of its class at
therapeutically equivalent doses based on the procedures below. Drug classes that will participate in the
therapeutic interchange policy are as follows:
a. Insulin Products
b. Proton Pump Inhibitors
c. HMG CoA Reductase Inhibitors (Statins)
d. Angiotensin Converting Enzyme (ACE) Inhibitors
e. Ophthalmic Products
IV. Responsibility:
It is the responsibility of the pharmacist to interchange non-formulary medications for therapeutically equivalent
dose of the formulary agent, fill out the therapeutic substitution sticker correctly, properly label and dispense
the therapeutically equivalent agent. It is the responsibility of the nurse to acknowledge the therapeutic
interchange, place the completed therapeutic interchange sticker on the medical chart, and administer the
substituted formulary medication. Physicians will be notified upon daily review of patients’ medical chart.
V. Procedure/Guidelines:
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1. When a nurse obtains a complete and legible order for a non-formulary medication that is in the
therapeutic interchange program, the nurse shall accept the medication order and send it to the pharmacy
for prescription processing. The nurse will also transcribe the medication order to the Medication
Administration Record (MAR).
2. Upon receiving an order for a non-formulary medication to be substituted, the pharmacist will review the
patient profile and ensure no contraindications to the medication substituted exist. The pharmacist will use
the therapeutic dosage conversion chart for each P&T approved drug class to initiate the therapeutic
interchange policy.
3. The pharmacist will fill out and sign a Therapeutic Interchange/Clarification Alert sticker indicating that the
prescribed non-formulary medication has been substituted for the formulary agent at the therapeutic
equivalent dose determined by the P&T Committee.
4. The pharmacist must document in the pharmacy computer system that a therapeutic interchange has
occurred indicating the originally prescribed agent, dose, route, and duration and the newly substituted
agent, dose, route, and duration.
5. The Therapeutic Interchange/Clarification Alert sticker will be sent along with the first dose of the formulary
agent to the corresponding nurse who will place it in the Progress Notes section of the patient chart. This
sticker will serve as a notification to the medical team of the therapeutic interchange.
6. When the therapeutic interchange sticker is sent from pharmacy with the first dose of the newly substituted
agent, the nurse shall update the MAR to reflect that the order for the non-formulary item has been
substituted with an order for the newly substituted item and sign the alert to acknowledge that the MAR
has been updated. The newly substituted drug order will be added to the end of the list of medication
orders.
7. At the time of administration of the first dose of the newly substituted medication, the nurse will attempt to
inform the patient of the therapeutic interchange and identify the medication by name and dose. In the
event that the patient reports lack of efficacy with, intolerability to, or a previously undocumented allergy to
the newly substituted medication, the nurse will notify the prescriber of this information. If necessary, the
prescriber may discontinue the order for the newly substituted medication and pursue the non-formulary
process with a clear and complete request indicating the reason that the non-formulary medication is being
requested instead of the formulary agent.
8. A request from a prescriber for a particular product for a specific patient will be honored. The prescriber
may write “Do Not Substitute” on the order to prevent the initiation of the substitution process. A non-
formulary request form should also be completed prior to dispensing the non-formulary medication. The
P&T Committee will track these requests.
9. When a prescriber writes a complete and legible order for a combination medication that is not available
on the formulary as a combination product, but the components of the products are available, pharmacy
shall dispense the components of the combination product or drugs that can be substituted for one or
more components based on the approved therapeutic interchange policy.
10. Dosage form interchange will be indicated on the Therapeutic Interchange/Clarification Alert by the
pharmacist completing the sticker.
11. The Order Duration Clarification alert shall be used when the duration of a written order for a restricted
medication (e.g., restricted antimicrobial) conflicts with the approved duration relayed to pharmacy
personnel. In the event of conflicting duration of treatment on the order, the pharmacist shall complete the
Therapeutic Interchange/Clarification Alert sticker with the approved duration provided by the authorizing
service (e.g., Infectious Disease Fellow) and send the alert to the nurse with the first dose of the
medication.
12. The nurse will follow the same procedure as outlined above for updating the MAR and alerting the patient
as to the nature of the interchange for both the dosage form interchange and order duration clarification.
The MAR will be updated accordingly to reflect the names of the substituted components or the new
duration on the medication order, respectively.
295
Appendix A. Therapeutic Interchange for Insulin Products
INSULIN
NOVO Nordisk™
TY Lilly™ Brand Onset Peak Duration Route Time (AC)
Brand
PE
Rapid Acting
LIS ® 10-15 ½ - 1.5 IV or
Humalog >>>> 3-4 hours 5-15 min
PRO* min hour Sub-Q
® 10-15
ASPART* >>>>Novolog 1-3 hours 3-5 hours Sub-Q 5-10 min
min
Short Acting
® ® ½-1 IV or
REGULAR Humulin R >>>>Novolin R 2-4 hours 8-12 hours 30-60 min
hour Sub-Q
Intermediate Acting
® ® 4-12 4-12
NPH Humulin N >>>>Novolin N 24 hours Sub-Q 30-60 min
hours hours
® 7-15 7-15
LENTE Humulin L (No Subsitution) 24 hours Sub-Q 30-60 min
hours hours
Long Acting
® 10-24 10-24
ULTRA-LENTE Humulin U (No Subsitution) 36 hours Sub-Q 30-60 min
hours hours
Mixed Insulins
NPH 70% and
Humulin >>>>>Novolin ½-1 2-12 16-24
Regular Insulin ® ® Sub-Q 30-60 min
70/30 70/30 hour hours hours
30%
Formulary Oral
Non-Formulary Oral Agents
Agent
Lansoprazole Pantoprazole Esomeprazole Omeprazole Rabeprazole
(Prevacid®) (Protonix®) (Nexium®) (Prilosec®) (Aciphex®)
Dose to be Dose Dose Dose Dose
substituted prescribed prescribed prescribed prescribed
15 mg 10 mg
30 mg 40 mg 20 mg 20 mg 20 mg
45 mg 30 mg
60 mg 80 mg 40 mg 40 mg 40 mg
75 mg 50 mg
90 mg 120 mg 60 mg 60 mg 60 mg
296
Appendix B. Therapeutic Interchange for Proton Pump Inhibitors
Intravenous PPI Therapeutic Conversion

Formulary IV Agent Non-Formulary IV Agent
Lansoprazole (Prevacid) Pantoprazole (Protonix)
Dose to be substituted Dose prescribed
30 mg 40 mg
GI Bleed*: 60 mg IV bolus, then continuous GI Bleed*: 80 mg IV bolus, then continuous

infusion at 6 mg/hr** infusion at 8 mg/hr
*Continuous infusion of PPI for active GI bleeding is not a FDA indication.
**Mixed 60 mg of lansoprazole IV in 100 mL of normal saline or D5W and infuse over 1 hour for the initial bolus. A
second admixture of 60 mg of lansoprazole IV in 100 mL should be prepared and infused at 6 mg/hr (10 mL/hr).
Append
Formulary Agent Non-Formulary Agents ix C.
Atorvastatin Simvastatin Fluvastatin Lovastatin Pravastain Rosuvastatin Therape
(Lipitor®) (Zocor®) (Lescol®) (Mevacor®) (Pravachol®) (Crestor®) utic
Dose to be Dose Dose Dose Dose Dose Intercha
substituted prescribed prescribed prescribed prescribed prescribed nge of
---- 5 mg 20 mg 10 mg 10 mg HMG
---- 10 mg 40 mg 20 mg 20 mg
CoA
Reducta
10 mg 20 mg 80 mg 40 mg 40 mg 5 mg se
20 mg 40 mg 80 mg 10 mg Inhibito
40 mg 80 mg 20 mg
rs
80 mg Note:
40 mg
There
are no therapeutically equivalent doses of atorvastatin for simvastatin 5 mg and 10 mg, fluvastatin
20 mg and 40 mg, lovastatin 10 mg and 20 mg, and
297
Appendix D. Therapeutic Interchange of ACE Inihibitors
Formulary
Non-Formulary Oral Agents
Oral Agent
Lisinopril
Enalapril Benazepril Fosinopril Moexipril Perindopril Quinapril Ramipril Trandolapril
(Prinivil®,
(Vasotec®) (Lotensin®) (Monopril®) (Univasc®) (Aceon®) (Accupril®) (Altace®) (Mavik®)
Zestril®)
Dosage Conversion
3.75 1.25
5 mg/day 5 mg/day 5 mg/day 5 mg/day 2 mg/day 5 mg/day 1 mg/day
mg/day mg/day
10 mg/day
2.5
(2 divided 10 mg/day 10 mg/day 10 mg/day 7.5 mg/day 4 mg/day 10 mg/day 2 mg/day
mg/day
doses)
20 mg/day
(2 divided 20 mg/day 20 mg/day 20 mg/day 15 mg/day 8 mg/day 20 mg/day 5 mg/day 4 mg/day
doses)
40 mg/day
10-20
(2 divided 40 mg/day 40 mg/day 40 mg/day 30 mg/day 16 mg/day 40 mg/day 8 mg/day
mg/day
doses)
Captopril (Capoten®) will remain as a formulary agent since it is the sole ACE-Inhibitor classified as a short-acting agent. Therefore,
no agents will be automatically substituted for captopril.
298
Appendix E. Therapeutic Interchange of Ophthalmic Medications
Non-formulary Medication
Non-formulary Medication Formulary Alternative Formulary Medication Dose
Dose
Nefpafenac 0.1% (Nevanac®) Ketorlac 0.5% (Acular®)
1 drop in affected eye TID
or [If unavailable, may give 1 drop in affected eye QID
1 drop in affected eye QID
Diclofenac 0.1% (Voltaren®) ketorlac LS 0.4% (Acular LS®)]
Loteprednol 0.5% (Lotemax®)
Fluorometholone suspension
or 1 drop in affected eye QID 1 drop in affected eye QID
0.1%
Loteprednol 0.2% (Alrex®)
Brimonidine 0.15% (Alphagan-
1 drop in affected eye TID Brimonidine 0.2% (Alphagan®) 1 drop in affected eye TID
P®)
Timolol 0.25% or 0.5%,
Levobunolol 0.25% or 0.5% 1 drop in affected eye BID 1 drop in affected eye BID
respectively
Bimatoprost 0.03% (Lumigan®)
or Latanoprost 0.005% 1 drop in affected eye HS Travatan 0.04% (Travoprost®) 1 drop in affected eye HS
(Xalatan®)
Ofloxacin 0.3% (Ocuflox®) or
Ciprofloxacin 0.3% (Ciloxan®) variable Moxifloxacin 0.5% (Vigamox®) 1 drop in affected eye TID
or Gatifloxacin 0.3% (Zymar®)
Dorzolamide 2% at 1 drop in
Dorzolamide (Trusopt®) 2%
Dorzolamide 2%/Timolol 0.5% affected eye BID and timolol
1 drop in affected eye BID AND Timolol 0.5% (2 separate
(Cosopt®) 0.5% at 1 drop in affected eye
orders)
BID
Note: If a different dosing schedule is desired for formulary medications, the prescriber must write an order for the formulary
medication with that dosing schedule.
299
IV. Reason for Revisions:
⁪ Changes in regulatory or statutory laws or standards
⁪ System failures/changes
⁪ Institutional/operational changes
VIII. Attachements:
9/1/05 Yes No Nicholas Galeota, MS, RPh
3/1/06 Yes No LilyAnn Jeu, Pharm.D., BCPS
6/13/06 Yes No LilyAnn Jeu, Pharm.D., BCPS
Alan Hui, Pharm.D.
10/8/07 Yes No
Yes No
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No: CH 37
Subject MEDICATION RECONCILIATION Page __1___ of __3__
Prepared by: LilyAnn Jeu, Pharm.D. Original Issue Date: 1/1/06

Maureen Green, RN, Ed.M
Muhammad Islam, MS, MCH
Reviewed by: Nicholas Galeota, M.S., R.Ph.____ Supersedes: 2/06

Diane Woods, RN_____________
Constance Shames, M.D. _____ Effective Date: 5/06
JCAHO Standards:
Distribution:  Administrative Manual
Approved by: Margaret Jackson, RN, MA______
 Department Manual
David Conley, MBA_____________  Patient Care Manual
 AOD Manual
Michael Lucchesi, M.D._________
Debra D. Carey, MS___________
I. PURPOSE
To establish the policy and procedure for obtaining, documenting and reconciling patients’
medication orders accurately and completely upon hospital admission and with each
change in setting, provider, or level of care across the continuum of care and when
new medication orders are written.
II. POLICY
For all patients admitted to UHB, a list of medications the patient was taking at home at the
time of admission shall be collected within 24 hours of admission and documented on the
hospital-wide “Medication Reconciliation Form.” This list will be used for reconciliation of
admission medication orders.
Upon transfer between services or levels of care, medication orders

written following the transfer shall be reconciled against medication orders active
at the time of transfer. Upon discharge from the hospital, the discharging
physician must provide a list of medications the patient will continue to take as
a reference for the patient and next medical provider.
Upon patient entry to an ambulatory setting of the institution, medication reconciliation will be
conducted. At subsequent visits, medications will be reviewed and an updated “Medication
301
Flow Sheet” will be maintained in clinics and made available to patients. An updated list will
be provided to the patient only if there is a change.
When a patient is unable to actively or fully participate in the medication reconciliation process,
authorized person(s) will be involved in the reconciliation process (e.g. family member,
significant other, surrogate decision maker).
III. DEFINITION(S)
“Reconciling medications” is a systematic process that develops an accurate, up-to-date
medication list for patients at admission, and then compares that list against the physician’s
admission orders. Discrepancies are brought to the attention of the physician and, if
appropriate, changes are made to the orders. Any resulting changes in orders are
documented. The process is designed to promote communication and information transfer at
patient handoffs, a well-known opportunity for error.
“Medications” shall refer to drugs including, but not limited to, oral prescription and over-the
counter medications, parenteral medications, vitamins, nutriceuticals, herbal remedies, and
intravenous solutions (with and without additives).
IV. Responsibilities
The active admission medication list for medications the patient was taking at the time of
admission may be compiled by a nurse, physician or other licensed prescriber, or pharmacist.
The prescriber reconciles the medication orders collected upon admission, transfer and
discharge.
V. Objectives
Reduce errors of omission, duplications in therapy and potential adverse drug reactions.
1) Provide accurate and complete medication list across continuum of care.
2) Improve communication between providers regarding medication history and course
of treatment at different stages of hospitalization.
3) Involve the patient (and/or patient caregivers) in the process of documenting and
reconciling medication orders.
VI. PROCEDURE/GUIDELINES
HOSPITALIZED PATIENTS
Admission: In the Emergency Department (ED), the first clinician to interview the patient
should initiate the medication reconciliation process by obtaining a list of active home
medications taken prior to admission. The name, dose, route, and frequency of each
medication listed shall be recorded in the electronic charting system, “T-system”, in the ED. If
the patient is unable to recall his/her medications, other sources of information shall be
consulted (e.g., caregiver recall, patient’s pharmacy, patient’s primary care provider). For
patients who are treated and discharged directly from the ED (“treat and release patients”), an
ED clinician shall document discharge medications in the medication reconciliation section of
the T-system. A printed hard copy of the discharge medications will be generated and given to
the patients at discharge from the ED. For patients that are admitted from the ED, the “Home
Medication Reconciliation List” shall be completed and signed by the admitting service. The
admitting service will be granted access to view the home medication list in the T-system and
a hard copy of the electronic patient chart, which includes home medication list, will be printed
to remain permanently in the physical medical chart.
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All medications shall be listed on one form for the same patient. If additional pages are
needed, indicate at the bottom of the page. If a second nurse, prescriber or other health-care
provider identifies additional medications during his or her review of medications, the Home
Medication Reconciliation List shall be updated, as appropriate. Additional medications shall
be recorded on the same list. Clinicians involved in interviewing the patient and obtaining the
medication list must sign and print his/her name at the bottom of the Home Medication
Reconciliation List.
After admission, the ordering prescriber must review the home medication list and choose to
continue or discontinue each medication. All medication orders must be reconciled within 24
hours of admission.
Nursing staff shall fax/send a copy of the reconciled (completed and signed) Home Medication
Reconciliation List to the Department of Pharmacy Services with the admitting medication
orders for the patient. If the Home Medication Reconciliation List is not received, admitting
orders cannot be processed and medications cannot be dispensed. The pharmacist shall
page the attending on record to request a completed and signed copy of the Home Medication
Reconciliation List.
The Home Medication Reconciliation List shall be placed in the Physicians Orders section of
the chart. Clerical staff shall be instructed that this form must remain in the patient’s medical
record throughout the hospitalization (i.e., not removed in the event the chart must be thinned
out).
The nurse shall write on the Nursing Data Base “See Medication Reconciliation Form.”
Transfer: Medication reconciliation is required with any change in level or care or change in
service. As per the policy “Patient Medication Orders,” medication orders from the previous
service or level of care are discontinued upon transfer and new medication orders shall be
written by the prescriber of the receiving service.
To comply with the medication reconciliation requirement, the prescriber shall review the
admission home medication list and list of active medication orders for medications the patient
was taking at the time of transfer (which is available in the Medication Administration Record
[MAR]). The MAR should be consulted for the time and date of administration of the last dose
of each medication.
Discharge: Upon patient discharge, the discharging prescriber shall review admission home
medication list and list of active medication orders for medications the patient was taking at the
time of discharge and agree upon medications to continue after discharge, as part of the
medication reconciliation process.
The prescriber shall then list the medications the patient should continue after discharge in the
designated area on the Home Medication Reconciliation List. The original list should be
attached to the rest of the Discharge Summary and kept in the medical record. One copy of
the Home Medication Reconciliation List shall be attached to the patient’s copy of the
Discharge Summary. The patient shall be encouraged to bring the list to the next appointment
with the patient’s provider of follow-up care. If the next provider of care is known, a copy of the
Home Medication Reconciliation List shall also be provided to the next provider of care.
AMBULATORY CARE PATIENTS

Initial Visit: Upon initial presentation to an ambulatory setting in which medication
reconciliation must take place, a Medication Reconciliation Form will be completed for each
303
patient and filed in the clinic chart. The Medication Reconciliation Form will replace the
medication section on the “Adult Ambulatory Care Summary” (Form UH-286-98), where
applicable.
The patient should be interviewed and involved in obtaining the list of medications for
medications the patient had been taking prior to entry in the clinic or office-based setting.
As part of the clinic or office records, starting with the first patient visit, a Medication Flow
Sheet will be completed for each patient. The Medication Flow Sheet shall serve as a record
of the medications that the patient is taking. An original copy of the Medication Flow Sheet
remains in the clinic file, while a copy of the Medication Flow Sheet should be provided to the
patient at the end of the initial visit.
For providers who are not part of the clinic but who are currently participating in the care of the
patient, a copy of the Medication Flow Sheet should be provided when the provider is known.
The patient should be encouraged to keep a copy of this list in his/her wallet or to at least bring
the list to each clinic appointment.
Follow-up Visits: The Medication Flow Sheet shall be reviewed at each subsequent visit and
updated accordingly. A copy of the updated list, reflecting changes in the medication regimen,
shall be provided to the patient at the end of the visit. The original copy of the Medication Flow
Sheet will be continually updated and filed in the clinic chart.
A copy of the Medication Reconciliation Form and the Medication Flow Sheet shall be
provided to the next provider with any change in service, setting, or provider.
Outpatient Procedure Visits: In outpatient encounters in which systemically administered

medications may be administered or prescribed, a Medication Reconciliation Form must be
completed upon the patient’s presentation. A Medication Flow Sheet should be completed at
the end of the encounter if there was initiation, modification, or discontinuation of medications.
If medications were initiated and/or administered during this outpatient encounter and should
not be continued, the initiation and discontinuation dates should be clearly recorded on the
Medication Flow Sheet and the patient should be counseled about such changes. The patient
should be provided an updated copy of the Medication Flow Sheet.
This reconciliation process shall apply if intravenous contrast agents may be administered,
conscious sedation may be used, or if other medications may be administered during the
encounter.
In brief outpatient encounters in which there appears to be minimal medication use, a

Medication Reconciliation Form must be completed upon the patient’s presentation, even
though few medications may be administered in these encounters. In these situations, the
Medication Reconciliation Form can facilitate the review of medications and review of history
of allergies and past sensitivities. Prescribers shall use the medication reconciliation process
to screen for potential drug interactions or contraindications between medications to be
administered in the brief encounter and medications taken on a regular basis.
In these encounters with minimal medication use, a Medication Flow Sheet is not required if
ALL of the following conditions apply:
a. “Minimal medication use” is in the context of a brief outpatient encounter.
304
b. Medications administered in the encounter act locally with negligible systemic effects
(e.g., minimally absorbed topical agents, topical fluoride dental treatment, non-
absorbable enteric (oral or rectal) contrast agents
c. Medications are administered under the direct control of a licensed independent
practitioner
d. No other medications are used during the encounter
e. No new medications are prescribed for or provided to the patient for use after
discharge
f. There are no changes to the patient’s “current medications”
g. Any provider of care to whom the patient is being referred already has the patient’s
current medication information.
STAFF EDUCATION
UHB will provide orientation and ongoing education on procedures for reconciling medications
to all health care providers.
VII. Attachments: Medication Reconciliation Form

Medication Flow Sheet
VIII. References: JCAHO 2007 National Patient Safety Goal 8

FAQs for the 2007 National Patient Safety Goals (updated 1/07). Accessed on
5/11/07 from the following web site: www.jointcommission.org
Date Revision Required Responsible Staff Name and Title

Reviewed (Circle One)
12/27/05 Yes Nicholas Galeota, M.S., R.Ph.
12/27/05 Yes Diane Woods, R.N.
3/14/06 Yes Constance Shames, M.D.
5/9/06 Yes LilyAnn Jeu, Pharm.D.
5/24/06 Yes Adeola O. Dabiri, MBA, MPA
6/12/07 Yes LilyAnn Jeu, PharmD
Pharmacy & Therapeutics Committee
11/7/07 Yes Alan Hui, PharmD
Pharmacy & Therapeutics Committee
305
Patient Name:
MRN:
HOME MEDICATION RECONCILIATION LIST

FORM MUST BE FAXED TO PHARMACY WITH ADMITTING ORDERS.
Check the following, if applicable: PATIENT PHARMACY AND PHONE NUMBER:
 No home medications.
 Medication list not available at time of admission.
 Only partial list available at time of admission.
Documented by: ___________________________ Date: ___________
ADMISSION HOME MEDICATION LIST Continue on Resume at

Admission? Discharge?
Admitting prescriber must indicate whether home medications should be continued or discontinued within 24 hours of Y (yes) Y (yes)
admission. If additional space is needed, please use second copy of Home Medication List. or N (no) or N (no)
Dose, Route, Last Dose Recorded
Drug Name Indication
Frequency Date Time Date Initials
1. Y N Y N
2. Y N Y N
3. Y N Y N
4. Y N Y N
5. Y N Y N
6. Y N Y N
7. Y N Y N
8. Y N Y N
9. Y N Y N
10. Y N Y N
11. Y N Y N
12. Y N Y N
Recorded by: __________________________________________________________ RN / LPN / MD / PA / NP /RPh / _____ Date: ___________
Medications reviewed on admission by: ______________________________________ MD / PA / NP / _____ Date: ___________
Additions/Corrections by: _________________________________________________ RN / LPN / MD / PA / NP / RPh / _____ Date: ___________
DISCHARGE HOME MEDICATION LIST (To be completed upon patient discharge.)

Discharge prescriber reviews Admission Home Medication List and current orders in MAR prior to writing prescriptions at discharge. Indicate above
whether admission home medications will be continued and list all medications patient should take upon discharge below.
Instructions for the Patient:  Take the medications listed below after you leave the hospital.
 Bring a copy of this list with you to your next doctor’s appointment.
Drug Name /Dose / Route / Frequency / Duration if necessary. (Use Patient Language).
Medications reviewed on discharge by: ______________________________________ MD / PA / NP / _____ Date: ___________
306
Signature of Translator (if applicable): _______________________________________ MD / RN / PA / NP / _____ Language: __________
 Check here if multiple forms needed. Please indicate: Page ____ of ____.
Chart Copy: White Patient Copy: Yellow Provider Copy: Pink
PLACE LIST IN PHYSICIAN’S ORDERS SECTION OF CHART. ATTACH TO DISCHARGE SUMMARY UPON
DISCHARGE.
307
Patient Name:
MRN:


1. Y N Y N
2. Y N Y N
3. Y N Y N
4. Dear Patient, Y N Y N
5.
STOP these medications. Y N Y N
6.
After hospital discharge, take
Y N Y N
7. Y N Y N
8. medications listed below. Y N Y N
9. Y N Y N
10. Y N Y N
11. Y N Y N
12. Y N Y N

308
DISCHARGE.
309
Patient Name:
MRN:


1. Y N Y N
2. Y N Y N
3. Y N Y N
4. Dear Patient, Y N Y N
5.
STOP these medications. Y N Y N
6.
After hospital discharge, take
Y N Y N
7. Y N Y N
8. medications listed below. Y N Y N
9. Y N Y N
10. Y N Y N
11. Y N Y N
12. Y N Y N

310
DISCHARGE.
Medication Reconciliation in Ambulatory Care Areas

MEDICATION RECONCILIATION is the process of identifying the most accurate medication list
and resolving disparities in medication orders as the patient moves across the continuum of
care. Purpose: To improve patient safety with medications by screening for omissions,
duplications, and potential interactions at each stage of a patient’s care.
311
Initial Visit
RN records patient’s current medications on Ambulatory Care Medication List and signs page.
↓
MD may add medications to list, if necessary, and reviews medication list as part of medication
reconciliation.
↓
RN sees patient at end of visit for brief exit interview.
RN reviews medications listed in progress note and transcribes list onto Patient Medication List.
↓
Distribution of Patient Medication List
White copy: Scanning
Yellow copy: Patient
Pink copy: Medical chart
↓
Patient is encouraged to bring list to all appointments.
Follow-up Visits
Scanned copy of most recent Patient Medication List is available in centralized database.
↓
RN interviews patient to find out about medication changes since the last appointment. Ask patient to see
list of current medications.
↓
MD reviews medication changes and current list of medications as part of medication reconciliation.
↓
RN sees patient at end of visit for brief exit interview.
RN reviews medications listed in progress note and updates Patient Medication List, as needed. Copy of
last scanned list may be provided to patient if no medications have been changed.
↓
Patient is reminded to bring list to all appointments.
312
Patient Name:
MRN:
FIN:
Date of Birth:
Patient Medication List (Date Started: ________)

Dear Patient: Please bring this list to all clinic visits. Update this list with changes in medications.
Date Date Special
Medication Name Dose How Often How Taken Initials Initials
Started Stopped Instructions
Prescription Medications
Over-the-
Counter
Supplem
Vitamins
ents
and
313
Scan Copy: White Patient Copy: Yellow Chart Copy: Pink
314
Patient Name:
MRN:
FIN:
Date of Birth:

Date Date Special
Over-the-
Counter
Supplement
Vitamins
and
315
316
Patient Name:
MRN:
FIN:
Date of Birth:

Date Date Special
Over-the-
Counter
Supplement
Vitamins
and
317
318
How Can You Help Prevent getting Information
Patient the right treatments and state-of-the-art quality and
medications by the right health safety standards, such as that
Medication Errors?
care professionals. Don’t
Name provided
Patient ’s by the Joint
Doctors
List all medications you take inside this assume anything.
______________________________ Commission.
Primary Care Provider
card. Include prescription medications Name: _______________________
ordered by any one of your doctors, any
Allergies and Drug Reactions
Participate in all decisions
Phone Number: ________________
over -the-counter medications, and about your treatment. You are
vitamins and supplements you may take. _______________________________
the center of the health care
_______________________________ Specialty Doctors
team.
Name: _______________________
Include the dose (or amount of
medication) you usually take and how Emergency Contacts Phone Number: ________________
often you take it, even if you take some Name: _________________________ Type of Specialist: ______________
medications only once in a while. Relationship: ____________________
Phone Number: __________________ Name: _______________________
Carry this list with you and share it with Phone Number: ________________
all your doctors. This will help all your
Name: _________________________ Type of Specialist: ______________
medical providers stay up -to-date about
your medications. Relationship: ____________________
Phone Number: ________________
Be sure to bring this list with you to
all your doctor visits and appointments Patient ’s Community Pharmacy Type of Specialist: ______________
for medical tests. Name: _________________________
If any medications are changed, the Phone Number: ________________
list should be updated. Name: _________________________ Type of Specialist: ______________
Phone Number: __________________
This medication card

is based on the Joint
Commission’s Speak UpTM
patient safety program. Educate yourself about your
Launched in March 2002, Speak diagnosis, the medical tests you University Hospital of Brooklyn
450 Clarkson Avenue
UpTM urges patients to take a are undergoing, and your Brooklyn, NY 11203
role in preventing health care treatment plan. 718-270-1000
errors by becoming active,
involved and informed Ask a trusted family member or
participants on the health care friend to be your advocate.
ream. Speak UpTM encourages
the public to: Know what medications you
take and why you take them.
Speak up if you have questions Medication errors are the most
or concerns, and if you don’t common health care mistakes.
understand, as again. It’s your
body and you have a right to Use a hospital, clinic, surgery Patient Medication
know. center, or other type of health List
care organization that has
Pay attention to the care you are undergone a rigorous on-site
receiving. Make sure you are evaluation against established
319
For more patient safety health care
tips, visit the Joint Commission on
Accreditation of Healthcare
Organizations web site at
http://www.jointcommission.org/Patien
tSafety/
SpeakUp.
320
Patient Name:
MRN:
FIN:
Date of Birth:
Ambulatory Care Medication List
TO BE FILLED OUT BY NURSE OR PROVIDER
Check the following, if applicable:
 No home medications. PATIENT PHARMACY AND PHONE NUMBER:
 Medication list not available at initial clinic visit.
 Only partial list available at initial clinic visit.
Documented by: ____________________ Date: _______
LIST ALL MEDICATIONS PATIENT TAKES AT HOME.
 Include the dose, number of doses each day, and when the last dose was taken.
 Include prescription and over-the-counter medications, vitamins and supplements or herbal products.
HOME MEDICATION LIST

How often do When did you
How do you Initials of
Medication Name Dose you take this last take this?
take this? Recorder
each day? Date Time
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
321
25.
List recorded by (Indicate name and title): ________________________________________ Date: _________
Providers should review this list of home medications, in accordance with medication reconciliation.
PILOT
322
Subject: ADVANCED ECHO EMERGENCY No: __Chapter 38__ Section: _______
MEDICATION BOX Page __1___ of __3___
Prepared by: ALAN HUI

Original Issue Date: NEW
Reviewed by: WILLIAM GERDES
NICHOLAS GALEOTA
Implementation Date: _11/1/04__
Approved by: CONSTANCE SHAMES, M.D.
Department Manual
Patient Care Manual
AOD Manual
I. Purpose: During procedures in the Advanced ECHO lab, emergency situations may arise when
administration of certain medications is necessary to alleviate the current condition of the patient.
These emergency situations include respiratory distress secondary to bronchospasm or chronic heart
failure (CHF) exacerbation, hypoglycemia, frequent premature ventricular contractions (PVC) > 5 per
minute, complex ventricular ectopy, supraventricular tachycardia (SVT), or allergic reactions. Specific
medications will be made available to the medical staff present in the advanced ECHO lab for the
treatment of these emergency situations.
II. Definition(s): NA
® ®
III. Policy: Medications such as albuterol (Proventil ), Dextrose 50% in Water, furosemide (Lasix ),
® ®
metoprolol (Lopressor ) and methylprednisolone (Solu-Medrol ) will be made available to the medical
staff in the Advanced ECHO lab that will be used to treat patients in distress. These medications will
be kept in a secured box that is prepared and dispensed by pharmacy. The physician will assess and
prescribe the necessary medication for the patient and the nurse will administer as prescribed.
IV. Responsibility: It is the responsibility of the pharmacist to provide the appropriate dosage and
formulation of each medication for the Emergency Medication Box for the Advanced ECHO lab. It is
the responsibility of the nurse to administer the medication based on orders or prescriptions provided
by the physician and to inspect the Emergency Medication Box on a monthly basis. It is the
responsibility of the physician to prescribe the appropriate medication during the specified emergency
situations and to monitor the patient’s condition.
V. Procedure: The following medications and quantity will be dispensed by pharmacy in a sealed red box
labeled “Emergency Medications for Advanced ECHO Lab”:
Drug Quantity
®
Albuterol (Proventil ) 0.083% 3 mL Inhalation Solution 5
Dextrose 50% in Water (D50W) 50 mL vial 2
®
Furosemide (Lasix ) 40 mg/4 mL vial for injection 2
®
Metoprolol (Lopressor ) 5 mg/5 mL ampoule for injection 3
®
Methylprednisolone (Solu-Medrol ) 125 mg vial for injection 1
1. A pharmacist or a technician will prepare the Advanced ECHO Lab Emergency Medication
Box that contains the medications and quantities stated above. There will be two such boxes,
323
labeled #1 and #2, where one will be dispensed to the Advanced ECHO lab and the other will
remain in the main pharmacy until subsequent exchange for a new emergency medication box.
2. A pharmacist must verify the proper medication, dosage, formulation, expiration, and
quantity and document the verification in a log book. A plastic seal will be placed on the box to
ensure integrity and should not be broken until the time of use.
3. A label indicating the earliest expiration date of any medication within the box will be
placed on the outside of the box for future inspection.
4. A nurse from the Advanced ECHO lab will sign out and pick up the Emergency Medication
Box from pharmacy when needed. Only one box will be dispensed each time.
5. The Emergency Medication Box should be placed in a secured area of the Advanced ECHO
lab until it is needed.
6. Medications in the box will be used in the following manner:
Respiratory Distress secondary to bronchospasm:

®
Administer 3 mL of albuterol (Proventil ) 0.083% inhalation solution via a hand-held nebulizer X 1
dose. Repeat one dose after 15 minutes if necessary.
Hypoglycemia (Symptomatic and/or blood glucose < 80 mg/dL):

Administer 50 mL of D50W via IV push and repeat finger stick in 15 minutes.
Respiratory Distress secondary CHF exacerbation:

®
Administer furosemide (Lasix ) 40-80 mg IV push X 1 dose.
Frequent PVC (> 5 per minute), complex ventricular ectopy, or SVT:

Administer metoprolol 5 mg IV push. May repeat metoprolol 5 mg IV push q 5 minutes X 2 doses if
necessary.
Allergic Reactions:
®
Administer methyprednisolone (Solu-Medrol ) 100 mg IV push X 1 dose
7. After assessment of the patient, the physician will write a prescription or order (for in-
patients and out-patients) indicating the appropriate medication, dose, route, frequency, and
duration. The orders and prescriptions must also include the full name of the patient, medical
record number, patient number, date of use, and signature of physician and nurse.
8. The nurse or physician will break the plastic seal of the Emergency Medication Box and
remove the medications to be administered.
9. After the treatment is completed, the orders or prescriptions for the medications used will
be place back in the Emergency Medication Box. The nurse will transport the opened Emergency
Medication Box to the pharmacy to obtain a new Emergency Medication Box for the Advanced
ECHO lab.
10. Upon receiving the opened Emergency Medication Box, a pharmacist or technician will
charge for the medications used based on the orders or prescriptions received.
11. A pharmacist or technician will replaced any missing medications from the opened
Emergency Medication Box. However, a pharmacist must follow procedure #2 and #3 and provide
the final verification prior to the plastic seal being placed on the box.
12. A nurse on a monthly basis will inspect the Emergency Medication Box in the Advanced
ECHO lab for expiration (expiration label).
13. If an Emergency Medication Box is expired, a nurse from the Advanced ECHO lab will
exchange for a new Emergency Medication Box from pharmacy.
V. Reason for Revisions:

324
One)
12/21/04 Yes No Nicholas Galeota, MS, RPH
Yes No
325
No: CH. 39
Subject: PATIENT MEDICATION ORDERS
Prepared by: Alan Hui, Pharm.D. Original Issue date: 8/86

Reviewed by: Nicholas Galeota, M.S., R.Ph. Supersedes: 12/04
Cheryl Okundaye, RN
Diana Woods, RN
Approval date: 5/06
Approved by: Constance Shames, MD Distribution: Administrative Manual
Department Manual
William Gerdes Patient Care Manual
AOD Manual
Margaret Jackson, RN
I. Purpose:
To define the process by which a legally authorized prescriber may order medications and how medication
orders are handled by nursing personnel and pharmacists from the SUNY Downstate Medical Center.
II. Definition(s):
A medication is defined as a drug or chemical entity approved for use in humans by the FDA for the treatment
or diagnosis of disease or which otherwise affects the psychological function of the patient. This includes OTC
(Over - The - Counter) medication.
III. Policy:
All medication orders for patients shall be prescribed by the individuals legally authorized∗ and shall be written
on a “Prescriber’s Order Form” and filed in the patient’s chart. All medication orders shall include all
necessary information and be signed by the prescribing individual. Nursing personnel will obtain only
complete and clear medication orders and transcribe orders accurately to the Medication Administration
Record (MAR). The pharmacist will verify medication orders and dispense the medications when it is
appropriate.
"Prescriber's Order Form" will replace the previously named "Physician's Order Form" in policies. The function
of the order form will remain the same.
IV. Responsibilities (Include all departments/services involved in development/implementation

and/or monitoring):
Prescriber:
It is the responsibility of the prescribing healthcare practitioner to ensure that all medication orders are
complete according to the procedures noted below.
Nursing:
∗
Licensed and currently registered physicians and dentists
Registered Physicians Assistant
Certified Nurse Practitioners licensed and currently registered
House staff physicians (PGY 1 through PGY 7)
326
It is the responsibility of Nursing Personnel to obtain and transcribe only complete and clear medication
orders. Otherwise, Nursing Personnel shall clarify the medication order with the prescriber before forwarding
the medication order to the Pharmacy Department.
Pharmacist:
It is the responsibility of the pharmacist to dispense medication on the authority of a complete, clear, and
clinically sound and safe medication order written by an authorized prescriber. If the medication order does
not meet these criteria, then the pharmacist shall contact the prescriber, discuss the issues involving the
medication order, and ask the prescriber to correct the medication order, if necessary.
1. All medication orders shall be written on the right-hand section of the “Prescriber’s Order Form” in the
section marked “Medication and Intravenous Admixture Orders.” If either side of the order form is
completed, the nurse shall cross out the remaining white space on the opposite side of the page. New
orders for either side of the page will need to be written on a new order form.
2. Patient information must be completed on each order form, including patient first and last name,
patient medical record number (MRN) or in-patient account number, and allergy information.
3. Each medication order shall be written legibly and contain all required information including:
• Date and time the order was written
• Drug
i. Full name of the drug, brand or generic. Abbreviations of drug names are not
acceptable. (e.g., PCN is unacceptable)
• Dose
i. Dosage strength is written in metric units (without the use of unacceptable or
unapproved abbreviations)
ii. The prescribed dose does NOT contain trailing zeros after a decimal (e.g., 1.0
milligram is unacceptable)
iii. The prescribed dose MUST contain leading zeros before a decimal (e.g., digoxin 0.25
mg)
iv. The dosage prescribed for chemotherapy drugs is rounded to the nearest whole
dosage (e.g., 5.1 mg should be rounded to 5 mg)
• Route of administration
• Frequency
• Duration of therapy
i. The maximum duration of therapy that is prescribed will be 30 days for most
medication orders. Refer to the Automatic Medication Stop Order Policy for
exceptions.
4. For Pediatric/Neonatal medication orders, all doses are calculated by body weight or body surface
area (BSA) and the weight-based or BSA-based dosing shall be written on the medication order. The
patient’s body weight must be included on the medication order form.
5. The prescriber shall sign immediately below medication orders each time orders are written and then
stamp name with his/her rubber stamp or print his/her name after his/her signature. If multiple orders
are written at the same time, the prescriber may sign one time at the end of the list of medication
orders (a.k.a., order set) written at that time.
6. Any medication order containing unacceptable abbreviations as per SUNY Downstate Medical Center
policy is invalid and will NOT be accepted by nursing and/or pharmacy.
7. Upon encountering new orders, the nurse shall sign below the prescriber’s signature for the order or
order set. The nurse should indicate the date and time that the medication order or order set was
acknowledged and faxed to the pharmacy (a.k.a., the action time) next to his/her signature. In
addition, the nurse will indicate the number of valid, complete orders obtained for the order set next to
his/her signature.
8. If duration of therapy is not indicated on the medication order, the order will be valid for one dose only.
The nurse may give one dose only after the order has been reviewed by a pharmacist.
9. The nurse shall transcribe all the information on the medication order to the MAR.
327
10. Upon identifying an order that is incomplete, incorrect, unclear, unacceptable (e.g., contains
unacceptable abbreviations) or written for a non-formulary drug, the nurse shall specify the problem on
the Prescriber Order Form below his/her signature. Nurses should clearly identify the problem order
by drug name and problem. For example, the nurse may designate, "Problem order: Drug A order
incomplete, unclear, unacceptable, or non-formulary." If the medication order is not legible, the nurse
shall circle the medication name and make a similar notation on the order form (e.g., "Problem order:
Drug name not clear.") The nurse shall contact the prescriber for clarification or correction of the order
and document the name of the prescriber he/she spoke with, the date and time of the communication
on the order form, and his/her signature at the end of the communication.
11. Prescribers must discontinue and/or rewrite all medication orders that have been identified as unclear,
incomplete, incorrect, or unacceptable. For non-formulary medications, prescribers may complete a
non-formulary request form and follow the non-formulary request procedure.
12. Medication orders will be sent to the pharmacy, Room ALL1-469, via fax or pneumatic tube system (if
available to the unit). In the event the fax machine is not able to transmit orders, a copy of the
medication order can be sent to pharmacy via messenger.
13. The pharmacist checks the medication order for completeness and appropriateness and enters the
order into the patient’s database profile using the pharmacy computer system. If the order is
incomplete, incorrect, unclear, unacceptable, or written for a non-formulary medication, the pharmacist
must contact the prescriber for clarification, a new order, a non-formulary request form. Formulary
alternatives may be recommended to replace non-formulary medications. The pharmacist will
document communication with the prescriber for problem orders, as per procedures. If the duration of
therapy is not indicated on any medication order, the order will be valid for one dose only. The
pharmacist will contact the prescriber for a follow-up order, if appropriate.
14. All medication orders must be checked by the pharmacist and initialed before the corresponding
medications are dispensed.
®
15. Medications will be sent to nursing stations by messenger, Pyxis Helpmate , pneumatic tube system
or via cassette exchange system by Pharmacy Technicians.
16. Before administration, the nurse checks that the information on the MAR and medication container
label coincide.
17. If a patient is transferred from one unit to another within the hospital, the medication orders from the
previous unit are automatically discontinued and new medication orders must be written to continue
any drug therapy. Any order stating, “Resume orders,” is not acceptable.
18. STAT Medication Orders:

Time of day must be noted on all STAT medication orders. When the prescriber writes for a STAT order, that
prescriber is to personally speak with the nurse covering that patient to expedite the order being carried out. The
nurse shall fax the order to the Pharmacy for processing. All STAT medication orders should be transcribed onto
the section for STAT orders on the MAR.
19. PRN Medication Orders:

PRN medication orders must include the indication for administration along with all information
required for a standing medication order. If the PRN medication order is for a clinical symptom, the
nurse may act on behalf of the patient in determining the frequency of administration. These orders
are transcribed onto the PRN medication section of the MAR.
20. RANGE Medication Orders:

Medication orders with a dosage or frequency range, such as “Morphine sulfate 2 to 4 mg every 4 to 6
hours as needed for pain,” are NOT permitted and should not be transcribed or entered into the
pharmacy computer system. All medication orders must include a specific dose and a specific
frequency.
21. HOLD Medication Orders:
328
These orders are intended to provide a mechanism to temporarily suspend the administration of a
medication for a defined period of time. HOLD orders must be specific and include each drug name
and the specific schedule of doses to be held. If the order states “HOLD” without a specific time
period, then the prescriber should discontinue the medication order. The order must be re-written to
be re-started. The orders shall be transcribed to the MAR with specific time frames and
documentation of specific doses that were ordered to be held.
22. ON CALL Medication Orders:

Each dose of On Call medication is considered a “one time only” and is transcribed onto the MAR. If
more than one dose of an “on call” medication is required, the doses must be written separately. The
date of administration and reason for administration must be part of the order (e.g., On Call to OR on
12/23/04).
23. Any incomplete or incorrect medication order is to be documented as a medication error, when written
by the medical staff or others who have prescriptive authority within SUNY Downstate Medical Center.
XII. Reasons for Revision:

System failures/ changes
VII. Attachments:
Prescriber’s Order Form
VIII. References:
Policy and Procedure on Medication Order Completeness
Date Reviewed Revision Required (Check One) Responsible Staff Name and Title
8/01 Yes No Nicholas Galeota, Director of Pharmacy
8/03 Yes No Nicholas Galeota, Director of Pharmacy
12/04 Yes No Alan Hui, Pharm.D.
Nicholas Galeota, Director of Pharmacy
10/8/07 Yes No Nicholas Galeota, Director of Pharmacy
329
Subject: Medication Security When Patients are
Transferred Between Services No: Chapter 40 Section: _______
Page 1 of 2
Prepared by: Nicholas Galeota, M.S., R.Ph.
Director of Pharmacy NEW
Original Issue Date: _______________
Reviewed by: Diane Woods, R.N.
Deputy Director, Nursing Services 5/9/06
Implementation Date: ______________
Approved by: Pharmacy and Therapeutics Committee
Distribution: ⁪ Administrative Manual
Constance Shames, M.D. ⁪ Departmental Manual
Chairperson ⁪ Patient Care Manual
________________________________ ⁪ AOD Manual
I. Purpose: To insure security of medications when a patient undergoes inter unit transfer or evacuation from
the facility.
II. Definition(s): NA
III. Policy: All current medication orders are discontinued when a patient is transferred between services.
Medications are not to be moved between units. New medication orders must be re-written by the receiving
medical team upon arrival of the patient in the new unit. The receiving medical team is not required to obtain
re-approval for previously approved restricted antibiotics and/or previously approved non-formulary drugs. All
prior approvals remain in effect if the receiving medical team re-orders these classes of medications.
IV. Responsibility: Responsibility is broken up amongst the Nursing staff, medical staff, and the Pharmacy staff:
Nursing staff: The nurse on the originating unit shall remove all medications from the medication cart and
place the medications into the returns bin for the Pharmacy. The nurse should administer any medications to
the patient due within one (1) hour of the patient transfer. The nurse should notify the Pharmacy about the
patient’s new location.
Medical Staff: It is the responsibility of the receiving medical team to evaluate the patient upon arrival in the
new unit and re-write the medication orders based on an evaluation of the patient, evaluation of previous
medication orders, and any new medication orders required.
Pharmacy Staff: It is the responsibility of the pharmacist to review the new orders against the existing patient
profile to ascertain if any maintenance medications have been omitted and require re-ordering. The pharmacist
shall notify the physician if this situation occurs.
V. Procedure:
14. Within one (1) hour after transfer of a patient from a unit, all medication for the patient must be returned to
the Pharmacy
15. New medication orders at the patient destination unit are to be written as soon as possible by the receiving
service team upon arrival of the patient at the new unit.
16. The new medication orders are then processed according Pharmacy’s policy and procedures.
17. If a dose of medication is required immediately, a nurse may access a first dose, a “STAT” dose, or an
emergency dose from the Pyxis® cabinet.
18. Any medication due within one (1) hour of the transfer may be administered by the nurse before the
transfer.
19. In the event of a disaster, requiring the complete or partial evacuation of the facility, a review of the current
medications for the patients being evacuated would be performed, and for those medications that will be
readily available at the receiving institution the patient’s profile would be sent with the patient. If any of the
current medications the patient is receiving are not available at the receiving institution, the Pharmacy
330
Department would prepare a two (2) day supply that would be sent with the patient, including all pertinent
drug and ordering information. Controlled substances not available would also be sent with the patient in
a two (2) day supply, and a controlled substance administration record would be completed and sent with
the patient. The receiving facility would be required to sign off as receiving the controlled substances
intact and the exact quantity dispensed by the appropriate licensed professional and the original must be
returned immediately to Downstate for our records.
VI. Reason for Revisions:

VIII.
References: JCAHO Standards MM.2.30, MM.4.10, MM.8.10
NPSG #8
Yes No Nicholas Galeota, M.S., R.Ph.
Yes No Diane Woods, R.N.
Yes No Constance Shames, M.D.
331
No: PTSAF-13
Chapter 41
Subject: LABELING OF MEDICATION Page __1___ of __4__

/SOLUTION IN PERIOPERATIVE
AND PROCEDURAL AREAS
Original Issue Date: 01/06

Prepared by: Patient Safety Committee
Supersedes: New
Reviewed by: Lilyann Jeu, Pharm. D._______
Maria Mendez______________ Effective Date: 01/06
Prissana Alston, MA, RN______
Jaycinth Blackman, RN, CPHQ JCAHO Standards:MM.2.20,MM.4.20,NPS 3,MM.5.10,IM.6.10
P&T Committee_____________
Approved by: Nicholas Galeota, R.PH _____ Distribution  Administrative Manual

 Department Manual
Margaret Jackson, MA, RN____  Patient Care Manual
 AOD Manual
David Conley, MBA__________
Michael Lucchesi, M.D._______ Issued by: Regulatory Affairs
Debra D. Carey, MS_________
I. PURPOSE
To provide safe utilization of medication and solutions on or off the sterile field in all procedural
areas.
II. POLICY
SUNY Downstate Medical Center/University Hospital of Brooklyn is committed to provide safe

medication practices by ensuring the safe administration of medication and solution on or off the
sterile field and other procedural areas.
Medications and solutions on or off the sterile field will be labeled even if there is only one
medication being used.
Labeling occurs immediately when any medication or solution is transferred from the original
packaging to another container, and when medications or solutions are prepared but are not
administered immediately, the medication container must be labeled.
332
At a minimum all medications prepared in the hospital are labeled with the following:
• Drug name, strength, amount (if not apparent from the container)
• Expiration date and time, not more than 24 hours, from the date and time of preparation
• Expiration time when expiration occurs in less than 24 hours
• The date prepared and the diluents of all compounded IV admixtures and parenteral nutrition
solutions.
• Initial of the professional preparing the medication/solution.
When preparing individualized medications for multiple specific patients, or when the person preparing the
individual medications is not the person administering the Medication, the label also includes the following:
• Patient name
• Patient Location
• Direction for use and any applicable cautionary statements either on the label or attached
as an accessory label(for example, “requires refrigeration,” “for IM use only)
III. DEFINITIONS
Perioperative area – includes operating rooms and ambulatory surgery units.
Procedural settings – include Cardiac Catheterization and Endoscopy, suites, Radiology

Department, Respiratory and all other areas where surgical or other invasive procedures may be
performed, including the clinical units.
Medication– includes any prescription medication, radioactive medication, IV solutions (plain or with
additives), blood derivatives, albumin, diagnostic and contrast agents, respiratory therapy treatment
Solutions - include saline, water, chemicals and reagents such as glutaraldehyde and
chlorhexidine, alcohol, betadine, & hydrogen peroxide.
Immediate: Without interruption between withdrawal of medication/solution from original container

and administration to patient.
IV. RESPONSIBILITIES
Perioperative service, Radiology, Endoscopy, Cardiac Catheterization, Respiratory and all other
procedural areas, including the clinical units.
V. PROCEDURE/GUIDELINES
• Verify medication order(s) according to hospital policy.
• In case of emergency, confirm all verbal orders by repeating the order and document the
order in the patient’s chart as soon as feasible.
333
• Verbally and visually verify all medications delivered to the sterile or non sterile field,
including name of medication, strength, dosage, route of administration and expiration date.
• In the preoperative setting, circulating nurse and scrub person should concurrently verify the
medication/solution. If there is no scrub person, the circulating nurse will verify the
medication visually and verbally with the licensed professional performing the procedure.
• In the procedural setting, the person assisting such as the Physician, PA, will verify the
medication visually and verbally stating name of medication/solution dose, patients name
and location, with the licensed professional performing the procedure. In the event that there
is no other person assisting, the health care provider should follow the verification process as
outline in the (policy PTSAF-03) Patient Identification for Clinical Care and Treatment.
• Prior to labeling the medication or solution, visually inspect product for changes in color,
consistency or presence of precipitation that may suggest that the product is not safe for use.
• Label all medications or solution, medication or solution containers (e.g., syringes, medicine
cups, basins) with patient’s name, medication name and strength and dosage. Complete the
label with all required information.
• In accordance with the multi-dose policy, accurately labeled Original container from which
the solution or medication was withdrawn be accurately labeled with expiration date not more
than 14 days from the date of opening.
• All original containers from medications or solutions remain available for reference in the
perioperative area until the conclusion of the procedure.
• Discard any solution or medication found without any identification label. All labeled
containers on the sterile field must be discarded at the conclusion of the procedure.
• At shift change or break relief, all medications/solutions on or off the sterile field and their
labels will be noted and verified concurrently by entering and exiting personnel.
• All original containers including syringes used during any procedure must remain in the
perioperative and procedural area until completion of the procedure.
VI. SCOPE
This policy applies to all Downstate Medical Center physicians, nurses, and other healthcare
providers involved with patient care.
VII. RELATED UHB POLICIES
334
Policy (PHA-16) Handling of Multi-dose Vials of Inject able /Inhalation, and Ocular Medications
Policy (PTSAF-3) Patient Identification for Clinical Care and Treatment
VIII. ATTACHMENTS
None
VIII. REFERENCES
JCAHO National patient Safety Goal 3D

Yes No
Yes No
335
No: CHAPTER 42
Subject:
of
LOOK-ALIKE/SOUND-ALIKE DRUGS Page 1 3
Prepared by: Original Issue

LilyAnn Jeu, Pharm.D., BCPS date: 10/06
Reviewed by: Nicholas Galeota, M.S., R.Ph. Supersedes: NEW
Approval date: 10/10/06
Approved by: Constances Shames, MD Distribution: Administrative Manual

Department Manual
Patient Care Manual
AOD Manual
III. Purpose:
To define the organization’s process for identifying and compiling the look-alike/sound-alike drug list.
To define preventive measures implemented by the institution to prevent look-alike/sound-alike

medication errors.
IV. Definition(s):
Look-alike/sound-alike drug names are names that are similar in appearance or pronunciation, or
have the potential to be confused with other medication names due to these similarities. Confusion
between such agents may lead to potentially harmful medication errors.
IV. Policy:
The Department of Pharmacy will identify and annually review the list of look-alike/sound-alike drugs
used in the organization. The Department will implement measures to prevent errors involving
interchange of these drugs.
The organization’s list will consist of a minimum of 10 sets of look-alike/sound-alike drug names
based on the Joint Commission’s recommendations.
Pharmacist: The Department of Pharmacy will update the organization’s list of look-alike/sound-
alike drugs and disseminate the updated list to Prescribers and Nursing personnel through the
336
Pharmacy & Therapeutics Committee. Preventive strategies to reduce medication errors with such
drugs will be disseminated via the same venue. Pharmacists shall follow preventive strategies to
reduce these medication errors.
Prescribers: Medication orders shall be complete with drug names clearly and correctly spelled.
When applicable, the indication for use of look-alike/sound-alike medications shall be included on
the medication order.
Nursing: Nurses shall obtain and transcribe only complete, clear medication orders to reduce the
risk of medication errors with look-alike/sound-alike drugs. Nurses shall practice and/or participate
in preventive strategies to reduce such types of medication errors.
1. On an annual basis, the Department of Pharmacy will review the Joint Commission
recommendations for updating the organization’s list of look-alike/sound-alike drugs.
2. The following preventive strategies will be employed to reduce potential and actual medication
errors with look-alike/sound-alike drug names in medication storage and/or patient care areas:
a. Physical separation of agents with similar names.
b. Use of different drug delivery devices to distinguish drugs with similar names (e.g., NovoLog
FlexPen vs Novolin R vials).
c. Use of brand and generic names on unit-dose packaging, in medication storage areas, and/or
medication orders whenever possible.
d. Inclusion of prompts for nurses to specify indication for use when medication is retrieved from
the automated dispensing cabinet (Pyxis).
e. Inclusion of dosing limits for medications with similar names but different dosage ranges.
f. Placement of “Look-Alike, Sound-Alike” auxiliary alerts on medication storage bins.
g. Changing the appearance of names on shelf labels and bins, including the automated
dispensing cabinets (e.g., “tall man” letters).
h. Avoiding the use of abbreviations for drug names.
i. Remove drugs with potentially problematic names from formulary, whenever possible.
3. Guidelines outlined in the policy for Verbal and Telephone Orders shall be followed to prevent
medication errors when look-alike/sound-alike drugs are named.
4. The updated list of look-alike/sound-alike drugs shall be made available in nursing stations, within
the Department of Pharmacy, and in medication storage areas.
5. If at any time a nurse or pharmacist is unclear about the drug name, the health-care professional
shall contact the prescriber to clarify the medication order.
XIII. Reasons for Revision:

VII. Attachments:
Top 10 Sound-Alike & Look-Alike Drugs
VIII. References:
JCAHO 2006 National Patient Safety Goal 3C
Look-alike/sound-alike drug tables (2006-2007) available at web site www.jcaho.org
337
Reviewed
Yes No
338
No: __CH. 43________
Subject CHEMOTHERAPY ORDERING Page __1__ of __6__

AND DISPENSING
Prepared by: LilyAnn Jeu, PharmD, BCPS Original Issue Date: 6/07
Gerald Soff, MD__________
William Solomon, MD______
Yi-Chun Lee, MD_________
Sreedhar Rao, MD________
Megan Sargent, RN______
Marlene Ferguson, RN_____
Reviewed by: Nicholas Galeota, M.S., R.Ph.____ Supersedes: _NEW_

Dianne Woods, RN_____________
Patient Safety Work Group_______ Effective Date: 9/07
JCAHO Standards: MM.3.10,3.20,4.10-4.80,5.10

Distribution:  Administrative Manual
Approved by: Michael Lucchesi, M.D._________  Department Manual
Margaret Jackson, RN, MA______
Torrance Akinsanya_________  Patient Care Manual
Debra D. Carey, MS____________  AOD Manual
Issued by:
I. PURPOSE
To delineate the inter-disciplinary process for ordering and dispensing of chemotherapy and
associated medications for patients receiving treatment in the Ambulatory Chemotherapy
Unit.
To describe medication management practices targeted to reduce medication errors with

chemotherapy agents as a class of high-risk medications.
To increase patient satisfaction by improving the work flow and reducing waiting time for
medications in the Ambulatory Chemotherapy Unit.
II. POLICY
Physicians of oncology services at University Hospital of Brooklyn who are authorized by
their respective departments shall prescribe chemotherapy, in accordance with
requirements for medications orders (e.g., policies “Patient Medication Orders,”
“Unacceptable Abbreviations,” and “Look-Alike/Sound-Alike Drugs.”) Nurses shall execute
those orders in accordance, when appropriate. The pharmacy department shall process
these orders that are complete and correct and free of unacceptable abbreviations. In
339
addition, responsibilities and procedures specific to staff providing care in the Ambulatory
Chemotherapy Unit are outlined below.
III. DEFINITION(S)
Chemotherapy agents (or antineoplastics) are those used to treat oncology disorders.
Non-chemotherapy agents may be administered in combination with chemotherapy agents
to enhance their therapeutic effects or to reduce adverse effects associated with their use in
chemotherapy regimens.
Premedicants are non-chemotherapy agents administered prior to the administration of

chemotherapy to prevent known side effects of chemotherapy regimens (e.g., antiemetics,
antihistamines, corticosteroids, etc).
IV. Responsibilities
Physicians authorized to prescribe chemotherapy at University Hospital of Brooklyn shall

write orders on the “Physician’s Chemotherapy Orders” form based on the evaluation of
individual patients’ clinical status. Evaluation of height, weight, body surface area,
appropriate laboratory evaluation, and chemotherapy cycle number shall be indicated on the
form. For patients receiving medications with a cumulative lifetime dosing limit, physicians
should maintain records of total doses received to date for individual patients.
Nurses authorized to administer chemotherapy shall screen orders for completeness,

fax/send orders to the chemotherapy pharmacy satellite for compounding, administer
medications, and monitor patients for side effects. In addition, to promote a more efficient
rate of patient turn-around time, the nursing staff of the Ambulatory Chemotherapy Unit will
attempt to schedule patients requiring visits of anticipated shorter duration (e.g., patients
receiving intravenous bolus of medication or regimens with relatively shorter infusion times)
for earlier appointments during the working hours of the Ambulatory Chemotherapy Unit.
Nursing staff shall also provide guidance to the pharmacy staff on the priority in which
patients’ medications shall be prepared, in order to improve communication, work flow and
patient satisfaction.
Pharmacists shall verify doses and calculations used to derive those doses (e.g., body
surface area, cumulative lifetime dose for pertinent medications) for chemotherapy agents,
non-chemotherapy agents in chemotherapy regimens, and premedicants prior to
compounding. Premedicants shall be prepared by batching in standardized intravenous
concentrations, when possible. The pharmacy department shall maintain a par level of
these batched medications according to stability data. Chemotherapy orders shall be
processed based on individual orders.
V. PROCEDURE/GUIDELINES
340
Ambulatory Chemotherapy Unit Medication Ordering and Dispensing (May 2007) PROPOSAL
Patient is informed
Patient
RN administers medications to
Patient arrives in of cancellation and
patient and monitors for adverse
unit in AM given follow -up
effects .
(Step 2) instructions .
(Step 12 and 15)
(Step 7)
Blood work not RN acknowledges RN staff of unit Investigational

RN staff pick up
Nurse
Nursing staff RN draws blood satisfactory . MD medication orders and faxes / pick up pharmacist
chemotherapy
schedule patient from patient and informs nurses sends them to chemotherapy premedicants for delivers meds to
products from
for appt . sends to lab chemotherapy canceled (and/ or investigational ) administration unit, when
chemo satellite .
(Step 1) (Step 3) for patient . pharmacist . prior to chemo applicable .
(Step 14a)
(Step 6a) (Step 8) (Step 11) (Step 14b)
Laboratory
Lab processing of
blood work
(Step 4)
If blood work is
satisfactory , MD writes
orders for premedicants
Physician
and chemotherapy .
(Step 6b)
MD reviews blood
work
(Step 5)
Pharmacist
Chemo pharmacist
and second Chemo pharmacist When preparations ready ,
Pharmacy department
pharmacist verify alerts RN when chemo and / or investigational
batches and maintains
orders. Chemo premedicants ready pharmacist alerts RN staff of
supply of premedicants .
pharmacist for pick up . the unit .
(Preparation for step 9)
processes orders . (Step 10) (Step 13)
(Step 9)
1. Nursing staff schedule patient for ambulatory chemotherapy session. Staff shall attempt to
schedule patients with anticipated visits of shorter duration for earlier appointments in the day,
as to promote more efficient use of space in the Ambulatory Chemotherapy Unit.
2. Scheduled patient arrival.
3. Nurse performs blood draw and sends to lab.
4. Lab processing of blood work.
5. Physician evaluates blood work.
6a. If blood work is not satisfactory for the patient to receive chemotherapy that day, physician
cancels chemotherapy for that day.
6b. If blood work is satisfactory for patient to receive chemotherapy, physician writes orders for
premedicants (if needed) and chemotherapy orders on “Physician’s Chemotherapy Orders”
form. Physician completes the height, weight, body surface area calculation, chemotherapy
cycle number, allergy information, medication order information, and indication blood work was
evaluated and deemed appropriate. For pediatric orders, weight-based dosing is required.
Whenever possible, the physician is encouraged to select pre-printed premedicants listed on

the order form.
If a patient is part of an investigational protocol that requires a product to be compounded by

the investigational pharmacist, the physician must indicate the protocol number on the order
and indicate that the investigational pharmacist should be contacted to compound the product.
341
If a patient is receiving carboplatin, serum creatinine and target area-under-the curve must be
indicated on the order form.
If a patient is receiving a chemotherapy agent that has a cumulative lifetime dose limit (e.g.,
doxorubicin), it is recommended that the physician should evaluate the total dose to date prior
to writing the order.
7. If chemotherapy is cancelled by the physician, the nurse shall inform the patient of the
cancellation and provide subsequent instructions for follow-up care.
8. If medications have been ordered, the nurse acknowledges orders and faxes/sends order form
to Chemotherapy Pharmacy Satellite. Nurse verifies patient information is complete (e.g.,
height, weight, blood work evaluation) and medication orders are complete before
acknowledging order.
The nurse communicates the order in which products should be compounded to the pharmacist
as follows: In the top, right-hand corner of the order form for each patient, a nurse will number
orders in order of priority of compounding (i.e., “#1” indicates the first order the pharmacist
should compound for that day). The nurse shall then send/fax orders to chemotherapy
pharmacy satellite.
Orders for different services (e.g., Pediatric Oncology, Medical Oncology,

Obstetrics/Gynecology Oncology) shall be sent to the pharmacy when available. There is no
need to wait for all orders from all services to be available before sending these orders to the
Chemotherapy Pharmacy. However, all orders shall be labeled with a priority number for
compounding.
If the physician has indicated that a product must be compounded by the investigational
pharmacist, the nurse shall contact this pharmacist and send the order to the appropriate lab.
9. Upon receipt of chemotherapy orders, chemotherapy pharmacist faxes/sends orders to main

pharmacy for verification of calculations by a second pharmacist. The chemotherapy
pharmacist verifies the medication order for completeness, as well as body surface area
calculation, evaluation of appropriateness of blood work, and total cumulative dose for pertinent
medications (when applicable).
If a chemotherapy order is found to be incorrect, incomplete, unclear, or contains an

unauthorized abbreviation, the pharmacist shall contact the physician to discuss the problem
and request that the order be re-written, if necessary.
10. If chemotherapy orders have been written for a patient, the chemotherapy pharmacist
processes orders and prepares premedicants for dispensing. Batched premedicants shall be
labeled appropriately prior to dispensing.
The chemotherapy pharmacist shall iinform nursing staff when premedicants are ready to be
picked up. The premedicants should be ready and available for dispensing prior to preparation
of the chemotherapy.
11. Nursing staff will pick up the premedicants. Staff will sign the log to document which
products have been received by the Ambulatory Chemotherapy Unit.
12. Nurses administer premedicants to patients in a timely fashion.
342
13. When the chemotherapy preparations have been prepared, the chemotherapy pharmacist
or investigational pharmacist will alert the nursing staff of the unit.
14a: Nursing staff will pick up the chemotherapy agents from the chemotherapy satellite. Staff
will sign the log to document which products have been received by the Ambulatory
Chemotherapy Unit.
14b: The investigational pharmacist will deliver products to the unit, when applicable.
15: Chemotherapy agents are administered. Patients are monitored by nursing staff.
VI. Attachments: Physician’s Chemotherapy Orders
VII. References:
Policy and procedure on “Patient Medication Orders.”
Policy and procedure on “Unacceptable Abbreviations.”
Policy and procedure on “Medication Orders and Completeness Standard.”
Policy and procedure on “Look-Alike/Sound-Alike Drug Names.”
Institute of Safe Medication Practices’s List of High Alert Medications. Available on website
www.ismp.org/Tools/highalertmedications.pdf. Accessed May 22, 2007.
Schauberger CW, Larson P. Implementing Patient Safety Practices in Samll Ambulatory

Care Settings. Joint Commission Journal on Quality and Patient Safety. 2006;32(8):419-
425.
Robinson DL, Heigham M, Clark J. Using Failure Mode and Effects Analysis for Safe
Adminsitration of Chemotherapy to Hospitalized Children with Cancer. 2006;32(3):161-166.

Yes No
Yes No
343
Patient Name:
MRN: Financial Number:
PHYSICIAN’S CHEMOTHERAPY ORDERS
DIAGNOSIS NS or Clinic: DOB:
2
HEIGHT WEIGHT SURFACE AREA (m ) Appropriate Blood
Work Evaluated
Patient Age: Sex:  Male  Female
________ inches _________ pounds
 YES  NO Attending Physician’s Name:
________ cm _________ kg
ALLERGIES CYCLE ________ OF _________
NON-CHEMOTHERAPY (Include IV fluids without additives)

If doses for
Check How Often?
IV Fluid and different days,
box to Drug Name Dose Route No. of Doses (e.g., Once/Daily/q __ h/Before
Volume indicate days of
order. chemo/etc). Indicate special directions.
cycle.
Dexamethasone 10 mg IVPB 50 mL D5W
Diphenhydramine 25 mg IVPB 50 mL D5W
Ondansetron 16 mg IVPB 50 mL D5W
Ondansetron 32 mg IVPB 50 mL D5W
Famotidine 20 mg IVPB 50 mL NS
CHEMOTHERAPY (Include drugs to be added to chemotherapy preparations)

If investigational
drug, MD writes Dosing Dose Route (e.g., IVPB/IV
If doses for
protocol Schedule (e.g., mg, push, PO, continuous
2 IV Fluid and No. of different days,
number. Circle Drug Name (e.g., mg/m , grams, infusion) and How Often?
if investigational Volume Doses indicate days
mg/kg, units, Rate/Duration of
pharmacist of cycle.
units/kg, etc.) etc.) Infusion
should prepare.*
DOXOrubicin
®
(Adriamycin )
Cyclophosphamide
®
(Cytoxan )
5-Fluorouracil
Methotrexate
vinCRISTine
®
(Oncovin )
CISplatin
®
(Platinol )
vinBLASTine
®
(Velban )
CARBOplatin
®
(Paraplatin )
For carboplatin orders, also indicate: Serum creatinine: _________ mg/dL AND AUC target: ___________.
Paclitaxel
®
(Taxol )
Mannitol (mixed
with cisplatin)
Magnesium (mixed
with cisplatin)
* Call Investigational Clinical Research Pharmacist to order dose (×4340).

MD SIGNATURE PAGER NO. RN SIGNATURE RPh #1 NAME/SIGNATURE
PRINT NAME PRINT NAME DATE TIME

344
DATE TIME DATE TIME RPh #2 NAME/SIGNATURE
PILOT replacement SD 033-D (5/07)

No: CHAPTER 44
Subject: ORDERING AND DISPENSING OF

PARENTERAL CHEMOTHERAPY FOR
NON-ONCOLOGY INDICATIONS
Prepared by: LilyAnn Jeu, PharmD, BCPS Original Issue date: 1/07
Reviewed by: Nicholas Galeota, M.S., R.Ph. Supersedes: New

Donald Caracciola, RPh
Dianne Woods, RN
Approval date:
Approved by: MEC Distribution: Administrative Manual
Department Manual
Patient Care Manual
AOD Manual
I. Purpose: To reduce the potential for medication errors with antineoplastic agents. To improve the safe
preparation of parenteral chemotherapy for non-oncology indications. To enhance patient safety with
parenteral chemotherapy when used for non-oncology indications by requiring a standardized ordering
process.
II. Definition(s):
Antineoplastic agents (or chemotherapy) are those agents used to treat oncology disorders. This policy
discusses agents prepared for parenteral administration.
Parenteral administration refers to administration by injection of medications (e.g., intravenous, intramuscular,
subcutaneous, etc).
III. Policy:
All parenteral chemotherapy shall be ordered using the Physician’s Chemotherapy Order Form by prescribers
authorized to prescribe chemotherapy at UHB.
When dosing regimens for chemotherapy for non-oncology indications are not FDA approved or are not readily
available for pharmacist verification, prescribers who order chemotherapy for non-oncology indications shall
provide evidence-based protocols (or references) to the pharmacy department for verification of medication
orders. Pharmacists shall make the request for these protocols when there is a concern regarding the dosing
regimen ordered.
Chemotherapy orders for non-oncology indications written before 4 PM Monday through Friday shall be sent to
the Chemotherapy Pharmacy Satellite for processing and verification and preparation of medication. Orders
written after 4 PM or on weekends or holidays shall be sent to the Main Pharmacy.
All parenteral chemotherapy shall be prepared in the Pharmacy Department and dispensed in ready-to-
administer form. No vials of chemotherapy shall be sent to patient care areas.
Physicians, nurses, pharmacists
345
1. Physicians authorized to prescribe chemotherapy shall write orders for parenteral chemotherapy on the
Physician’s Chemotherapy Order Form. All required elements of the order form must be completed,
including patient height and weight, body surface area calculation, chemotherapy cycle number, allergy
information, medication order information, and indication blood work was evaluated and deemed
appropriate. Medication orders shall indicate weight- or body-surface-area-based dosing, where
appropriate.
2. Nurses shall acknowledge chemotherapy orders and fax/send the order form to Chemotherapy Pharmacy
Satellite. Nurses shall verify the patient information is complete (e.g., height, weight, blood work
evaluation) and medication orders are complete before acknowledging orders.
3. Upon receipt of chemotherapy orders, chemotherapy pharmacist faxes/sends orders to main pharmacy for
verification of calculations by a second pharmacist. The chemotherapy pharmacist verifies the medication
order for completeness, as well as body surface area calculation, evaluation of appropriateness of blood
work, and total cumulative dose for pertinent medications (when applicable as defined in the policy
“Chemotherapy Ordering and Dispensing”).
4. If a chemotherapy order is found to be incorrect, incomplete, unclear, or contains an unauthorized

abbreviation, the pharmacist shall contact the physician to discuss the problem and request that the order
be rewritten, if necessary.
5. The pharmacist shall verify the dose of chemotherapy ordered using available references (e.g.,
® ®
MicroMedex , Up To Date , the text Hematology-Oncology Therapy edited by Boyiadzis et al, or protocols
provided by the specialists who are prescribing the chemotherapy for non-oncology indications.
Pharmacists shall contact prescribers for resources to verify doses when there is a concern regarding the
dosing regimen. (See attachment.)
6. Upon verification of doses of chemotherapy, the pharmacist shall prepare all doses for parenteral
administration according to procedures in the policy “Cytotoxic Drug Admixtures.” This includes drawing
up syringes for intramuscular or intravenous push injection.
7. Upon completion of preparation of the medication, pharmacy personnel shall deliver the dose of
chemotherapy to the nursing unit.
XIV. Reasons for Revision:

VII. Attachments:
Physician’s Chemotherapy Orders
Uses of Antineoplastics for Non-oncology Indications
VIII. References:
UHB Policy on “Patient Medication Orders” (PHA-02)
Pharmacy Policy on “Cytotoxic Drug Admixtures”
Pharmacy Department Policy on “Chemotherapy Ordering and Dispensing.” (Chapter 43)
Boyiadzis MM, Lebowitz PF, Frame JN, Fojo T, eds. Hematology-Oncology Therapy. New York, NY: McGraw
Hill, 2007
Yes No
346
Uses of Antineoplastics for Non-oncology Indications
Updated Dec 2007. Doses accessed from www.uptodate.com and www.micromedex.com on 12/19/07.
Brand
Specialty Generic Name Name Indication
Psoriasis: Oral: 2.5-5 mg/dose every 12 hours for 3 doses given

Dermatology Methotrexate weekly or Oral, I.M.: 10-25 mg/dose given once weekly
Active Crohn's disease (unlabeled use): Induction of remission: I.M.,
SubQ: 15-25 mg once weekly; remission maintenance: 15 mg once
Gastroenterology Methotrexate weekly
Sickle cell anemia (investigational use): I.V., SubQ: 0.15-0.3
mg/kg/day over 2 minutes 5 days/week for 2 weeks (5 days on, 2
Hematology Decitabine Dacogen days off, 5 days on; 10 doses total) every 6 weeks
Multiple sclerosis, Secondary progressive, progressive relapsing, or
worsening relapsing-remitting; to reduce neurologic disability and/or
frequency of clinical relapses: 12 mg/m(2) IV every 3 months; should
not be administered to patients who have received a cumulative
Neurology Mitoxantrone Novantrone dose of 140 mg/m(2) or greater
Ob/Gyn Methotrexate Ectopic pregnancy (unlabeled use): I.M.: 50 mg/m2 single-dose

Age-related macular degeneration. Intravitreal: 1.25 mg (0.05 mL)
monthly until improvement/resolution, usually ~1-3 injections (Avery,
Ophthalmology Bevacizumab Avastin 2006) or 2.5 mg (0.1 mL) every 4 weeks for 3 doses
Glaucoma surgery (unlabeled use): 0.2-0.5 mg (0.2-0.5 mg/mL
solution). Glaucoma surgery (unlabeled route): Apply to pledget and
place in contact with surgical wound for 2-5 minutes (doses and
Ophthalmology Mitomycin Mutamycin techniques may vary)
Glaucoma: 5 mg subconjunctival injections in various dosing

Ophthalmology Fluorouracil Adrucil protocols has been used
Pleural sclerosing: Intrapleural: 60 units as a single instillation (some

recommend limiting the dose in the elderly to 40 units/m2; usual
maximum: 60 units). Dose may be repeated at intervals of several
Pulmonary Bleomycin sulfate Blenoxane days if fluid continues to accumulate (mix in 50-100 mL of NS);
Renal/ Lupus nephritis: Adult usual dose is 1 g/m(2)/month IV. Peds 500 to
Rheumatology Cyclophosphamide Cytoxan 750 mg/m(2)/month IV, titrate to 1 g/m(2)/month
Rheumatology Cyclophosphamide Cytoxan JRA/vasculitis: I.V.: 10 mg/kg every 2 weeks
Rheumatology Cyclophosphamide Cytoxan SLE: I.V.: 500-750 mg/m2 every month; maximum dose: 1 g/m2
Juvenile rheumatoid arthritis (peds): Oral, I.M.:10 mg/m2 once
weekly, then 5-15 mg/m2/week as a single dose or as 3 divided
Rheumatology Methotrexate doses given 12 hours apart
Rheumatoid arthritis (Moderate to Severe), In combination with

methotrexate, in patients who had an inadequate response to one or
more tumor-necrosis-factor antagonist therapies: 1000 mg IV
followed by a second 1000 mg IV dose 2 weeks later; MAX: a total of
Rheumatology Rituximab Rituxan 2 doses; used in combination with methotrexate
Transplant Cyclophosphamide Cytoxan Anti-rejection kidney
347
No. Chapter 45
Subject: MEDICATION ORDERS FOR Page 1 of 4

CONTRAST MEDIA FOR
IMAGING PROCEDURES
Prepared by: James Shanahan__________ Original Issue Date 12/07

Lily Ann Jeu, PharmD_______
Reviewed by: Hyman Shwarzberg, M.D.____ Supersedes: NEW

Roger Holt, M.D.___________
Dianne Woods, RN________ Effective Date: 12/07
Salvatore Sclafani, M.D._____
P&T Committee
Medical Executive Committee
Approved by: Nicholas Galeota, MS, RPh__ The JC Standards: MM.4.10
Anny Yeung, RN, MPA_____
Margaret Jackson, MA, RN__
David Conley, MBA________
Stanley Fisher, M.D._______
Michael Lucchesi, M.D._____
Debra D. Carey, MS_______ Issued by: Regulatory Affairs
I. PURPOSE
To expedite ordering and performance of procedures requiring radiocontrast and to facilitate

the pharmacy review of medication orders for contrast media
II. POLICY
The Physician ordering an imaging procedure that requires contrast shall order the contrast
in RIS at the same time as the procedure. The RIS shall prompt the ordering physician with
the safety information necessary to make a risk-benefit analysis of the order. The Ordering
Physician may, as needed, consult with the radiologist and the radiologist will be considered
the supervisor of the imaging study.
348
Orders for contrast media in RIS shall be based on radiologist-approved protocols. These
orders shall contain the required elements for medication orders (medication name, dose,
route, frequency, duration) as per the Patient Medication Orders policy.
For contrast media not ordered via the approved protocols, a radiologist and/or pharmacist
shall review the order prior to administration, as applicable.
Before the administration of contrast media, a pharmacist reviews the medication orders,
except when the medication is urgently needed and a delay in medication administration
may harm the patient or licensed independent practitioner supervises the patient during and
after administration of IV contrast.
In the event of an adverse reaction to a patient during the administration of contrast, the
radiologist and the physician ordering the imaging study shall be notified. The ED physician
provides supervision of the patient for timely intervention in the event of a patient
emergency. The hospital code team shall be called to respond to patients with severe
reactions to contrast media.
III. DEFINITION(s)
Studies requiring Contrast:

• MRI and CT Studies with contrast (Some are done without contrast).
• Gastrointestinal Imaging Procedures
• Genitourinary Imaging Procedures
• Interventional Radiology
Approved contrast media protocols (including agent, dose, route of administration) as

indicated on attached lists.
RIS: Radiology Information System

Protocolling of cases: Radiologist decision as to the methodology to be used for imaging,
including the use of contrast.
IV. RESPONSIBILITIES
Ordering Physician: Orders procedure, orders contrasts associated with the procedure,
reviews contraindication and safety information associated with the contrast order, makes a
risk/benefit judgment regarding the use of contrast.
Radiologist: Protocols the case in RIS in a timely manner. In the case of off-hours
coverage where the radiologist is not present at UHB, protocolling shall be done verbally.
Technologist: Records the protocol in RIS for verbal orders and performs the imaging
procedure in accordance with the protocol.
Nurse: Administers the contrast material as ordered by the Licensed Independent

Practitioner ordering the procedure and contrast. The Nurse is authorized to instruct the
patient on holding the regular doses of metformin as it relates to the use of contrast.
Pharmacist: Verifies and reviews order for contrast media for completeness. Pharmacist
screens patient medication profile for allergies, contraindications, and drug interactions
according to the policy, “Verification and Review of Prescription Orders.” For patients
349
actively receiving metformin according to the medication profile and who have been
prescribed intravenous contrast media, the pharmacist shall contact the patient’s primary
care team to discontinue metformin for 48 hours after administration of IV contrast (as
recommended by the manufacturer).
V. PROCEDURES/GUIDELINES
1. CT, MRI, or GI/GU Exams are ordered and Contrast selected by ordering MD in RIS
from the NS or Clinic or Outpatient arrives with MDs written request for CT. MRI,
Nuclear, or GI/GU Exams. All hand written requests are scanned in to be reviewed by
Radiologist
2. All requests are scheduled in RIS.
3. Radiologist opens Approve/Protocol Queue. By selecting a Patient, the Reason for
Exams, Contrast Selection & Order Comments popup.
A. If Approve is selected a screen opens for

a. Selection of protocol from list
b. Selection of Contrast for Outpatients
c. Review of Contrast ordered by Nursing Stations and Clinics
d. Proceed to next patient for approval
e. If emergency, flag as STAT.
Exam is then flagged by RIS to let the staff know that it was approved & Protocolled
& is ready to be performed. Protocols & Contrast selections can be viewed from
today’s schedule & Tech Worklist and can be printed. Printed request will display
protocol, contrast, dosage and the approving MD.
B. If Reject is selected a screen opens with possible rejection reasons including:

a. Inadequate History
b. Inappropriate exam ordered
c. MRI Suggested
d. CT Suggested
e. Sono suggested
f. Pt. has Allergies
g. Not medically necessary
h. MRI contraindicated
i. A Free Text Entry
4. If Radiologist is not in the CT vicinity, technologist pages the Radiology

Resident/Radiologist. The radiology resident opens the queue remotely and reviews
the requested contrast study. A radiologist is available by telephone for consultation,
if needed. The technologist reads the request to the radiology resident and takes a
telephone order from the radiology resident to approve or reject the exam. If the
exam has been approved, the technologist enters protocol information in RIS, does a
read-back to verify the order and then finalizes the order.
5. Upon approval of an imaging study that requires contrast media, the order for
contrast media shall be sent to the pharmacy department.
6. Nurse administers contrast as per protocol.
7. For patients receiving IV contrast media, the physician and/or nurse instructs the
patient to hold his/her metformin or metformin-containing medication the day of the
study and until 48 hours after the study. They should have their labs evaluated by
their physician before restarting the held medication.
350
XV. ATTACHMENTS
CT/MRI Contrast Media Orders

Diagnostic Radiology Contrast Media Orders
Adult Code Team Activation Criteria
VII. REFERENCES
“Interim Action for Standard MM 4.10, Element of Performance 1, for Critical Access
Hospitals and Hospitals. Modifications for the Emergency Department and
Radiology Practitioners.” Joint Commission Perspectives. January 2007: 9.
UHB Policy on Rapid Response Code Team Activation
Pharmacy Department Policy on “Verification and Review of Prescription Orders” (Ch 4,
Section G)
Pharmacy Department Policy on “Look-alike, Sound-alike Drugs” (Ch 42)
Date Reviewed Revisi Required Responsible Staff Name and Title

on (Circle One)
No
No
No
No
351
RIS Work flow for Protocal
of Contrast cases
ED Cat Scans are done as CT . M RI, or G I /G U Exams

are ordered & Contrast selected
ordered . N o approval or
scheduling necessary . by ordering M D . in RIS from O utpatient arrives w ith M D s w ritten request for
the N S or Clinic . CT. M RI, N uclear , Sonography or G I /G U
O rders go directly to Tech
w orklist . ED w ill Select Exams . A ll hand w ritten requests are scanned in
protocol & contrast from a to be review ed by Radiologist
drop dow n list w hen
A ll requests are scheduled in RIS .
ordering exam
Radiologist opens A pprove /Protocol Q ueue .

Radiologist on Yes By selecting a Patient the Reason for Exams ,
duty at U H B ? Contrast Selection & O rder Comments popup .
Radiologist Selects A pprove or R eject

No & validates by selecting his /her name
from drop dow n list
If A pprove is selected a screen opens for

1 . Selection of protocol from list
Exam is protocoled 2 . Selection of Contrast for O ut patients If R eject is selected a screen opens w ith possible
by phone & 3 . Review of Contrast ordered by N S , CL rejection reasons including :
Contrast review ed 4 . Precede to next patient for approval 1. Inadequate H x
by our Radiologist 5 . If emergency , flag as STA T . 2. Inappropiated exam ordered
or Resident Exam is then flagged by RIS to let the staff know that it 3. M RI Suggested
w as approved & Protocoled & is ready to be performed . 4. CT Suggested
Protocols & Contrast selections can be view ed from 5. Sono suggested
today’s schedule & Tech Worklist and can be printed . 6. Pt . has A llergies
Printed request w ill display protocol , contrast , dosage and 7. N ot medically necessary
the approving M D . M edication order prints in pharmacy . 8. M RI contraindicated
9. A Free Text Entry
Clerical Staff
Technician enters Pharmacy review s Floor is notified by RIS
w ill arrive Pt in
Protocol and all Contrast orders . w ith reason for Rejection
RIS w hen Pt
selects radiologists
comes to
name in RIS .
modality
The exams goes to Tech

Tech closes exam in RIS . Technical
Worklist w here protocol &
charge is dropped & exams goes to
contrast selection can be
TA LK for dictation .
view ed by technologist .
Draft 12/07
Diagnostic Radiology Contrast Media Order Form
Radiologist checks box to order contrast media. Doses may be repeated up to maximum prn radiologist request.
Patient Name: _________________________________ Medical Record #: _____________ Allergies:  NKDA 
______
Exam Check Box to Order Contrast Medium
®
Angiocardiography, Visipaque (Iodixanol, 320 mg iodine/mL)
Angiography, or  Adult Dose: 10 mL intra-arterial x 1 dose. May repeat dose up to maximum 5ml/kg patient weight intra-arterial.
Arteriography Patient weight: __________. Maximum dose: __________ mL.
 Patient requires increased dosage of contrast due to_______________________________
 Pediatric Dose: 2 mL/kg intra-arterial x 1 dose. Patient weight: __________. Dose = ______ mL. May repeat
dose up to maximum 4 mL/kg intra-arterial prn radiologist request. Maximum dose: _________ mL.
Angiocardiography, Omnipaque (Iohexol, 300 mg iodine/mL)
Angiography or  Adult Dose: 50 mL IV x 1 dose. May repeat dose up to 3-5 mL/kg patient weight IV prn radiologist request.
Arteriography Patient weight: __________. Maximum dose: __________ mL.
 Patient requires increased dosage of contrast due to _______________________________________
 Pediatric Dose: 2 mL/kg IV x 1 dose. Patient weight: __________. Dose = __________ mL.
®
Barium Enema, Single  Sol-O-Pake (Barium sulfate for suspension, 99% w/w)
Contrast Preparation: Add 500 mL water to 454 grams powder contrast in enema bag and shake vigorously 30 seconds.
Wait 5 minutes, then add water to make 2000 mL final volume (23% w/v, 19% w/w).
Dose: 2000 mL PR x 1 dose via enema bag. Shake well before administration.
®
Barium Enema with Air,  Liquid Polibar Plus (Barium sulfate suspension, 105% w/v, 58% w/w)
Double-Contrast Dose: 700 mL (undiluted) PR x 1 dose via enema kit.
®
Barium Swallow  1) E-Z-HD (Barium sulfate for suspension, 98% w/w)
Preparation: Add 65 mL water to 340 grams powder contrast in bottle and mix. Shake vigorously 30 seconds.
Wait 5 minutes, then reshake thoroughly to make 135 mL suspension (85% w/w, 250% w/v).
Dose: 135 mL PO x 1 dose. Shake well before administration.
®
 2) Varibar Pudding (Barium sulfate esophageal paste, 40% w/v, 30% w/w)
Dose: 2 tablespoonsful PO x 1 dose. May repeat dose up to maximum 3 tablespoonsful PO as per MD.
®
Enteroclysis with  1) Entero-H (Barium sulfate suspension, 80% w/v, 49% w/w). Dose: 500 mL (undiluted) PO x 1 dose.
®
Methylcellulose, Double-  2) Hydroxypropyl Methylcellulose (after Entero-H administration)
Contrast Preparation: Mix 500 mL methylcellulose solution with 1500 mL water in feeding bag.
®
Dose: 500 mL PO x 1 dose after Entero-H dose
®
Enteroclysis, Single-  Entero-H (Barium sulfate suspension, 80% w/v, 49% w/w)
®
Contrast Preparation: Dilute 1 part Entero-H in 3 parts water. Dose: 1000 mL PO x 1 dose.
®
ERCPs, T-tubes  Visipaque (Iodixanol, 320 mg iodine/mL)
Dose: 10 mL intra-arterial x 1 dose. May repeat up to maximum 150 mL intra-arterial.
®
G-tube Placement  Gastrografin (Diatrizoate meglumine 660 mg/Diatrizoate sodium 100 mg per mL). Dose: 20 mL PO/NG/G tube
x 1. Repeat as necessary as per MD up to maximum 60 Ml
®
GI Series, Double Contrast  E-Z-HD (Barium sulfate for suspension, 98% w/w)
Preparation: Add 65 mL water to 340 grams powder contrast in bottle and mix. Shake vigorously 30 seconds.
Wait 5 minutes, then reshake thoroughly to make 135 mL suspension (85% w/w, 250% w/v).
®
GI Series, Single-Contrast  Liquid E-Z-Paque (Barium sulfate suspension, 60% w/v, 41% w/w)
GI Tract Visualization  Gastrografin (Diatriazoate meglumine 660 mg/Diatriazoate sodium 100 mg per mL)
Preparation: Dilution of 1:1 recommended for patients < 10 years old. Dilution of 1:3 recommended for
patients < 10 kg body weight. May dilute in water, carbonated beverage, or milk.
 Age < 5 years. Dose: 30 mL PO x 1 dose
 Age 5-10 years. Dose: 60 mL PO x 1 dose
®
Hysterosalpingography  Sinografin (Diatrizoate meglumine 527 mg/Iodipamide meglumine 268 mg per mL)
Dose: 10 mL injection for hysterosalpingography x 1 dose. May repeat dose up to maximum 20 mL.
®
Intravenous Urography  Omnipaque (Iohexol, 300 mg iodine/mL). Dose: 50 mL IV x 1 dose.
Pelvic Studies  Rectal READI-CAT via CAT-PAK. Dose: 400 mL suspension PR x 1 dose
®
Retrograde Hypaque-Cysto 240 (Diatrizoate meglumine, 141 mg iodine/mL; 30% w/v)
®
Cystourethrography Preparation: Dilute 200 mL Hypaque-Cysto to 500 mL with sterile water for injection.
 Age < 3 years. Dose: 20 mL injection into bladder x 1 dose. May repeat dose up to maximum 50 mL.
 Age 3 - 8 years. Dose: 150 mL injection into bladder x 1 dose. May repeat dose up to maximum 180 mL.
 Age > 8 years. Dose: 200 mL injection into bladder x 1 dose. May repeat dose up to maximum 300 mL.
®
Small Bowel Series  Entero Vu 24% (Barium sulfate suspension, 24% w/v, 20% w/w)
Dose: 600 mL PO x 1 dose, within 15 minutes of radiography. Shake well.
For patients receiving IV contrast and taking metformin or metformin-containing medications, patient was instructed to discontinue these agents for 48
hours after receiving IV contrast. Check one:  Yes  No  Not Applicable
Radiologist Name and Signature: ____________________________________________________ Date: _____________ Time: __________
Nurse Signature: __________________________________________________________________ Date: _____________ Time: __________
Return Fax Pharmacist Initials: ________________ Date: ________ Time:

#:___________ ________ 353
PILOT 12/07
CT/MRI Contrast Media Order Form

Radiologist checks box to order contrast. Doses may be repeated up to maximum prn
radiologist request.
Patient Name: ____________________________________ Medical Record #: __________ Allergies:  NKDA
________
Exam Check Box to Order Contrast Medium
Computed Tomography
Abdomen Studies  Oral READI-CAT (Barium sulfate suspension, 1.3% w/v, 1.2% w/w)
Dose: 300 mL suspension PO x 1 dose 60 minutes before scan and 150 mL PO x 1 dose prior to scan. May
repeat dose up to maximum 2000 mL PO prn radiologist request.
Abdomen/Pelvic Studies  Rectal Gastrografin (Diatriazoate meglumine 660 mg/Diatriazoate sodium 100 mg per mL)
Preparation: Dilute 30 mL to 1 liter with tap water.
Dose: 400 mL solution PR x 1 dose. May repeat up to 1 liter prn radiologist request.
Angiocardiography, Omnipaque (Iohexol, 300 mg iodine/mL)
Angiography or  Adult Dose: 50 mL IV x 1 dose. May repeat dose up to 200 mL IV prn radiologist request.
Arteriography
 Pediatric Dose: 2 mL/kg IV x 1 dose. Patient weight: __________. Dose = __________ mL.
®
Angiocardiography, Visipaque (Iodixanol, 320 mg iodine/mL)
Angiography or  Adult Dose: 10 mL intra-arterial x 1 dose. May repeat dose up to maximum 150 mL intra-arterial.
Arteriography
Contrast-Enhanced CT Omnipaque 300 (Iohexol, 300 mg iodine/mL)
 Adult Dose: 50 mL IV x 1 dose. May repeat dose up to maximum 200 mL IV prn radiologist request.
 Pediatric Dose: 2 mL/kg IV x 1 dose. Patient weight: _________. Dose: ________ mL.
Contrast-Enhanced CT Visipaque (Iodixanol, 320 mg iodine/mL)
 Adult Dose: 100 mL x 1 dose. May repeat up to maximum 150 mL IV prn radiologist request.
 Pediatric Dose: 2 mL/kg IV x 1 dose. Patient weight: _________. Dose: ________ mL.
May repeat dose up to maximum 4 mL/kg IV prn radiologist request. Maximum dose: _____ mL.
GI Tract  VoLumen (Barium sulfate suspension, 0.1% w/v, 0.1% w/w)
Dose: 900 mL PO x 1 dose within 45-60 minutes prior to scan. Recommended rate 150 mL every 5 mins. May
repeat dose up to maximum 1800 mL PO prn radiologist request.
®
Lower/Upper Extremity or Visipaque (Iodixanol, 320 mg iodine/mL)
Central Venography  Adult Dose: 10 mL intra-venous x 1 dose. May repeat dose up to maximum 5ml/kg patient weight intra-arterial.
Patient weight: __________ Maximum dose: __________ mL.
 Patient requires increased dosage of contrast due to _______________________________________
Tomography  Gastrografin (Diatriazoate meglumine 660 mg/Diatriazoate sodium 100 mg per mL)
(CT of Torso) Preparation: Dilute 30 mL to 1 liter with tap water.
Dose: 240 mL of diluted solution PO x 1 dose 15-30 minutes prior to imaging. May repeat dose up to maximum
2000 mL PO prn radiologist request.
Magnetic Resonance Imaging
Contrast-Enhanced MRI  Omniscan (Gadolinium or Gadodiamide, 287 mg/mL)
Dose: 0.1 mL/kg IV x 1 dose. Patient weight: __________ Dose = __________ mL.
May repeat dose up to 0.4 mL/kg IV prn radiologist request. Max dose: ______ mL.
GI Tract  GastroMark (Ferumoxsil oral suspension, 175 micrograms iron/mL)
Dose: 600 mL PO x 1 dose at rate of 300 mL over 15 minutes. May repeat up to 900 mL PO.
For patients receiving IV contrast and taking metformin or metformin-containing medications, patients should be instructed to
discontinue these agents for 48 hours after receiving IV contrast. Check one:  Yes  No  Not Applicable
Radiologist Name and Signature: ____________________________________________________ Date: _____________ Time: __________
Nurse Signature: __________________________________________________________________ Date: _____________ Time: __________
Return Fax
Pharmacist Initials: ________________ Date: ________ Time:
#:___________ ________
354
No. Chapter 46
Subject: TITRATION OF MEDICATION Page 1 of 3

FOR
CONTINUOUS INFUSION
Prepared by: Theresa Chan, Pharm.D. Original Issue Date 1/08
Reviewed by: Dianne Woods, Supersedes: NEW

RN__________
Cheryl Okundaye,
RN________
Alan Hui, Pharm.D., BCPS Effective Date: 1/08
Approved by: Nicholas Galeota, MS, The JC Standards: MM.3.20

RPh___
Anny Yeung, RN, MPA_____

Related Policies
Margaret Jackson, MA, RN__ PHA-2 Patient Medication Order
David Conley, MBA________
Stanley Fisher, M.D._______
Michael Lucchesi, M.D._____
Debra D. Carey, MS_______ Issued by: Regulatory Affairs
I. PURPOSE
• To delineate responsibility and provide clinical guidelines/indicators in monitoring

patient’s response to medications requiring continuous infusion, which includes the
first dose of a new medication.
• To establish clinical parameters to monitor and/or titrate such medications
administered to patients.
II. POLICY
It is the policy of University Hospital of Brooklyn to ensure that safe and therapeutic
medication practices are utilized. This includes but is not limited to appropriate medication
procedures/ guidelines for prescribing, preparation, administration, titration, and monitoring.
III. DEFINITION
355
Titration of continuous infusion medications refers to adjusting the rate of the infusion to
meet parameters set by the clinical practitioner. Typical medications requiring titration
includes vasoactive agents, analgesics, sedatives, paralytics, anticoagulants,
antiarrhythmics, antihypertensives, and hypoglycemics.
IV. CHARACTERISTICS OF MEDICATION ORDERS FOR CONTINUOUIS INFUSION
Orders for drugs administered via continuous IV infusion must specify the following:
• The name of the drug
• The amount of the drug in a specific volume of diluent
• The diluent used for dilution
• Standard concentration as listed on the SUNY Downstate Critical Care drip chart or
by manufacturer guidelines shall be used for all continuous infusion medications.
• The administration route and initial rate of infusion expressed as dose per unit time
(e.g. mg/hr, unit/hr) or dose per kilogram weight per unit time (e.g. mcg/kg/min or
mg/kg/hr).
• Orders containing ONLY volume per time (e.g. mL/hr or mL/min) are unacceptable
due to potential medication errors
• The duration of therapy (must comply with the Automatic Medication Stop Order
Policy)
• Monitoring parameter(s) according to subjective (e.g. sedation or pain) and/or
objective (e.g. hemodynamic or laboratory) goals or statement to notify prescriber
when such parameters are out of range or unable to reach must be specified on the
medication order
V. RESPONSIBILITIES
Prescriber:
• It is the responsibility of the prescribing healthcare practitioner to ensure that the
complete medication orders complies with the Patient Medication Order policy (PHA-
2) and must write medication orders for continuous infusion containing the above
characteristics. Any orders lacking the above information shall be referred back to the
prescriber for correction or completion.
Nursing:
• It is the responsibility of the registered nurse to check all medication orders for
completeness prior to acknowledging and transcribing orders. The Registered Nurse
caring for a patient is responsible for the monitoring, titration, and documentation of
response to medications. This is particularly important when a patient is to receive
the first dose of a new medication.
Pharmacist:
• It is the responsibility of the registered pharmacist to verify any medication order for
appropriateness and safety. The registered pharmacist shall dispense the
medication after appropriateness and safety of the medication order has been
confirmed. The Pharmacist will also be a source of drug information.
VI. PROCEDURES/GUIDELINES
1. All critical care areas (ED, MICU, CTICU, CCU, OR, PACU and Stepdown) may use
continuous intravenous medications. Any medications requiring continuous infusion must
have critical care monitoring.
356
2. All non-critical care areas with cardiac monitoring may infuse continuous intravenous
medications with appropriate equipment and personnel.
3. ALL medications requiring titration and continuous monitoring shall be infused using the
smart infusion pumps in ALL areas.
4. Upon administering the first dose of a new medication to a patient, the nurse is
responsible for observing the patient‘s response to the medication for therapeutic and
adverse effects. Monitoring parameters are defined either within the order itself or by
protocol.
5. The frequency of monitoring for the effect of medications will be determined by the
clinical discretion of the prescriber and nurse, the clinical condition of the patient, and
clinical standards of the medications. Established protocols may also dictate frequency
of monitoring.
6. In addition, the nurse shall elicit subjective and objective information including, patient
vital signs and other appropriate parameters as necessary. This information shall be
documented in the patient flow sheet or nursing progress note.
VII. REFERENCES
JCAHO Medication standard

SUNY Downstate Standard Critical Care IV Drip Chart
Micromedex
Handbook of Injectable Drugs 14th edition by Lawrence Trissel
Lippincott’s Critical Care Drug Guide

YES NO
YES NO
YES NO
357
SUNY Downstate Medical Center - Department of Pharmacy
PLEADE NOTE: SUNY Downstate Medication Policy does NOT accept range orders. Dosing ranges are provided for references ONLY.
STANDARD CRITICAL CARE IV DRIP
DILUENT
MEDICATIONS STANDARD DILUTIONS PREPARATION DOSAGE RANGES
S
ALTEPLASE (tPA) for pulmonary embolism 100 mg/100 mL (1 mg/mL) Sterile Water 100 mg in 100 mL 100 mg over 2 hours
450 mg/250 mL (peripheral line) Loading: 150 mg/100 mL (bag) Loading= 150mg IV bolus over 10min
AMIODARONE (CORDARONE®) (1-6mg/mL, central line for high D5W Maintenance: 450 mg/250 mL Maintenance= 1mg/min X 6hrs then 0.5mg/min X
concentration) (USE GLASS BOTTLE) 18hrs (max 2.2g/day)
ARGATROBAN 250 mg/250 mL NS 250 mg (2.5 mL) in 250 mL 0.5–2 mcg/kg/min (Titrate to target PTT)
Initial: 0.08-0.1 mg/kg (IBW) IV bolus. (Higher initial
doses-up to 0.3 mg/kg-may be used for rapid onset
CISATRACURIUM (NIMBEX®) 100 mg/100 mL D5W or NS 100 mg (50 mL) in 50 mL
Maintenance: 0.01-0.015 mg/kg q25 to 45min prn
1-3 mcg/kg/min (titrate to Train Of Four)
DILTIAZEM (CARDIZEM®) 125 mg/125mL D5W or NS 125 mg (25 mL) in 100 mL 5-15mg/hr
500-1000 mg/250 mL
DOBUTAMINE (DOBUTREX ) ®
D5W or NS 500 mg (40 mL) in 210 mL 2-20mcg/kg/min (titrate)
500 mg/250 mL (premix)
400-800 mg/250 mL 5-10 mcg/kg/min (beta-1)
DOPAMINE D5W or NS 400 mg (10 mL) in 240 mL
400 mg/ 250 mL D5W (premix) ≥10mcg/kg/min (α)
EPINEPHRINE 2-4 mg/250 mL D5W or NS 2-4 mg (2-4 mL) in 250 mL Shock: 1-10mcg/min (titrate)
Loading= 500mcg/kg over 1min,
ESMOLOL (BREVIBLOC ) ®
2 g/100mL (premix) NS Not Applicable
Maintenance= 50-200mcg/kg/min (titrate)
FENTANYL 1250 mcg/250 mL (premix) NS Not Applicable 25-500mcg/hr (titrate)
FUROSEMIDE (LASIX®) 250 mg/50-250 mL (1-5mg/mL) D5W or NS 250 mg (25 mL) in 225 mL 5-10mg/hr (titrate)
Heparin weight-based nomogram(Titrate to target
HEPARIN 25,000 Units/250 mL (premix) D5W Not Applicable
PTT)
INSULIN 100 Units/100 mL NS 100 units (1 mL) in 100 mL Titrate
100-300 mg/100 mL 1:1 = 100 mg (20 mL) in 80 mL
LABETALOL D5W or NS 0.25-3 mg/min (titrate)
(1.25-3.75mg/mL) 2:1 = 200 mg (40 mL) in 60 mL
LIDOCAINE 1-2g/250mL D5W or NS 1000 mg (50 mL) in 200 mL 1-4mg/min
40 mg/40 mL or 60mg/60 mL 40 mg (10 mL) in 30 mL
LORAZEPAM (ATIVAN®) D5W preferred 0.5-10 mg/hr (titrate slowly)
(1mg/mL) 60 mg (20 mL) in 40 mL
MIDAZOLAM (VERSED ) ®
100 mg/50 mL (2mg/mL) (premix) NS Not Applicable 2-10mg/hr (titrate)
0.375 → 0.5 → 0.75mcg/kg/min (reduce dose in
MILRINONE (PRIMACOR ) ®
20 mg/100 mL (premix) D5W Not Applicable
renal insufficiency)
50mg/50mL or 100mg/100mL
MORPHINE D5W or NS 50 mg (5 mL) in 45 mL 1-10mg/hr (titrate)
(1mg/mL)
Bolus= 2mcg/kg over 60 second; infusion=
NESIRITIDE (NATRECOR®) 1.5 mg/250 mL D5W or NS 1.5 mg (5 mL) in 245 mL
0.01mcg/kg/min
(NEXIUM®) ESOMEPRAZOLE 80 mg/100 mL NS 80 mg/100 Ml 80 mg IV bolus then infuse at 8 mg/hr
25 mg/250 mL (peripheral) 25 mg (10 mL) in 240 mL Initial: 5 mg/hr, increase by 2.5 mg/hr to maximum
NICARDIPINE (CARDENE ) ®
D5W or NS
125 mg/250 mL (central) 125 mg (50 mL) in 200 mL dose of 15 mg/hr
NITROGLYCERIN (TRIDIL ) ®
100 mg/250 mL (premix bottle) D5W or NS Not Applicable 5-200mcg/min (titrate)
NITROPRUSSIDE (NIPRIDE®) 50-100 mg/250 mL D5W preferred 50 mg (2 mL) in 250 mL 0.5-10mcg/kg/min (titrate)
4 mg ( 4mL) in 250 mL
NOREPINEPHRINE (LEVOPHED®) 4-16 mg/250 mL D5W preferred 1-30mcg/min (titrate)
8 mg (8 mL) in 242 mL
OCTREOTIDE (SANDOSTATIN ) ®
500 mcg/100 mL D5W or NS 500 mcg in 100 mL 25-50mcg/hr
PHENYLEPHRINE (NEO-SYNEPHRINE®) 20-40 mg/250 mL D5W or NS 20 mg (2 mL) in 250 mL 40-200 mcg/min (titrate)
PROCAINAMIDE (PRONESTYL®) 1-2 g/250 mL D5W or NS 1 gm (10 mL) in 240 mL 1-4mg/min
PROPOFOL (DIPRIVAN®) 500 mg/50 mL (premix bottle) Lipid emulsion Not Applicable 5-50mcg/kg/min (titrate)
VASOPRESSIN (PITRESSIN®) 60 Units/100 mL D5W or NS 60 Units (3 mL) in 100 mL Vasodilatory shock= 0.04 Units/min (do NOT titrate)
VECURONIUM (NORCURON®) 10-20 mg/100 mL D5W or NS 10 mg (10 mL) in 90 mL 0.5-1.7 mcg/kg/min (titrate to Train Of Four)
(7/04,12/04,3/06, 10/07, 11/07)

Initial Treatment Protocol for Extravasation Injuries with Antineoplastic Drugs
Local Care
For all injuries: Agent-specific treatments
1. Stop infusion. 1. Apply cold or hot protocol, as listed below.
2. Aspirate residual drug through access device.
3. Elevate extremity.
 Cold Protocol: Apply cold to area for 15-60 minutes at least 4
times per day for 24-48 hours.
4. Avoid applying pressure to extravasation site.
5. See recommendations for agent-specific  Warm Protocol: Apply warm pack to area for 15-20 minutes at
treatments. least 4 times per day for 24-48 hours.
2. Follow additional local care instructions listed.
Agent-Specific Treatments
Medication Name Additional Local Care Antidote Preparation and Administration
®
Actinomycin D (Cosmegen ) Cold protocol None routinely recommended
®
Carboplatin (Paraplatin ) No specific recommendations None routinely recommended
Carmustine (BiCNU) No specific recommendations None routinely recommended
®
Cisplatin (Platinol ) No specific recommendations Sodium thiosulfate
In a syringe, mix 1.6 mL of 25% sodium thiosulfate with
8.4 mL sterile water. Inject 2 mL sodium thiosulfate
subcutaneously for each 100 mg cisplatin extravasated
into tissue surrounding site with multiple injections.
®
Dacarbazine (DTIC-Dome ) Protect exposed tissues from None routinely recommended
light.
Dactinomycin (actinomycin-D, Cold protocol None routinely recommended
®
Cosmegen )
®
Daunorubicin (Cerubidine ) Cold protocol Dimethyl sulfoxide 99%
®
Doxorubicin (Adriamycin ) Apply 1-2 mL of 99% dimethyl sulfoxide with gauze to
affected site every 6 hours.
Daunorubicin citrate liposome Cold protocol None routinely recommended
®
injection (DaunoXome )
®
Docetaxel (Taxotere ) Cold protocol None routinely recommended
Doxorubicin hydrochloride Cold protocol None routinely recommended
®
liposome injection (Doxil )
Epirubicin hydrochloride Cold protocol Dimethyl sulfoxide 99%
®
(Ellence ) Apply 1-2 mL of 99% dimethyl sulfoxide with gauze to
®
Etoposide (VePesid ) Warm protocol Hyaluronidase (150 units/mL) [REFRIGERATOR]
Inject 1 mL of hyaluronidase (150 units) subcutaneously
into site with multiple injections for each 1 mL
extravasated.
®
Fluorouracil (Adrucil ) No specific recommendations None routinely recommended
Gemcitabine hydrochloride No specific recommendations None routinely recommended
®
(Gemzar )
Idarubicin hydrochloride Cold protocol Dimethyl sulfoxide 99%
(Idamycin) Apply 1-2 mL of 99% dimethyl sulfoxide with gauze to
®
Ifosfomide (Ifex ) Cold protocol Dimethyl sulfoxide 99%
Apply 1-2 mL of 99% dimethyl sulfoxide with gauze to
Irinotecan hydrochloride Cold protocol None routinely recommended
®
(Camptosar )
Mechlorethamine Remove IV access device. Sodium thiosulfate
hydrochloride (nitrogen In a syringe, mix 1.6 mL of 25% sodium thiosulfate with
®
mustard. Mustargen ) 8.4 mL sterile water. Inject 2 mL sodium thiosulfate
subcutaneously for each 1 mg mechlorethamine
extravasated into tissue surrounding site with multiple
injections.
®
Mitomycin (Mutamycin ) Protect area from sunlight. Dimethyl sulfoxide 99%
Cold protocol Apply 1-2 mL of 99% dimethyl sulfoxide with gauze to
Mitoxantrone hydrochloride Cold protocol None routinely recommended
®
(Novantrone )
Nitrogen mustard Remove IV access device. Sodium thiosulfate
Agent-Specific Treatments
Medication Name Additional Local Care Antidote Preparation and Administration
®
(Mustargen ) In a syringe, mix 1.6 mL of 25% sodium thiosulfate with
8.4 mL sterile water. Inject 5 mL sodium thiosulfate
subcutaneously into tissue surrounding site with
multiple injections.
®
Oxaliplatin (Eloxatin ) No specific recommendations None routinely recommended
®
Paclitaxel (Taxol ) Cold protocol Hyaluronidase (150 units/mL) [REFRIGERATOR]
extravasated.
®
Pemetrexed (Alimta ) No specific recommendations None routinely recommended
®
Teniposide (Vumon ) Warm protocol Hyaluronidase (150 units/mL) [REFRIGERATOR]
extravasated.
Topotecan hydrochloride Cold protocol None routinely recommended
®
(Hycamtin )
®
Vinblastine (Velban ) Warm protocol Hyaluronidase (150 units/mL) [REFRIGERATOR]
®
Vincristine (Oncovin ) Inject 1 mL of hyaluronidase (150 units) subcutaneously
®
Vinorelbine (Navelbine ) into site with multiple injections for each 1 mL
extravasated.
No: CHAPTER 47
Subject: MANAGEMENT OF EXTRAVASATION INJURIES
Prepared by: LilyAnn Jeu, PharmD, BCPS Original Issue date:

Maureen McColl, PharmD
Megan Sargeant, RN 1/08
Reviewed by: Nicholas Galeota, M.S., R.Ph. Supersedes: New

Cheryl Okundaye, RN
Dianne Woods, RN
Approval date:
Approved by: MEC Distribution: Administrative Manual
Department Manual
Patient Care Manual
AOD Manual
I. Purpose:
To standardize the list of drugs to be provided in extravasation kits for treatment of extravasation
injuries with antineoplastic agents. To standardize the accessibility of antidotes for extravasation
injuries from non-antineoplastic agents. To provide guidelines for preparation and administration of
pharmacologic treatments for extravasation injuries.
II. Definition(s):
Extravasation is the inadvertent leakage or escape of a drug or solution from a vein or unintentional
injection surrounding healthy tissues.
Antineoplastic agents (or chemotherapy) are those used to treat oncology disorders. This policy relates
to such agents that may become extravasated through intravenous administration.
Antidotes for antineoplastic extravasation injuries are the following:

Hyaluronidase
Dimethyl sulfoxide solution
Sodium thiosulfate
Approved protocols for treatment of antineoplastic extravasation injuries are attached and shall be
included in chemotherapy extravasation kits (“Initial Treatment Protocol for Extravasation Injuries with
Antineoplastic Drugs”).
Antidotes for non-antineoplastic extravasation injuries are the following:

Hyaluronidase
Phentolamine
Topical nitroglycerin ointment
III. Policy:
Extravasation kits shall be stocked with antidotes (see attached list) that will be used for treatment of
extravasation injuries due to antineoplastic agents. Extravasation kits shall be stored in the Ambulatory
Chemotherapy Unit (in NS 62), Pediatric Ambulatory Oncology (Suite N), and Nursing Station 72.
Refrigerated items shall be stored in refrigerators in the vicinity.
have not been tampered. Pharmacy personnel shall be called to remove the opened box and provide a
replacement box.
Each kit shall be labeled with the expiration date of the earliest expiring medication. Any box that will expire
within one month shall be replaced by pharmacy personnel. Nurses shall inspect the expiration date at a
minimum of the first Monday of every month. Pharmacy personnel shall also review expiration dates on a
monthly basis.
Protocols for treatment of chemotherapy extravasation injuries shall be approved jointly by Oncology,
Pharmacy, and Nursing Departments. For chemotherapy extravasation injuries, nurses shall prepare and
administer recommended initial treatments for chemotherapy extravasation injuries as per protocol included in
the kit.
For non-chemotherapy extravasation injuries, medication orders shall be written by a licensed independent
practitioner to initiate pharmacologic treatment. Antidotes for non-chemotherapy extravasation injuries may be
stored in automated dispensing units in nursing stations, as requested per unit. Otherwise, these medications
shall be obtained from the main pharmacy.
Pharmacists, pharmacy technicians
Pharmacy personnel are responsible for the completeness and integrity of medications used for treatment of
extravasation injuries. Pharmacy personnel are also responsible for maintaining records for the distribution of
tamper-evident locks for chemotherapy extravasation kits provided to nursing staff.
Registered nurses
Registered nurses shall assess intravenous access sites for extravasation injury. In the event of an
antineoplastic extravasation injury that requires treatment, the nurse shall initiate treatment per protocol, even
prior to the arrival of a physician at the bedside. For non-antineoplastic extravasation injuries, nurses may
obtain antidotes located in automated dispensing machines pursuant to a medication order for treatment.
Providers (e.g., physicians, physician’s assistants, certified nurse practitioners, etc)

Providers shall evaluate patients with suspected extravasation injuries. For injuries from antineoplastic
agents, providers may prescribe additional therapies not included in the initial treatment protocol via
medication orders as per the policy “Patient Medication Orders.” Medication orders shall be required for
antidotes for non-antineoplastic extravasation injuries.
Registered Nurses
1. Monitor patients for signs and symptoms of extravasation injury.
2. If extravasation is recognized, stop infusion to the infiltrated site. If applicable, do not remove
angiocatheter until after treatment.
3. Identify the fluids or medications that infiltrated to determine appropriate treatment strategy.
4. Notify prescriber to assess potential injury and to prescribe appropriate therapy.
5. For chemotherapy extravasation injuries, nurses may initiate treatment as listed in the “Initial Treatment
Protocol for Extravasation Injuries with Antineoplastic Drugs” even prior to the arrival of the physician at
the patient bedside, as needed.
6. Document extravasation event and treatment in the patient’s medical record.
7. Call extension 1890 to report adverse drug reaction to UHB Pharmacy Department.
8. Nursing staff shall check extravasation kits with each shift change to ensure the kit has not been opened
and contents have not been tampered. The integrity of the lock is checked every shift and recorded.
9. Nursing staff shall check the expiration date for the kit at a minimum on the first Monday of each month.
The expiration date is checked and recorded. Pharmacy shall be called for a replacement kit if the kit
contents will expire within one month.
10. Manager of unit/nursing station will maintain signature log for checks on lock and expiration date for one
year. (See “Extravasation Kit Checklist”.)
11. Extravasation kit will be kept in a secured area when not being used.
Pharmacy Department
1. Pharmacy personnel shall stock medications and supplies for chemotherapy extravasation kits according
to the attached list. Guidelines for the preparation and administration of antidotes for chemotherapy
extravasation kits shall also be included in the kit contents.
®
2. Each month, pharmacy personnel shall review expiration dates of the kits and antidotes placed in Pyxis .
If a kit will expire within one month, pharmacy personnel shall remove the kit (and any refrigerated items
that belong to the kit) and provide a replacement to the nursing unit or suite.
3. Medication orders for treatment of extravasation injuries shall be processed as per the policy, “Verification
and Reviewing of Prescription Orders.
4. The Pharmacy Department shall investigate adverse drug reactions according to the policy, “Adverse Drug
Reaction Reporting.”
Providers
1. Treatment with medications for extravasation from non-antineoplastics shall require a medication order.
Orders shall be written on the Prescriber’s Order Form, as per policy on “Patient Medication Orders.”
2. Guidelines for treatment with other antidotes are listed below for non-antineoplastic extravasation injuries:
Extravasated Drug(s) Antidote Dose and Preparation of Antidote*

Aminophylline Hyaluronidase (150 units/mL) Infants and children:
Calcium salts Dilute to 15 units/mL by adding 0.1 mL of
Dextrose > 10% Administer within 1 hour of IV hyaluronidase 150 units/mL to 0.9 mL of 0.9%
Mannitol > 5% extravasation to minimize sodium chloride. Inject 0.2 mL aliquots
Parenteral nutrition tissue necrosis. subcutaneously or intradermally at the leading
Phenytoin edges of the extravasation site. Change needle
Contrast media after each injection.
Sodium bicarbonate 8.4%
Sodium chloride > 0.9% Adults:
Tetracycline May use undiluted hyaluronidse 150 units/mL or
Tromethamine may dilute as above. Inject 150 units (1 mL
(and other hyperosmolar undiluted) in 0.2-mL aliquots subcutaneously or
and acidic or alkaline non- intradermally along leading edges of the
chemotherapeutic agents) extravasation site.
Adrenergic/vasoactive Phentolamine (5 mg/vial) Dilute to phentolamine 0.5 mg/mL solution
agents: according to steps below:
Dobutamine Vial holds 2 mL of fluid. 1. Reconstitute powder with 1 mL 0.9%
Dopamine sodium chloride for concentration 5 mg/mL.
Epinephrine Administer within 12 hours of 2. Add 0.1 mL of 5mg/mL phentolamine
Norepinephrine IV extravasation. solution to 0.9 mL of 0.9% sodium chloride
Phenylephrine to make final concentration 0.5 mg/mL.
Vasopressin 3. Inject 0.5 mg (1 mL) of phentolamine
subcutaneously into site of infiltration in a
circular fashion. Change needle after each
injection.
Neonates: Recommended dose 0.1 mg/kg.

Maximum 2.5 mg total.
Infants and children: Recommended dose
0.1-0.2 mg/kg. Maximum 5 mg total.
Adults: Recommended dose 0.1-0.2 mg/kg.
Maximum 10 mg total.
If dose is effective, normal skin color should return

to the blanched area within 1 hour.
Topical nitroglycerin 2% NOT for neonatal use.
ointment
Apply thin layer to extravasated area (not to exceed
total dose of one inch).
* RN Note: Clean area with povidone-iodine prior to subcutaneous or intradermal administration of antidote.
XVI. Reasons for Revision:

VII. Attachments:
Chemotherapy Extravasation Kit Contents
Initial Treatment Protocol for Extravasation Injuries with Antineoplastic Drugs
Extravasation Kit Checklist
VIII. References:
Pharmacy Department Policy on “Adverse Drug Reaction Reporting” (Chapter 9, Section E)
Polovich M, White JM, Kelleher LO, eds. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice.
Second Edition. Pittsburgh, PA: Oncology Nursing Society, 2005:78-88.
Kohler DR. Antineoplastic Drugs: Preventing and Managing Extravasation. In: Boyiadzis MM, Lebowitz PF, Frame JN,
Fojo T, eds. Hematology-Oncology Therapy. New York, NY: McGraw Hill, 2007:582-588.
Reeves D. Management of Anthracycline Extravasation Injuries. Ann Pharmacol. 2007;41:1238-1242.
Wichham R, Engelking C, Sauerland C, Corbi D. Vesicant Extravasation Part II: Evidence-Based Management and
Continuing Controversies. Oncology Nursing Forum. 2006;33(6):1143-1150.
th
Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook International. 13 Ed., 2006-2007. Hudson, OH:
Lexi-Comp, Inc., 2006: 1542-1543.
rd
Zenk KE, Sills JH, Koeppel RM. Neonatal Medications and Nutrition A Comprehensive Guide. 3 Edition, NICU Ink, Santa
Rosa CA 2003.
Yes No
Yes No
Chemotherapy Extravasation Kit Contents
Check lock on kit with change of each nursing shift. Check expiration date on kit at least on the first Monday
of every month. Call Pharmacy Department (x2854) if kit will expire within one month.
Item Quantity Special Instructions
Dimethyl sulfoxide 99% solution (100 mL) 1 bottle
Sodium thiosulfate 25% (250mg/mL in 50 mL vial) 1 vial Must dilute prior to use.
Hyaluronidase (150 units/mL) 2 vials Must be refrigerated.
Sterile water for injection (10 mL) 1 vial
12-mL syringes 2 syringes
3-mL syringes 2 syringes
20-gauge needle 3 needles
25-gauge needle 10 needles
Alcohol swabs 6 swabs
4 x 4 Sterile gauze sponges 6 sponges
List “Initial Treatment Protocol for Extravasation 1 copy
Injuries with Antineoplastic Drugs”
White tamper-evident seal 1 seal Secure kit after it has been opened and
call pharmacy for replacement kit.
Also, call x1890 to report an adverse
drug reaction.
STATE UNIVERSITY OF NEW YORK
DOWNSTATE MEDICAL CENTER
EXTRAVASATION KIT CHECKLIST

Kit Location/Nursing Station: __________________
Lock Number: ________________ Kit Expiration Date: _______________
MONTH: ___________________________
Nurse checks integrity of kit and lock with change of each nursing shift and signs record below to indicate kit and lock
are intact. Day tour (Tour II) nurse also checks expiration date on kit at least on the first Monday of every month. Call
Pharmacy Department (x2854) for a replacement if kit will expire within one month.
1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day
Night Night Night Night Night Night Night
29 Day 30 Day 31 Day
Night Night Night
Revised 1/08
No: CHAPTER 48
Subject: FENTANYL PATCH
Prepared by: LilyAnn Jeu, PharmD, BCPS Original Issue date:

Ed Porosnicu, MD
Noelle Best, NP
Carline Sainvil, RN 5/08
Reviewed by: Nicholas Galeota, M.S., R.Ph. Supersedes:

Dianne Woods, RN
Marilyn Resurreccion, MD
Bonnie Arak-Druven, RN New
Approval date:
Approved by: Michael Lucchesi, MD Distribution: Administrative Manual
Department Manual
Margaret Jackson, MA, RN Patient Care Manual
AOD Manual
I. Purpose:
To promote patient safety with the use of fentanyl patches for pain management.
To delineate the process for safe application and disposal of fentanyl patches.
II. Definition(s):
Fentanyl patch (a.k.a. fentanyl transdermal system) is a high-concentration formulation of the
Schedule II opiate pain medication fentanyl that is applied to the skin for treatment of persistent,
moderate-to-severe pain for opioid-tolerant patients who require around-the-clock pain
management for more than a few days.
Opioid-tolerant patients should be receiving opioids for pain management on an around-the-clock

schedule at the time fentanyl transdermal system is prescribed. Patients may be considered
opioid tolerant if they have been receiving at least 60 mg of morphine per day or an equianalgesic
dose of another opioid for at least one week or longer.
III. Policy:
Fentanyl patches shall not be ordered for opioid-naïve patients. Fentanyl patches should not be
used to treat sudden, occasional, or mild pain. Patches shall be applied and removed in
accordance with guidelines to promote safe use of the patch. Patches shall be safely disposed
after use to prevent unintended release of fentanyl remaining in the transdermal system.
Prescribers, Nurses, Pharmacists
1
Prescribing
1. Prescribers shall review the patients’ medication histories and clinical indications prior to
ordering fentanyl patches for pain management. Fentanyl patches shall be ordered only for
opioid-tolerant patients.
2. Fentanyl patches may be ordered for a maximum duration of 72 hours per inpatient
medication order, as per the “Automatic Stop Order Policy.”
3. Due to potentially life-threatening hypotension, fentanyl transdermal system is

contraindicated in the following situations:
a. Patients who are opiate-naïve
b. Patients with acute pain who require opioid analgesia for a short period of time
c. Management of post-operative pain, including use after out-patient or day surgeries
d. Management of mild pain
e. Management of intermittent pain
f. Situations of significant respiratory depression, especially in unmonitored settings with a
lack of resuscitative equipment
g. Patients with acute or severe bronchial asthma
4. Fentanyl transdermal system is also contraindicated in patients with known or suspected

paralytic ileus or hypersensitivity to fentanyl or components of the transdermal system.
5. Fentanyl transdermal system is not recommended for patients younger than 2 years old.
6. Concomitant use of fentanyl and potent cytochrome P450 3A4 inhibitors (e.g., ritonavir,
ketoconazole, itraconazole, clarithromycin, nelfinavir, nefazodone) may increase plasma
concentrations of fentanyl and increase or prolong the potential for adverse effects. Dosage
adjustment and/or additional monitoring of patients is recommended.
7. Fentanyl transdermal system is not recommended for use in patients who have received a
monoamine oxidase (MAO) inhibitor within 14 days due to severe and unpredictable
potentiation of fentanyl effects.
8. Changes in fentanyl patch dose should not be made until at least 24 hours after change in
dose, unless the patient is experiencing side effects that warrant a dosage reduction.
9. Breakthrough pain medication should be ordered for patients receiving the fentanyl patch for
pain management.
Administration/Application
1. Clean intended site of application with plain, clear water, if necessary, and allow skin to dry
completely. Do not use soaps, oils, lotions, alcohol, or any other agents to cleanse skin
before application as these may irritate the skin or alter absorption of fentanyl from the
transdermal system.
2. Hair at the application site may be clipped (not shaved) prior to patch application.
2
3. Apply patch to intact, non-irritated and non-irradiated skin on a fat pad on chest, back, flank,
or upper arm immediately after removal from the sealed package. Press patch firmly in place
with the palm of the hand for 30 seconds, making sure contact is complete.
4. Do not cut or alter the patch in any way, as damage to the patch may result in rapid release
of fentanyl and may lead to the absorption of a potentially fatal dose.
5. Document on the patch the date and time of application of the patch and initials of the nurse
who applied the patch.
6. Nurse documents on the Pain Assessment/Intervention Record the location of the fentanyl
patch (e.g., left upper back) with the medication order.
7. Each patch may be worn continuously for up to 72 hours. Change patch according to
prescriber’s orders. After removal of a used patch, apply new patch to a different skin site.
8. If the fentanyl patch that was applied to a patient is discovered missing before the time for
removal, the nurse shall notify the primary team and complete an incident report.
9. If the dose of a fentanyl transdermal system is changed (i.e., increase or decrease in

dosage), remove all patches the patient is currently wearing and dispose of the patch(es)
according to procedures outlined below. Then, apply one or more unused fentanyl
transdermal patches to deliver the entire new dose prescribed.
10. If the fentanyl patch order is discontinued (or dose is changed), the nurse shall remove the
used patch from the patient and document wastage as described below.
Monitoring and Precautions

1. Patient shall be monitored for efficacy of pain management according to the “Pain
Management” Policy.
2. Patients shall be monitored for side effects of fentanyl including, but not limited to, the
following:
a. Respiratory distress or slow, shallow breathing
a. Bradycardia
b. Severe drowsiness, confusion or change in mental status
c. Dizziness
d. Risk for falls
e. Difficulty walking or talking
f. Constipation and urinary retention
3. Heat may increase the absorption of fentanyl from the transdermal system.
a. Patch application sites should not be directly exposed to external heat sources, such as
heating pads, electric blankets, heat lamps, saunas, hot tubs, or heated water beds.
b. Prescriber should be notified in the event of patients presenting with or developing fever
while wearing the fentanyl transdermal system.
3
Removal and Disposal
1. Upon removal of a fentanyl patch system, wastage should be documented on the Pain
Assessment/Intervention Record. The nurse removing the patch should make and entry,
:Patch removed” or “Patch wasted” and document the date and time of removal. Two nurse
signatures are required to document the wastage of fentanyl patch.
2. After removal of a fentanyl patch from a patient, the used fentanyl transdermal patch shall be
folded so that the adhesive side of the patch adheres to itself AND the patch shall be flushed
down the toilet.
Patient Discharge
1. If a patient shall be discharged with a fentanyl patch, the nurse documents in the Discharge
Summary that the patient is being discharged from the hospital with a patch and directions for
when the patch shall be replaced, if applicable.
2. Patients who will continue to use the fentanyl transdermal system after discharge shall
receive patient education on safe use and disposal of the patch prior to discharge. Patients
shall be advised to dispose of used and unused patches by folding the patches so that the
adhesive side adheres to itself and the patches are flushed down the toilet. Unused patches
that are no longer needed should be removed from pouches, folded, and flushed, as well.

VII. Attachments:
None.
VIII. References:
®
Duragesic [package insert]. Titusville, NJ: Janssen Pharmaceutica Products, LP; 2007.
Office of National Drug Control Policy. Proper Disposal of Prescription Drugs. Available at:
http://www.whitehousedrugpolicy.gov/publications/pdf/prescrip_disposal.pdf. Accessed January
21, 2008.
FDA Public Health Advisory: Important Information for the Safe Use of Fentanyl Transdermal
System (Patch). Available at http://www.fda.gov/cder/drug/advisory/fentanyl_2007.htm.
Accessed January 4, 2008.
UHB Policy and Procedure on “Pain Management.”
UHB Policy and Procedure on “Automatic Stop Order Policy.”
Yes No
4
No: CHAPTER 49
Subject: THALIDOMIDE (THALOMID®) Page 1 of 9
Prepared by: LilyAnn Jeu, Pharm.D., BCPS Original Issue date: n/a
Reviewed by: Gerald Soff, MD Supersedes: New

William Solomon, MD
Nicholas Galeota, M.S., RPh
Donald Caracciola, RPh
Dianne Woods, RN
Approval date:
Approved by: Pharmacy and Therapeutics Distribution: Administrative Manual
Committee
Medical Executive Committee Department Manual
Patient Care Manual
AOD Manual
I. PURPOSE
To delineate procedures for prescribing, dispensing, and storage of thalidomide for inpatient orders.
II. POLICY
Thalidomide may only be prescribed by prescribers registered with the S.T.E.P.S.® program.
Thalidomide may only be dispensed to patients registered with the S.T.E.P.S.® program.
Thalidomide medication orders shall be restricted to Hematology/Oncology physicians at UHB who

are registered with the S.T.E.P.S. ® program.
All requirements of the S.T.E.P.S. ® program must be completed for patients to receive thalidomide
from the UHB Pharmacy Department.
Thalidomide shall be dispensed in the form of 28-capsule blister packs. Upon patient discharge
from the hospital, any remaining thalidomide dispensed for any inpatient shall be given to the patient
to continue after discharge.
III. DEFINITION(s)
Thalidomide is an immunomodulary agent with FDA indications for usage in patients with newly
diagnosed multiple myeloma and cutaneous manifestations of moderate-to-severe erythema
1
nodosum leprosum. Thalidomide is a teratogen known to cause severe, life-threatening human birth
defects and, thus, should not be used by women who are pregnant or who could become pregnant
while taking the drug.
Thalidomide is only available through the System for Thalidomide Education and Prescribing
(S.T.E.P.S. ®), a restrictive distribution system by Celgene Corporation to minimize the chance of
fetal exposure to thalidomide.
The Customer Care Center number for Celgene Corporation is (888) 423-5436. This number should
be called for prescribers to register with the manufacturer and prior to prescribing and dispensing.
IV. RESPONSIBILITES
Prescribers, Pharmacists, Nurses
V. PROCEDURES/GUIDELINES
Prescribing
1. Both the patient and prescriber must be registered with the S.T.E.P.S. ® program (888-423-
5436).
2. The primary team for the patient shall contact the Hematology/Oncology consult team to order
thalidomide via the S.T.E.P.S. ® program. The Hematology/Oncology Attending Physician or
Fellow shall call Celgene Corporation to obtain an authorization number to prescribe thalidomide.
3. The registered prescriber shall write the medication order for thalidomide. The order must
include the authorization number provided by the S.T.E.P.S.® program.
4. The medication order for thalidomide should not exceed 28 days in duration.
5. If a patient would like to use his/her own medication, the Hematology/Oncology prescriber shall
be consulted and the complete medication order shall be written and include a notation that the
“Patient may take own medication.” The patient’s supply of thalidomide should then be brought
to the pharmacy for verification and labeling, as per the policy, “Patient Medication Brought Into
UHB.” Additional procedures listed below for thalidomide shall also be followed.
Dispensing
1. The medication order for thalidomide can only be accepted if it was written within the last 7 days.
Telephone prescriptions are NOT permitted.
2. Prior to dispensing thalidomide, the pharmacist must call the S.T.E.P.S. ® program to activate the
authorization number on the prescription and to obtain a confirmation number to dispense.
3. To obtain the confirmation number the pharmacist must also submit the following information to
the S.T.E.P.S. ® program:
a. Pharmacy DEA Number (AH 3303992)
b. Number of milligrams and number of capsules to be dispensed for each dosage strength
4. Prior to dispensing, the pharmacist shall transcribe BOTH the authorization number and the
confirmation number to the label marked, “Required information needed before dispensing
thalidomide,” and affix this label to the medication order. The order shall then be filed in the
Thalidomide binder for monitoring usage.
5. The pharmacist shall dispense one “Thalidomide Kit” for each valid medication order that
receives a confirmation number. Each kit contains the following:
2
a. Pharmacy label for the recording of the authorization and confirmation numbers for the
medication order (to be completed prior to dispensing of thalidomide and then filed with
the prescription). This label is NOT to be given to the patient.
b. One 28-capsule blister pack of thalidomide.
c. Copy of Drug Administration Record to be completed by nurses administering the drug.
d. Copy of the Patient Resource Pack from the S.T.E.P.S. ® program to be given to the
patient.
6. The Thalidomide Kit shall be given to a nurse directly. The nurse shall sign for receipt of the
blister pack on the Drug Administration Sheet.
7. The pharmacist shall dispense ONE INTACT BLISTER PACK for the medication order as part of
the Thalidomide Kit. Each blister pack contains 28 capsules of one strength. Thalidomide
should be dispensed in the original package, since the packaging contains patient warnings for
its use.
8. Blister pack should be labeled with instructions for use of thalidomide. The patient shall be given
the blister pack to continue the medication after discharge from the hospital.
9. The pharmacist shall not dispense more than 28-days supply of thalidomide to any one patient at
one time.
10. The inpatient pharmacy supervisor shall be notified that thalidomide has been dispensed and
requires tracking.
11. When the patient is discharged or the Drug Administration Record has been completed,
pharmacy personnel shall obtain the Record and attach it to the medication order filed in the
thalidomide binder.
12. If a patient brings his/her own supply of thalidomide, a Thalidomide Kit containing the Drug
Administration Record shall still be signed out to the nursing staff and nursing staff shall
document doses of thalidomide administered on the Record until all capsules have been
consumed and a new supply of thalidomide needs to be authorized by the S.T.E.P.S. ® program.
The patient’s supply of thalidomide shall be brought to the pharmacy for verification and labeling.
13. If the patient is transferred between services during the same hospital admission, the nurse of
the receiving unit shall bring the remaining capsules in the blister pack, the Drug Administration
Record, and the new medication order for thalidomide to the pharmacy for verification of doses
administered. A new Drug Administration Record shall be issued from the pharmacy with an
update on the number of capsules remaining in the blister pack.
14. If a thalidomide blister pack is discovered missing, an incident report shall be filed by nursing
staff. The incident report must be brought to the pharmacy before additional doses may be
dispensed. A new confirmation number may also be required to be issued by the Celgene
Corporation prior to dispensing.
Storage
1. Thalidomide capsules shall remain in blister packs until ingestion.
2. Nurses shall secure the remaining doses in the thalidomide blister pack for any individual patient
in the controlled substance cabinet of the patient care unit. The Drug Administration Record
shall be kept with the blister pack.
3. Remaining capsules of the blister pack should be given to the patient upon discharge from the
hospital.
Handling and Administration
3
1. Health-care providers should wear gloves when handling thalidomide capsules.
2. Health-care providers should wash hands with soap and water after handling of thalidomide or
bodily fluids from patients who are taking thalidomide.
3. Nurses shall document doses administered on the Drug Administration Record in the
Thalidomide Kit and the Medication Administration Record.
4. When the Drug Administration Record is complete, the nurse shall return the completed record
to the pharmacy in order to obtain a new Record for documenting additional doses to be
administered.
5. If a patient is transferred between different services during the same hospital admission, the
blister pack with remaining doses of thalidomide and the current Drug Administration Record
shall be brought to the pharmacy by a nurse of the receiving service. A new medication order
shall be required for the patient to continue thalidomide on the new service.
Patient Education
1. Patients shall be warned that exposure of a fetus to thalidomide will almost certainly result in
death or severe, life-threatening birth defects in the fetus.
2. Thalidomide is not intended for women who are pregnant, women who are breast-feeding, or
women who are able to get pregnant and not using two forms of contraception.
3. All patients (male and female) registering with the S.T.E.P.S.® program shall receive mandatory
contraception counseling and pregnancy testing, as applicable, upon enrollment.
4. A Patient Resource Pack shall be given to the patient with each blister pack of thalidomide
dispensed.
5. Patients shall be counseled not to share thalidomide, not to engage in blood or sperm donation
while taking the medication and for four weeks after stopping the medication, and to use
appropriate contraception while taking thalidomide and for four weeks after discontinuation.

x Institutional/operational changes
VII. Attachments:
Step-By-Step Guide to Dispensing Thalidomide
Thalidomide Administration Summary for Nurses
VII. References:
System for Thalidomide Education and Prescribing Safety (S.T.E.P.S. ®) Program at (888)423-5436
or www.THALOMID.com.
Policy and Procedure for Patient Medication Brought Into UHB (PTSAF-5)
Reviewed
Yes No
Yes No
4
STEP-BY-STEP GUIDE TO DISPENSING THALIDOMIDE
Registration with Celgene Coroporation’s S.T.E.P.S.® Program
 S.T.E.P.S.® stands for System for thalidomide Education and Prescribing Safety. It can be accessed
through the Celgene Customer Care Center at 1-888-423-5436.
 All patients and prescribers must be registered with the S.T.E.P.S.® Program
 Medication orders for thalidomide at UHB are restricted to Hematology/Oncology physicians.
Procedure for Dispensing Thalidomide
1. The prescribing physician calls the Celgene Customer Care Center for an authorization number.
The authorization number is written on the prescription.
2. The pharmacist may ONLY accept a medication order written within 7 days.
3. The pharmacist calls the Celgene Customer Care Center to activate the authorization number. The
pharmacist should be prepared to provide the following:
a. Hospital pharmacy DEA number (AH 3303992)
b. Strength of thalidomide capsules to be dispensed
c. Number of capsules of thalidomide to be dispensed (28 capsules per blister pack)
4. Celgene provides the pharmacist with a confirmation number to dispense.
5. Pharmacist profiles the medication order in Rx Connect.
6. Pharmacist obtains the Thalidomide Kit from its high-alert bin to give to nurse.
7. From the kit, pharmacist records both the authorization number and confirmation on pharmacy label
marked, “Required information needed before dispensing thalidomide.” Pharmacist affixes this label
to the hard copy of the medication order and files the order in the thalidomide binder.
8. Pharmacist completes the required information on the Drug Administration Record and the patient
label on the blister pack of thalidomide in the Thalidomide Kit. Pharmacist dispenses no more
than 28 days of thalidomide for the confirmation number.
9. Pharmacist requests the nurse for this patient to retrieve and sign for the thalidomide blister pack.
The nurse will be given the Thalidomide Kit, containing the INTACT 28-capsule blister pack, the
Patient Resource Pack, and the Drug Administration Record.
10. Pharmacist attaches the receipt from the Drug Administration Record to the original hard copy of the
thalidomide medication order in the thalidomide binder. Alert the inpatient supervisor that
thalidomide has been dispensed and requires tracking.
11. If a thalidomide blister pack is discovered missing, an incident report shall be filed by nursing staff.
The incident report must be brought to the pharmacy before additional doses may be dispensed. A
new confirmation number may also be required to be issued by the Celgene Corporation prior to
dispensing.
Patients Using Their Own Medications

1. The thalidomide order shall be written by the Hematology/Oncology physician with a notation that
“Patient may use own medication.”
2. The nurse shall acknowledge the order and bring the thalidomide to the pharmacy.
3. The pharmacist shall verify the identity and dose of thalidomide in the blister pack and label it
according to hospital policy.
4. The pharmacist shall profile the thalidomide as patient taking own medication.
5. The pharmacist shall issue a Drug Administration Record to the nurse to record doses of thalidomide
administered while the patient is admitted to UHB.
Updated February 25, 2008 (L. Jeu, PharmD) Page 5 of 9

STEP-BY-STEP GUIDE TO DISPENSING THALIDOMIDE (Continued)
Documentation on the Drug Administration Record

1. Nurses shall document all doses of thalidomide administered on the Drug Administration Record.
2. If the Drug Administration Record is completed prior to the completion of therapy, the nurse shall
bring the completed Record to pharmacy in order to obtain a subsequent Administration Record.
3. The pharmacist shall verify that the number of doses administered (as per the Administration Record
and blister pack) appears complete and correct.
4. The pharmacist shall issue a replacement Drug Administration Record with an updated number of
capsules remaining in the blister pack.
5. The pharmacist should attach the original Drug Administration Record to the hard copy of the
thalidomide order in the thalidomide binder.
Change in Thalidomide Dose or Discontinuation

1. If the thalidomide dose changes, the Hematology/Oncology physician will need to call Celgene for a
new authorization number.
2. The pharmacist shall call Celgene to activate the authorization number and to obtain a new
confirmation number ONLY WHEN additional capsules must be dispensed. [However, the patient
may not have more than 28 days of medication at one time.]
3. The nurse shall bring the blister pack and the Drug Administration Record to pharmacy with the new
medication order for evaluation and updating of instructions.
4. If the thalidomide order is discontinued, the nurse shall return the blister pack and the Drug
Administration Record to the pharmacy.
Patient Transfer Between Units

1. For any change in service, a new medication order for thalidomide is required from the
Hematology/Oncology physician.
2. For any change in service or change in unit location of the patient, the nurse of the receiving unit
shall bring the blister pack, the Drug Administration Record, and the current thalidomide order to
pharmacy for verification of doses administered.
3. The pharmacist shall verify that the number of doses administered (as per the Administration Record
4. The pharmacist shall issue a replacement Drug Administration Record with an updated number of
Patient Discharge
1. Upon patient discharge, the blister pack should be given to the patient to continue at home.
2. The Drug Administration Record should be brought to the pharmacy or may be left in the controlled
substance cabinet in the patient care unit until pharmacy retrieval.
3. Pharmacist should attach the Drug Administration Record to the hard copy of the thalidomide order
in the thalidomide binder.

THALIDOMIDE ADMINSTRATION SUMMARY FOR NURSES
Medication Orders for Thalidomide

 Medication orders for thalidomide at UHB are restricted to Hematology/Oncology physicians who are
registered in the S.T.E.P.S.® (System for thalidomide Education and Prescribing Safety) Program. It
can be accessed through the Celgene Customer Care Center at 1-888-423-5436.
 Physicians must obtain an authorization number to prescribe thalidomide. All medication orders for
thalidomide MUST contain an authorization number.
 The pharmacist MUST activate the authorization number and obtain a confirmation number in order to
dispense thalidomide.
Obtaining Thalidomide from the Pharmacy Department

 At UHB, the pharmacist dispenses thalidomide in a Thalidomide Kit directly to a nurse.
 Each kit contains the following:
12. One INTACT 28-capsule blister pack
13. One Patient Resource Pack
14. One Drug Administration Record (the same as the one used for controlled substances)
 The nurse must sign for receipt of the Thalidomide Kit and treat thalidomide with the same scrutiny as
used for controlled substances.
 If a thalidomide blister pack is discovered missing, an incident report shall be filed by nursing staff. The
incident report must be brought to the pharmacy before additional doses may be dispensed. A new
confirmation number may also be required to be issued by the Celgene Corporation prior to dispensing.
Patients Using Their Own Medications

 If the patient prefers to use his/her own supply of thalidomide, the order shall be written by the
Hematology/Oncology physician with a notation that “Patient may use own medication.”
 The nurse shall acknowledge the order and bring the patient’s thalidomide to the pharmacy for
verification, counting, and labeling according to hospital policy.
 The pharmacist shall issue a Drug Administration Record to the nurse for documentation of doses
administered at UHB.
Documentation of Administration
 All doses of thalidomide shall be documented on the Drug Administration Record and the Medication
Administration Record.
 Upon completion of a Drug Administration Record, the nurse shall bring the completed Record and the
blister pack to the pharmacy for verification of doses administered. The pharmacist shall then issue a
replacement Drug Administration Record, if needed.
Storage of Thalidomide
 Thalidomide capsules shall be stored with the Drug Administration Record in the controlled substance
cabinet of the patient care unit. This includes the patient’s own medications.
 Thalidomide capsules shall remain in the blister pack until ingestion.
 Upon patient discharge, the remainder of the blister pack should be given to the patient.
THALIDOMIDE ADMINSTRATION SUMMARY FOR NURSES (Continued)
Handling and Administration of Thalidomide
 Health-care providers should wear gloves when handling thalidomide capsules.
 Health-care providers should wash hands with soap and water after handling thalidomide capsules or
bodily fluids from patients taking thalidomide.
 Thalidomide is most commonly given once daily at bedtime.
 Thalidomide should be given with a glass of water at least one hour after a meal.
Patient Education
 The Patient Resource Pack in the Thalidomide Kit shall be given to the patient with each blister pack of
thalidomide dispensed.
 Thalidomide is not intended for women who are pregnant, women who are breast-feeding, or women
who are able to get pregnant and not using two forms of contraception.
 Patients shall be warned that exposure of a fetus to thalidomide will almost certainly result in death or
severe, life-threatening birth defects in the fetus.
 All patients (male and female) registering with the S.T.E.P.S.® program shall receive mandatory
contraception counseling and pregnancy testing, as applicable, upon enrollment.
 Patients shall be counseled not to share thalidomide, not to engage in blood or sperm donation while
taking the medication and for four weeks after stopping the medication, and to use appropriate
contraception while taking thalidomide and for four weeks after discontinuation.
Change in Thalidomide Dose or Discontinuation

 If the thalidomide dose changes, the Hematology/Oncology physician will need to call Celgene for a new
authorization number.
 The nurse shall bring the blister pack and the Drug Administration Record to pharmacy with the new
medication order. The pharmacist will verify the doses administered and then issue a new Drug
Administration Record. The blister pack instructions shall also be updated.
 If the thalidomide order is discontinued, the nurse shall return the blister pack and the Drug
Administration Record to the pharmacy.
Patient Transfer Between Units

 For any change in service, a new medication order for thalidomide is required from the
Hematology/Oncology physician.
 For any change in service or change in unit location of the patient, the nurse of the receiving unit shall
bring the remaining capsules in the blister pack, the Drug Administration Record, and the current
thalidomide order to pharmacy for verification.
 The pharmacist shall verify that the number of doses administered (as per the Administration Record
 The pharmacist shall issue a replacement Drug Administration Record with an updated number of
Patient Discharge
 Upon patient discharge, the blister pack should be given to the patient.
 The Drug Administration Record should be brought to the pharmacy or may be left in the controlled
substance cabinet in the patient care unit until pharmacy retrieval.

No: Chapter 50
Subject: ID Pharmacy PGY-2 Resident Qualifications and Obligations Page 1 of 5
Prepared by: Roopali Sharma, PharmD Original Issue date: 06/1/08
Reviewed by:Nicholas Galeota, Ms, RPh, Alan Hui, PharmD Supersedes: ________________
Approval date: NEW

Approved by: The Pharmacy and Therapeutics Committee
Department Manual
Patient Care Manual
AOD Manual
I. Purpose:
This policy has been developed for the Post Graduate Year Two (PGY -2) resident in Infectious
Diseases of the SUNY Downstate Medical Center to provide information on policies, procedures,
application process, qualifications for the program and obligations of the resident. These policies
and guidelines may directly affect a resident completing our program. It is recommended to read
this policy and keep a copy of it for future reference. Questions regarding the policy may be
addressed with the Residency Program Director (RPD) or the Director of Pharmacy Services.
Revision of policies and procedures may happen at any time and it is the obligation of the RPD to
inform the changes to the resident.
The purpose of this PGY-2 Residency is to provide an opportunity to accelerate their growth beyond
PGY-1 residency so they can become specialist in an area of pharmacy and can provide patient
care in infectious diseases. Further development of leadership skills that can be applied in any
position and in any practice setting is fostered during this residency. A PGY-2 Infectious Disease
Pharmacy Practice resident will acquire knowledge to refine their problem-solving strategies,
strengthen their professional values, work-ethics, attitudes, and advance the growth of their clinical
judgment. The residency year provides an educational environment to develop competencies
necessary to provide pharmaceutical care to patients with infectious diseases by providing patient
care, teaching, and clinical research in the area of infectious diseases pharmacotherapy. A
graduate of the program will be a competent and confident clinician in the management of Infectious
Disease Pharmacotherapy. Additionally, the resident will be an educator while working with patients
and other health care professionals in both inpatient and HIV clinic.
Upon successful completion of this PGY-2 residency, the graduate will be prepared to be a
prospective faculty candidate at the college of pharmacy and/or enter a clinical practice in Infectious
Diseases.
II. Definition(s):
Residency Candidate:
A resident candidate is a pharmacist who has completed a PGY-1 residency from an American
Society of Health-Systems Pharmacists (ASHP) accredited program who is applying for the post-
graduate year 2 residency program in Infectious Diseases at SUNY Downstate Medical Center. A
residency candidate must be enrolled in the ASHP Resident Matching Program to be considered for
the position.
Residency Committee:
The residency committee is made up of the following individuals Nicholas W. Galeota.,M.S.,RPh,

Roopali Sharma, PharmD, Alan Hui, PharmD, LilyAnn Jeu, PharmD, Maureen McColl, PharmD,
Teresa Chan, Pharm.D
Resident:
A resident is a resident candidate who is successfully matched to SUNY Downstate Medical Center
by the ASHP match process, and accepts an offer for employment. If no candidate is matched with
the program, then the program will attempt to interview candidates on a first-available basis until an
offer has been made and accepted.
III. Qualifications:
Applicants for the position of resident post-graduation year two (PGY2) should possess a PharmD
degree by an American Council of Pharmaceutical Education accredited college of Pharmacy and
should have completed (or be currently enrolled in) a PGY-1 Pharmacy Practice Residency. The
applicant must also demonstrate a commitment to excellent verbal and written communication skills,
professionalism and leadership, and to the provision of pharmaceutical care. Applicants should be
licensed, or otherwise eligible for pharmacy licensure, in New York State. The resident candidate
will apply for the program by submitting a curriculum vitae, completing an application, writing a letter
of intent and submitting an official college transcript. The candidate must also solicit three (3) letters
of recommendation to be submitted on their behalf by the recommender, one letter should be from
the director of the program. Only candidates who submit all of the required materials by the
application deadline will be considered for an onsite interview.
IV. Policy:
PGY-2 Infectious Disease resident are subject to and must comply with all SUNY Downstate
Medical Center Human Resources and Pharmacy Department Policies and Procedures. Policies
relating to conduct, attendance etc. are all reviewed at the institutional orientation sessions during
the first two days of employment. In addition, the PGY-2 resident must comply with the Program
Overview and Requirements as they relate to completing the goals set out by ASHP for completion
of the residency.
V. Responsibilities (Include all departments/services involved in development/implementation

and/or monitoring): Pharmacy
VI. Procedures/Guidelines:
INTERVIEW PROCESS:
• Candidates who submit all of the required materials, as outlined in the QUALIFICATIONS
section, by the deadline (January 20th), will be considered for an onsite interview.
• SUNY Downstate Medical Center will conduct a maximum of 10 onsite interviews for each
available residency position
• If it is necessary to limit those candidates who are invited onsite, the application materials will
be reviewed by the Residency Program Director (RPD), Director of Pharmacy, and at least one
Clinical Specialist (see: Resident Interview Form) for:
o Academic credentials
o Letters of recommendations
o CV (relevant work experience)
o Letter of intent
• Candidates with the highest scores in these areas will be invited for an onsite interview
o Onsite interviews will be conducted to determine, in addition to verification of relevant
work experience, academic credentials, letter of intent (see: Resident Interview
Evaluation Form):
o Professionalism
o Communication skills
o Clinical skills
o Service orientation
o Understanding of PGY-2 residency in infectious diseases
• The candidate will interview with the RPD, Director of Pharmacy, all the clinical specialists, two
infectious disease physicians and the current resident.
• After the last interview, the preceptors, director, clinical specialists, resident and RPD will meet
to determine the rank-order for the ASHP match process.
• When there are conflicting assessments, the interviewers will negotiate an agreement.
• Between the results of the negotiation and the overall Resident Interview Form assessment, the
rank order will be obtained and submitted.
• The ASHP match process is the final authority which determines placement of the resident
candidate with the institution.
POSITION ACCEPTANCE AND STARTING THE JOB:
• A resident candidate who successfully matches with the institution must agree to the terms and
conditions of employment, as outlined in the offer letter.
• The resident candidate must make every attempt to obtain New York Pharmacy licensure as
soon as possible.
• The resident candidate is expected to contact Human Resources and provide all requested
materials (i.e., proof of identity), complete a physical examination, and obtain an identification
badge prior to the start date.
• The start date will be on or about August 1 of the same year as the ASHP match.
• Pharmacy Practice Residents are subject to and must comply with all SUNY Downstate Medical
Center Human Resources Policies and Procedures.
• Policies relating to conduct, attendance etc. are all reviewed at the institutional orientation
sessions during the first two days of employment. In addition to those policies the following also
applies to the PGY-2 Resident:
DISMISSAL: The Residency Program Director may direct that a resident be dismissed during
the term of his/her residency for unsatisfactory performance or conduct. Examples include, but
are not limited to the following:
• Continued unsatisfactory performance and/or progress in the program
• Performance which presents a compromise to acceptable standards of patient care, or
jeopardizes patient’s welfare.
• Illegal and/or unethical conduct
• Excessive tardiness and or absenteeism
• Unprofessional behavior
• Inability to perform the obligations pursuant to the resident contract
DISMISSAL ACTION PROCESS: will be utilized if the resident fails to meet his/her obligations.
(see above Dismissal)
• Resident will be given two verbal warning by the preceptor. If the behavior does not change
then the Residency Program Director will be notified to conduct an investigation, including
meeting with the preceptor and the resident to identify information that relates to the
problem.
• If the resident continues to engage in behavior which are deemed harmful to the residency
program and fails to meet the obligations of the residency, the resident shall be given a
warning in writing and will have suggestions on the corrective action. This will be
documented in the resident’s file.
• If the preceptor determines that the resident may not be able to complete the obligations of
the rotation/residency, a plan to adequately complete the requirements shall be presented
by the preceptor and reviewed by the Residency Program Director and the Residency
Committee. No action will be taken against the resident until the Residency Committee has
reviewed the report and recommendations concerning any action.
• If the Residency Committee feels that the action recommended by the preceptor /
Residency Program Director is appropriate, the action will be implemented and the resident
will be in a probationary period.
• During the probationary period if significant improvement is not documented. Action may
include termination.
• The Director of Human Resources at SUNY Downstate Medical Center will be notified in
advance of placing a resident on probation. Dismissal of a resident requires consultation
with the Director of Human Resources.
• If dismissal is recommended the resident is given two weeks advance notice in writing by
the Residency Program director.
TIME OFF FOR EXTENDED LEAVE (DISABILITY/PROFESSIONAL/FAMILY/SICK): Attempts

will be made to accommodate in the event that the resident must take an extended leave for
certain life emergencies or life events. The resident must first use accrued sick time and vacation
time, unless the resident qualifies for Family Medical Leave Act (FMLA). If the leave extends
beyond the accrued time the resident will continue to be paid. However, the resident must sign a
contract to make up all missed time which does not qualify for accrued time, without pay until the
requirements and time (1-year) of the residency are satisfactorily completed. Failure to comply
with above will be a reason for dismissal from the residency program.

VII. Attachments: Interview evaluation, Evaluation form to screen for on-site interviews, signed offer,
application packet.
VIII. References:
One)
06/01/08 Yes No Roopali Sharma, PharmD
06/15/08 Yes No Alan Hui, PharmD
Yes No
No: Chapter 51
Subject: Intravenous to Oral Antimicrobial Conversion Program Page 1 of 1
Prepared by: Roopali Sharma, PharmD Original Issue date: 10/14/08
Reviewed by: Infectious Disease Division Supersedes:
Approval date: NEW

Pharmacy and Therapeutics Committee
Approved by: Distribution: Administrative Manual
Department Manual
Patient Care Manual
AOD Manual
I. Purpose: The purpose of this program is to provide a process and establish guidelines for the
conversion of intravenous to oral/enteral (IV to PO) anti-infectives when medically appropriate. The
advantages of this program are:
• To provide an oral/enteral dosage form with comparable bioavailability to the intravenous form,
this could reduce hospital length of stay.
• To avoid the added risks associated with continued intravenous therapy (e.g. IV infiltration, line
infection).
• To lower overall medication and associated costs to the patient and the hospital.
Background Information: A number of commonly used antimicrobial agents have near 100%
bioavailability*. The intravenous forms of these agents are useful in situations where the patient
may have compromised gastrointestinal function. In cases where the patient is in need of continued
antimicrobial therapy but is clinically stable with a functioning GI tract, oral therapy is a viable and
preferred option. Oral administration of medications has the advantages of greater safety,
decreased staff workload and decreased medication ancillary costs. A number of institutions have
implemented “Intravenous to Oral” conversion programs and have documented the
pharmacoeconomic benefit of an automatic, pharmacist-initiated automatic oral conversion
program.
Medications suitable for such “Intravenous to Oral” programs are those which are either well (>90%)
absorbed in patients with functioning GI tracts or those which have been shown to produce
equivalent therapeutic effects at appropriate doses with either route of administration.
*The exception to this is azithromycin. The oral bioavailability of azithromycin is about 40%.
Nevertheless, aside from treatment for community-acquired pneumonia in an ICU patient, oral
azithromycin is still recommended for patients able to take oral medications. Azithromycin has a
long half-life (11-68 hours) and concentrates intracellulary. In general, tissue concentrations are
much higher (10 to 100 times) than corresponding serum concentrations.
Ww/c/personal/draftprolprd.,doc
Cost Difference and Potential Savings at a Large teaching Hospital
PO IV 2006 IV Cost Potential % Potential Cost

conversion Savings
Linezolid $37.87 $52.00 $ 472,783 40% 40,114
(600 mg)
Voriconazole $21.27 $73.00 $ 444,646 30% 88,400
(200 mg)
Azithromycin $3.58 $12.00
(500 mg)
Levofloxacin $5.60 $11.73
(500 mg)
Fluconazole $0.08 $8.68
(200 mg)
Cost Difference of IV vs. PO Antimicrobials

at SUNY Downstate Medical Center
PO/unit IV/unit
Linezolid (600 mg) $60.00 $78.00

Voriconazole (200 mg) $32.00 $ 99.00
Azithromycin (500 mg) $6.60 $7.00
Moxifloxacin (400 mg) $2.55 $11.75
Fluconazole (200 mg) $0.02 $8.00
II. Policy:
In accordance with the Infectious Disease Division and P&T guidelines, the Department of
Pharmacy services shall facilitate an intravenous to oral conversion program to adult patients at
SUNY Downstate Medical Center with the goal of providing high-quality, cost-effective care. This
service will be provided Monday to Friday. Patients receiving certain IV antimicrobials (see
Appendix A) will be identified on a daily basis. The Post Graduate Year- 2 (PGY-2) infectious
disease resident and/or clinical pharmacist may automatically convert patients taking “approved
intravenous-oral equivalent medications” (see Appendix A) from intravenous to oral/per tube
administration when the PGY-2 infectious disease resident and clinical pharmacist patient
evaluation demonstrates the patient meets the established criteria for conversion.
III. Definition(s): (Optional)
IV. Responsibilities (Include all departments/services involved in development/implementation

and/or monitoring): Pharmacy
1. All patients taking any of the “approved intravenous –oral equivalent medications” will be
identified on a daily basis by the PGY-2 infectious disease resident and/or clinical pharmacist
Monday to Friday.
2. When a patient is prescribed one of the “approved intravenous-oral equivalent medications” the
medical record and medication administration record will be reviewed by the PGY-2 infectious
disease resident and/or clinical pharmacist. If necessary, the PGY-2 infectious disease resident
and/or clinical pharmacist will consult with the ID fellow/attending or patient’s physician to obtain
necessary information. If the inclusion criteria for route change are met without exclusion
criteria being present, the PGY-2 infectious disease resident and/or clinical pharmacist will
place an “Intravenous-Oral Equivalent Auto-substitution Order Sheet” (see Appendix B) and a
progress note in the chart documenting the route change “per P&T IV to PO conversion
protocol”.
3. Once the CONVERSION OCCURRS, the PGY-2 Infectious Disease Resident and/or Clinical
Pharmacist will continue to monitor the patient’s progress to assure the change was clinically
adequate and to identify and prevent any unexpected or untoward patient response.
4. If the primary physician refuses to accept the conversion, the IV to PO protocol may be
overridden by WRITING A NEW IV ORDER AS “Do not Auto Substitute” and no further changes
will occur for the patient during that admission. Reasons for declining the conversion
should be stated on the progress note.
5. Patients who did not initially fall under the inclusion criteria will be followed-up by the PGY-2
infectious disease resident and/or clinical pharmacist and monitored for IV to PO conversion per
protocol. Once the clinical presentation improves and patients fall under the inclusion criteria,
the IV to PO protocol will apply.
6. Stop Date – the new order stop date should be the same as that of the original order.
7. Applicable Antimicrobials – Linezolid, Azithromycin, Moxifloxacin, Ciprofloxacin, Fluconazole,
Voriconazole, Metronidazole
8. Criteria for Switch: (IV therapy for > 24 hours and must meet at least one of the Inclusion
Criteria and none of the Exclusion Criteria)
9. INCLUSION CRITERIA for automatic pharmacy conversion from intravenous to oral/per tube
administration of approved medications are:
a. Patient is receiving and tolerating oral/enteral medications and/or oral/enteral diet.
b. Patient is hemodynamically stable.
c. Absorption of oral/per tube medication is expected to be reliable (see exclusion
criteria)
d. Patient is receiving an approved intravenous-oral equivalent medication.
e. Afebrile for at least 24 hours (temp < 100.4ºF) and WBC decreasing toward normal
range (if leukocytosis initially present)
f. If an organism is identified, it must be sensitive to current choice of antibiotic
g. Additional specific criteria for documented indications should be met prior to switching
therapy in patients:
1. Bacteremia: afebrile x 24 hours, blood cultures negative x 48 hours, and
received IV therapy for at least 3 days.
2. Septic arthritis/osteomylelitis: Afebrile x 24 hours, received IV therapy for at
least 5 days, negative repeat cultures (if recultured), and with adequate
drainage where appropriate.
3. Draining abscess: Afebrile x 24 hours
4. Candidemia/Invasive Candidiasis; afebrile x 24 hours, blood cultures negative x
72 hours, and received IV therapy for at least 3 days.
5. Invasive Asergillosis/other invasive fungal infections: Received IV therapy for at
least 7 days.
10. EXLUSION CRITERIA for automatic pharmacy conversion from intravenous to oral/per tube
administration of approved medications are:
a. Patient is NPO (including medications)
b. Vomiting and diarrhea present in the last 24 hours
c. Presence of continuous NG suction, short bowel syndrome, ileus, proximal resection
of the small bowel, active GI bleed, patient is on paralytics
d. Dysphagia associated with recent seizure episodes; risk of aspiration
e. Patients who are comatose or have decrease in consciousness
f. Patients with bacteremia due to (Staphylococcus aureus or Pseudomonas
aeruginosa); endocarditis, myocarditis, mediastinitis, meningitis, intracranial
abscesses; febrile neutropenia (ANC < 500), Legionella or Pseudomonas pneumonia,
inadequately drained abscesses and empyema, severe soft tissue infections (strep
Group A)
g. Sepsis (evidence of infection and two or more of the following criteria: temperature >
38ºC (100.4ºF) or < 36ºC (96.8ºF), heart rate > 90 beats/min, respiratory rate > 20
breaths/min or PaCO2 of < 32 mmHg, and WBC count > 12, 000/mm3 or <
3
4,000/mm or > 10% immature neutrophils)
h. Mucositis, esophagitis, stomatitis
11. The PGY-2 infectious disease resident and/or clinical pharmacist should also assess for drug
allergies, appropriate time of administration, drug interactions (drug-drug, drug-food) and
potential for adverse effects. In any notable issue is detected during the pharmacist’s
assessment, the PGY-2 infectious disease resident and/or clinical pharmacist should write a
note in the progress notes section of the patient chart.
12. In situations where the clinical assessment is ambiguous, the PGY-2 infectious disease resident
and/or clinical pharmacist will discuss individual cases with the prescribing physician/ID fellow
prior to proceeding to the switch.
13. The Acceptance/disregard of IV to PO recommendations will be tracked and reported back to
the P&T committee along with estimated cost implications. This data will also be reported to the
ID division.
14. Each IV to PO conversion will be documented as a clinical intervention.

VII. Attachments: Appendix A, Appendix B
VIII. References:
1. Ramirez J. Early discharge strategies: role of transitional therapy programs. In: Owens R, Ambrose
PG, Nightingale CH, eds. Antibiotic Optimization: Concepts and Strategies in Clinical Practice. Boca
Raton, FL: Taylor & Francis Group;2005:431-451.
2. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American
Thoracic Society consensus guidelines on the management of community-acquired pneumonia in
adults. Clin Infect Dis 2007;44:S27-72.
3. Sevinc et. Al . Early switch from intravenous to oral antibiotics: guidelines and implementation in a
large teaching hospital. Journal of antimicrobial Chemotherapy 1999; 43:601.
4. Wong-Beringer et. Al. Implementing a program for switching from IV to oral antimicrobial therapy.
AJHSP 2001;58:1146.
5. Kuti et. Al Pharmacoeconomics of a pharmacist –managed program for automatically converting
levofloxacin route from IV to oral. AJHP 2002;59:2209.
6.Ramirez et.al. Early switch from IV to Oral antibiotics in hospitalized patients with bacteremic
community acquired Streptococcus pneumoniae Pneumonia. Archives of Internal Medicine
2001;161:848.
7.Ankee at. Al Early switch from Intravenous to Oral Antibiotics in Hospitalized Patients with Infections:
A 6 month prospective study. Pharmacotherapy 1997; 30; 569
8. Lelekis et. al sequential antibiotic therapy for cost containment in the hospital setting; why not?
Journal of Hospital Infection 2001;48:249.
Yes No
Yes No
Yes No
Yes No
APPENDIX A : Proposed Intravenous - Adult Oral Equivalent Antimicrobials
IV DRUG ORAL Equivalent Rationale

Azithromycin 500 mg IVPB Q 24hr Azithromycin 500 mg PO Q24hr Recommended dosing
Azithromycin 250 mg IVPB Q24hr Azithromycin 250 mg PO Q 24hr Recommended dosing
Ciprofloxacin 400 mg IVPB Q12hr Cirpofloxacin 500 mg PO Q 12hr Equivalent serum levels
Ciprofloxacin 200 mg IVPB Q12hr Ciprofloxacin 250 mg PO Q 12 hr Equivalent serum levels
Moxifloxacin 400 mg IVPB Q 24hr Moxifloxacin 400 mg PO Q 24hr Equivalent serum levels
Linezolid 600 mg IVPB Q 12hr Linezolid 600 mg PO Q 12hr Equivalent serum levels
Metronidazole 250 mg IVPB Q 8h Metronidazole 250 mg PO Q 8hr Equivalent serum levels
Metronidazole 500 mg IVPB Q 8h Metronidazole 500 mg PO Q 8hr Equivalent serum levels
Fluconazole 400 mg IVPB Q 24hr Fluconazole 400 mg PO Q 24hr Equivalent serum levels
Higher doses can be converted 1:1
Fluconazole 200 mg IVPB Q 24hr Fluconazole 200 mg PO Q 24hr Equivalent serum levels
Fluconazole 100 mg IVPB Q 24hr Fluconazole 100 mg PO Q 24 hr Equivalent serum levels
Voriconazole 4 mg/kg* IVPB Q 12hr Voriconazole 200 mg PO BID, Equivalent serum levels
dose may be increased to 300 mg
BID if not responding
* Based on 70 Kg patient (4 mg/kg x 70 = 280 mg)
APPENDIX B - Intravenous-Oral Equivalent Auto-substitution Order Sheet
PHARMACY THERAPEUTIC
SUBSTITUTION ORDER SHEET
Instructions:
1. Imprint patient’s plate before placing in chart
2. Sign bottom of form.
3. Kardex order as substitution.
ALLERGIES: WEIGHT lb. kg. HEIGHT: CrCL:
Intravenous to Oral Conversion Therapeutic Substitution

BY DIRECTION OF THE SUNY DOWNSTATE MEDICAL CENTER P&T COMMITTEE, THE ROUTES OF THESE
AGENTS ARE DESIGNATED THERAPEUTIC EQUIVALENTS FOR AUTOMATIC SUBSTITUTION.
Physician – Please discontinue:
______________________________ __________ mg IV ____________

(drug) (dose) (frequency)
Nursing – Please document substitution in the MAR as follows:
______________________________ __________ mg po ____________

(drug) (dose) (frequency)
Clinical Pharmacist Signature: __________________________________

Date:_________Time:_______
Print Name: _______________________________Beeper #:
RN
Signature:_________________________________________Date:_________Tim
e:_______
Print Name:________________________________

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POLICY AND PROCEDURE MANUAL

Chapter 1. Definition and use of Policy & Procedures Manual

Chapter 2. Integration of Pharmacy Services into the Hospital Organization

Chapter 3. Personnel Issues

Chapter 4. Inpatient Dispensing of Medications MM.1.1.10, MM.3.20,

Chapter 5. Controlled Substances

Chapter 6. Repackaging of Pharmaceuticals Either in Unit Dose or Unit of Use Form

Chapter 7.Compounding of Pharmaceuticals for Internal or External Use MM.4.20

Chapter 8. Absolute and 95% Alcohol

Chapter 9. Adverse Outcomes M.M.6.10, MM.6.20, M.M.8.10

Chapter 10. Handling of Non-Formulary Medications (including Home Medications

Chapter 11. Nursing Station Inspections MM.2.20

Chapter 12. Automatic Medication Stop Order Policy MM.7.10

Chapter 13. Outsourcing of Medications

Chapter 14. Procurement of Pharmaceuticals MM.2.10

Chapter 15. Emergency Drugs and the Pharmacy’s Emergency Responsibilities

Chapter 16. Handling of Multi-dose Vials of Inhalation, Injectable, and Ocular

Chapter 17. Storage of Pharmaceuticals MM.2.20

Chapter 18. Antibiotic Control Program MM.8.10; NPSG 7

Chapter 19. Drug Information and Staff Education

Chapter 20. Prescription Transmission to the Pharmacy Via Fax Machine

Chapter 21. Hospital & Patient Confidentiality

Chapter 22. Inter-Departmental Pharmacy/Nursing Policies

Chapter 23. Out-Patient Prescription Dispensing MM.1.10

Chapter 24. Safety Policies

Chapter 25. Infection Control MM.4.20; NPSG 7

Chapter 26. Pharmacy and Therapeutics Committee MM.2.10, MM.6.10, MM.6.20,

Chapter 27. Administration of Drugs within University Hospital at Brooklyn

Chapter 28. Drug Samples on University Hospital at Brooklyn Property

Chapter 29. Sterile Parental Compounding MM.4.20; NPSG 7

Chapter 30. Dispensing of Albumin Solutions

Chapter 31. Dosing of Cardiac Medications: Nitrates and Other Anti-Anginals

Chapter 32. Pharmaceuticals Education for Patients and Family Members

Chapter 33. TPA Injection for Catheter Clearance

Chapter 34. Management of the Pyxis® Medication

Chapter 35. High Risk Electrolyte Solutions NPSG 3

Chapter 36. Therapeutic Interchange Policy NPSG 3

Chapter 37. Medication Reconciliation NPSG 8

Chapter 38. Advance ECHO Lab Emergency Medication Box

Chapter 39. Patient Medication Orders MM.3.20; NPSG 1 & 2

Chapter 41. Labeling of Medication/Solution in Perioperative and Procedural Areas

Chapter 42. Look-Alike/Sound-Alike Drugs NPSG 3C

Chapter 43. Chemotherapy Ordering and Dispensing MM.3.10.3.20,4.10-4.80,

Chapter 44. Ordering and Dispensing of Parenteral Chemotherapy for Non-Oncology

Chapter 46. Titration of Medication Continuous Infusion (PHA-18)

Chapter 47. Management of Extravasation Injuries (PHA-20)

Chapter 48. Fentanyl Patches

Chapter 49. Thalidomide

Chapter 50. ID Pharmacy PGY-2 Resident Qualifications and Obligations

Chapter 51. IV to Oral Antimicrobial Conversion Program

Prepared by: NICHOLAS GALEOTA Original Issue date: 3/17/00

Reviewed by: WILLIAM GERDES Implementation Date: ___8/17/99__

Approved by: CONSTANCE SHAMES, M.D. Distribution:

IV. Responsibilities (Include all departments/services involved in development/implementation and/or monitoring):

VI. Reasons for Revision:

VII. Attachments: NONE

VIII. References: NONE

Mission of the UHB Pharmacy Department

The Mission of the Hospital Pharmacy is:

This mission is accomplished by:

3. Bulk compounding or pharmaceuticals.

5. Inspection of medications on all nursing units at monthly intervals.

7. Participating in the teaching of a course in Clinical Pharmacy Practice to undergraduate students of

Reviewed by: WILLIAM GERDES Implementation Date: _8/17/99

No: _CH. 2_

Subject: INTEGRATION OF PHARMACY SERVICES Page __1 of 1

No: _CH. 3 SECT. A_

Subject: PHARMACY STAFFING Page 1 of 1

No: _CH. 3 SECT. B_

Subject: DEPARTMENTAL TABLE OF ORGANIZATION Page 1 of 1

No: _CH. 3 SECT. C_

Subject: EMERGENCY EVENING/NIGHT STAFF Page 1 of 1