28 Day Multi Dose Vial Expiration Chart - DOC by yww20846


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                       AND OFFICAL FORMULARY

      I-1    Statement of Mission
      I-2    Statement of Vision
      I-3    Service Delivery Plan
      I-4    Providers
      I-5    Organization
      I-6    Governance
      I-7    Continuous Quality Improvement
      I-8    Hours of Operation
      I-9    Pharmacy Security
      I-10   Disaster Plan

     II-1   Formulary Add/Delete/Non-Formulary
     II-2   Decision Tree for Admission Prescribing Practices
     II-3   Medication and Dispensing
     II-4   Packaging and Labeling
     II-5   Standard Ward Inventory
     II-6   Medication Orders and Signature Cards
     II-7   Refills
     II-8   Discontinued Orders and Medications
     II-9   Multi- Dose Vials
     II-10 Controlled Drugs
     II-11 Sample Medications
     II-12 Floor Stock
     II-13 Radioactive Drugs
     II-14 Methadone Usage
     II-15 Investigational Drugs
     II-16 Medication Guidelines for High Risk Drugs
     II-17 Medication Reconciliation
     II-18 Discharge and Pass Medications
     II-19 Pharmacy Automation
     II-20 Unapproved Abbreviations

     III-1 Informed Consent
     III-2 Maximum Dose For Psychoactive Medications
     III-3 Automatic Stop Orders
     III-4 Drug Recall Procedures
     III-5 Patients’ Personal Medications
     III-6 Drug Storage Areas

    REV 01-2010                                                 1
      III-7    Guidelines for Administration of Medications
      III-8    Medication Administration Times
      III-9    Procurement of Medications

      III-10   Minimal Sedation Procedure
      III-11   Medication Variance Reporting and Analysis
      III-12   Medication Reaction Reporting
      III-13   Food Drug Interactions Procedure
      III-14   Self Administration of Medications by ECRH (Gracewood Campus)
      III-15   Poisoning Information
      III-16   Look Alike and Sound Alike Drugs
      III-17   Anti-Coagulant Management

     IV-1 Patient/Consumer and Family Education
     IV-2 Clinical Pharmacy Services
     IV-3 Drug Regimen Review Procedures
     IV-4 Pharmacist Annual Assessments
     IV-5 Team Conference Attendance
     IV-6 Continuous Quality/ Performance Improvement


      V-1      After Hours Availability of Drugs__
      V-2      After Hours Drug List (Gracewood Campus)
      V-3      After Hours Drug List (Augusta Campus)
      V-4      Crash Carts
      V-5      Behavior Intervention Kit
      V-6      Emergency Kits and Crash Carts
      V-7      Overnight-Day Camp Kit
      V-8      Suturing Kit
      V-9      Dental Clinic Emergency Kit
      V-10     23 Hour Program


     VI-1      ECRH Formulary (alphabetical listing)

    REV 01-2010                                                                2
                        AND OFFICAL FORMULARY


The Pharmacy for the East Central Regional Hospital (ECRH) provides pharmacy
services for the Gracewood and Augusta Campuses. The Pharmacy Department is
consolidated, and through programs and services, provides for all the associated needs for
the clients/patients and staff of both campuses. This manual supplements the other
policies for ECRH that outline specific policies and procedures that are used to provide
pharmaceutical care.



       The role of the ECRH Pharmacy is to provide safe and effective programs for the
       acquisition, dispensing, distribution, storage and use of medications for
       consumers or patients. The department operates under the auspices of the
       Pharmacy and Therapeutics Committee which assists in the formulation of
       policies and procedures to meet these goals.

       To be a progressive Pharmacy Department which delivers quality, cost effective
       Pharmaceutical Care and Services. To provide leadership on medication use and
       drug procedures. To be recognized for consistently meeting the needs and
       exceeding the expectations of our consumers, the hospital, and others.

      REV 01-2010                                                                       3


       The ECRH Pharmacy Department's mission is to provide safe and effective
       programs for the acquisition, dispensing, distribution, storage and use of
       medication for our clients. The following goals are established in support of this

       1.     To promote good health and prevent disease.

       2.     To promote optimal use of pharmaceuticals.

       3.     To provide drug information to ECRH staff, consumers, patients and

       4.     To assume responsibility for the procurement, distribution and control of
              all drugs used within the hospital.

       5.     To improve the effectiveness of pharmaceutical care through continuing
              education and staff development.

       6.     To participate in ECRH committees and provide pharmacy related

       7.     To provide evidence-based recommendations regarding drug therapy.

       8.     To promote pharmacists as integral members of the health-care team.

       9.     To be a progressive pharmacy department that delivers quality, cost
              effective pharmaceutical care.

       10.    To ensure that appropriate clinical services and drug use controls are

       11.    To provide leadership to the institution on medication use and drug policy.

       12.    To be recognized for meeting the needs and exceeding the expectations of
              the consumers/patients, family and the facility.

      REV 01-2010                                                                           4

        1.    The Clinical Pharmacist(s) functions as an integral member of the
              consumers or patients interdisciplinary team, providing input in the
              individual program plans, and assessing the effects of the medications on
              the consumers/patients.

        2.    The Pharmacy staff serves as a resource for the staff at ECRH in the areas
              of pharmacotherapeutics, pharmacoeconomics, pharmacokinetics,
              pharmacodynamics, and other areas relating to pharmaceuticals. Inservice
              efforts in these areas are provided.

        3.    The Pharmacy staff provides for all medications that are needed by our
              clients/patients regardless of cost and in a timely manner that serves to
              optimize the medications expected outcome. A pharmacist is on-call to
              provide assistance to meet these needs (after-hours) 365 days a year.

        4.    The Pharmacy strives to meet all standards appropriate to our function; to
              include ICF/MR, Skilled Nursing, Hospital, Joint Commission, ACDD,
              HCFA and other standards as appropriate. The Pharmacy abides by all
              State, Federal, and local laws pertaining to operation of a licensed


              1.     Drug purchasing functions

                     A.      Select, purchase, and receive medication.

                     B.      Purchase non-formulary medication.

                     C.      Maintain ECRH formulary with the assistance of the
                             Pharmacy and Therapeutics Committee.

              2.     Drug Distribution Functions.

                     A.      Label and dispense consumer medications.

                     B.      Distribute floor stock medications.

                     C.      Distribute controlled drugs.

                     D.      Monitor and stock After-Hours Cabinet

                     E.      Maintain emergency kits.

              3.     Drug accountability and control functions.

       REV 01-2010                                                                         5
              A.     Maintain accountability of controlled drugs.

              B.     Inspect drug storage areas.

              C.     Verify, store, destroy, or return consumer/patient’s drugs
                     from home.

              D.     Verify physician's and dentist’s signatures.

              E.     Maintain/Monitor pharmacy QA plan.

              F.     Maintain psycho-active drug utilization database.

              G.     Maintain pharmacist competency files/standards.

       4.     Clinical functions

              A.     Perform drug regimen reviews.

              B.     Monitor adverse reactions.

              C.     Monitor medication errors

              D.     Monitor drug orders for correctness, completeness, and

              E.     Monitor for therapeutic duplication.

              F.     Monitor for medication allergies.

              G.     Monitor for drug interactions.

              H.     Provide drug information including classes on the
                     importance of complying with a medication regimen.

              I.     Maintain and Review client/patient medication profiles.

              J.     Perform medication reconciliation process.

              K.     Complete written annual pharmacy assessments for DD

              L.     Attend annual Interdisciplinary Team Conferences and
                     provide appropriate input.

              M.     Perform drug utilization reviews.

REV 01-2010                                                                       6
                    N.    Provide drug information to clients, patients, families, and
                          ECRH staff.

                    O.     Develop and monitor self-administration of medication

                     P.     Monitor laboratory values appropriate to medication use.

                     Q.    Monitor Food and Drug Interactions.

                     R.    Serve as pharmacy representative on facility appointed

                     S.    Provide pharmacy consultation (client/patient disease

                     T.    Participate in Periodic Health Reviews.

I-4          PROVIDERS

             Pharmacists are registered and licensed by the State of Georgia Board of
             Pharmacy. Pharmacy technicians work under the direct supervision of a
             pharmacist and many are certified by the PTCB. A pharmacist monitors all
             activities involving the dispensing of medication, the associated
             maintenance of records, and clinical pharmacy services.


             ECRH Pharmacy Department is managed by a Pharmacy Director and
             other Pharmacists and Technicians. Other support staff are also assigned
             to the department.

      REV 01-2010                                                                        7

             The Georgia State Board of Pharmacy Rules and Regulations, ECRH
             Policies govern the ECRH Pharmacy Department, and the standards and
             practices set forth by the Department of BHDD Pharmacy Practice
             Manual. Staff shall be accountable to perform according to ECRH
             Pharmacy Manual and Formulary.

             The pharmacists actively participate on many ECRH and Department
             Committees, including, but not limited to, the following: Medical
             Executive, Human Rights, Pharmacy and Therapeutics, Comprehensive
             Behavior Plan Review, Infection Control, Drug Utilization and
             Evaluation, Patient and Family Education, Management Team and
             Clinical Review Panel.

             The pharmacy staff also participates in the following activities: The Joint
             Commission preparation, facility planning, budget planning and
             management organization/reorganization of services, recruitment and
             selection of pharmacy staff and recommendations for FTE requirements to
             determine staffing plans.


             The ECRH Pharmacy Department follows the principals of continuous
             quality management and performance improvement. Processes are
             monitored and thresholds set to continuously monitor activities and seek
             out opportunities for improving performance. Monitoring is conducted
             monthly on important aspects of care covering all major activities of the
             pharmacy. The department actively participates in performance
             improvement activities. Drug regimen reviews and drug use evaluation
             projects provide a source of additional opportunities for improving
             performance. Annually ECRH Pharmacy Management team reviews its
             medication management system to identify areas to improve. Review of
             The Joint Commission standards additionally provides direction to
             enhance the overall medication management process.

      REV 01-2010                                                                        8

             Monday - Friday                              7:30 am - 4 pm
             Saturday                                     9 am - 1 pm
             Sunday                                       9 am - 1 pm
             Holidays                                     9 am - 1 pm

             Registered Pharmacists are continuously on call when the pharmacy is not
             in operation. Contact the Hospital Operator at (706) 790-2011 to contact
             the “on call” pharmacist.


       1.    Purpose

             To outline policies and procedures for maintaining the security of the
             Pharmacy on the Gracewood Campus in compliance with all Hospital,
             Local, State and Federal Regulations and policies regarding the storage of
             medications, records and other information. To maintain patient
             confidentiality as required and ensure that information systems are
             protected as required.

             A.     Pharmacy Dispensing Area (Gracewood Campus):

                    Keys to the Pharmacy are controlled at all times. Access to the
                    keys are restricted to pharmacists. Vault keys are signed for each

                    1. Regular work Hours

                    The dispensing area of the Pharmacy will be open 7am-4pm
                    Monday through Friday, and Saturday, Sunday and Holidays from
                    9am until 1pm. During these times, the door to the dispensing area
                    will be closed and locked. Only Pharmacy personnel will have
                    keys to the Day Lock. Only Pharmacy personnel and others who
                    have legitimate business in the Pharmacy are routinely allowed
                    admittance. Visitors must be escorted at all times. A registered
                    pharmacist must be on duty in the dispensing area during these
                    hours. The supervising pharmacist on duty in this area is
                    responsible to ensure that these policies are enforced.

      REV 01-2010                                                                        9
                       2. After-Hours

                       The Dispensing Pharmacy is protected by a security system. This
                       must be activated when closing the Pharmacy for the day. It is the
                       routine responsibility of the closing pharmacist to activate the
                       alarm upon closing the Pharmacy at the end of the day. All doors
                       and windows must be locked, checked and double-checked. Any
                       breech in Pharmacy security must be reported immediately to
                       Security and the Pharmacy Administration.

                       3. Storage of Medications

                       All Scheduled II and investigational drugs will be kept under
                       double lock and key in the Pharmacy, at all times. Other Scheduled
                       drugs ( III-V) will be kept under lock and key as well (except for a
                       sufficient quantity to conduct routine daily business). All
                       Scheduled drugs kept under lock and key will be inventoried
                       weekly by the on call pharmacist. Any discrepancies will be
                       immediately reported to the senior most staff member present.

               C.      Information System(s) Security

                       All Pharmacy staff will be required to follow all policies and
                       procedures regarding the confidentiality of patient records and
                       other information systems. All password protected programs will
                       be protected. Staff must follow proper protocols for use of
                       passwords and ensure that no unauthorized use of data occurs.



        In the event of a disaster to plan for the provision of pharmaceutical care for the
        patients and clients at the ECRH.

        As part of ECRH, the Pharmacy will follow the hospital disaster plans. An outline
        of the Pharmacy’s part in these plans are:

        1.     Maintain a 15 day supply of medications.
        2.     Establish a agreement to borrow or purchase medications from local
               hospitals and/or pharmacies as needed.
        3.     Maintain a supply of labels, records, and supplies to be able to dispense
               medications without the benefit of computerized data bases or electricity
               (if needed).

Establish and test an emergency call roster for Pharmacy employees, in the event of a
disaster. Employees are required to come to work in the event of an actual emergency.

       REV 01-2010                                                                         10



To establish a procedure for reviewing, adding to or deleting medications from the ECRH
drug formulary and outline criteria which will be used in deciding whether or not a drug
will be placed on the formulary, including procedures for non-formulary drug use.


The formulary system is a method whereby the medical staff, through the P & T
Committee, evaluates and selects the drugs considered useful in providing patient care.
Only those drugs selected for the formulary will be routinely available from the
pharmacy. A mechanism will be in place to provide for non-formulary drugs on an
individual basis.

Guidelines and Procedure

Additions and deletions:

The Pharmacy and Therapeutic Committee will serve as the vehicle for reviewing the
formulary and approving drugs for inclusion or deletion. Drugs on the formulary will be
tailored to the specific needs of our consumer population. Any member of the committee
or Medical Staff may request that a drug be considered for formulary inclusion. Drugs
may be considered for formulary addition or deletion throughout the year. The full
committee will vote on additions or deletions to the formulary. On an annual basis, the
committee will review the entire formulary. Deletions will be proposed on the basis of
usage and/or current best practices, safety and other factors.

The following criteria will serve as a basis for consideration of placing a drug on the
ECRH formulary. To be added to the formulary a drug should have at least one
advantage. If it does not, cost would be a major consideration. The following is a list of
advantages taken into account when considering a medication for the ECRH formulary:

   A.           Drug efficacy? Is the drug more efficacious than drugs currently on

   B.           Does the medication represent a new pharmacological class?

   C.           What is the potential for adverse reactions i.e. toxicity (alone and in
                combination with other products)? Is the drug safer than drugs currently
                on the formulary? What are the risks in using the drug? What are the
                known incidences of adverse effects?

   D.           Pharmacokinetic properties of drug? Is an advantage clinically relevant?

     REV 01-2010                                                                          11
 E.             Bioequivalence properties of drug?

 F.             Pharmaceutical equivalence? The degree to which two formulations of
                the same medications are identical in strength, concentration and dosage

 G.             Therapeutic equivalence? The degree to which two formulations of
                different active ingredients are judged to have acceptably similar
                therapeutic effects.

 H.             Perceived propensity to induce errors or to reduce errors?

 I.             What will the potential demand be for the drug? Is this drug widely used?
                Is the drug rarely used?

 J.             What is the cost and the impact on the ECRH budget? What is the
                cost/benefit ratio?

Non formulary medications:

The decision of drug selection is the ultimate responsibility of the licensed prescriber
(Physician / Dentist etc.). Therefore, it is recognized that there will be occasions when
there will be a need to use non-formulary medications. The following procedure will be
used to accommodate those needs.

Every effort should be made to treat the patient/client with formulary medications. The
physician may write for any drug that he/she feels is the best treatment for the patient,
regardless of the formulary status of the medication.

During regular Pharmacy hours the procedure will be as follows:

         Once the drug order is sent to the pharmacy the pharmacist will review the order
          and using his/her knowledge of the formulary make a determination as to
          whether they feel a formulary item may be a suitable substitute. If the
          pharmacist decides that a formulary item would be a suitable substitute they will
          consult the physician and make a recommendation. If the physician and
          pharmacist decide on the formulary item, the physician will rewrite the
          medication order accordingly.

         If despite the pharmacist recommendation, the physician still wishes to use a
          non-formulary drug the Physician must get approval from the Clinical Director.
          The attending physician who has received permission from the Clinical Director
          for non-formulary drug procurement (after review of formulary alternatives)
          should write on medication order “approved by Clinical Director”. This
          communicates valuable information to the pharmacy staff to expedite delivery
          of medication. The Clinical Director will either approve the non-formulary drug,
          or ask the prescribing physician to change to another regimen.

      REV 01-2010                                                                       12
         For tracking and trending purposes a Non-Formulary drug request form must be
         filled out by the pharmacist for every non-formulary drug ordered, including
         drugs that are subsequently changed to formulary drugs (regardless of the
         reason). The pharmacist must fill out this form to clearly indicate the outcome
         of the event. Non-formulary drug requests will be selectively reviewed at the
         next P & T meeting. This information will be used to guide the Committee
         when making formulary decisions.

After regular Pharmacy hours the procedure will be as follows:

        See the Decision Tree for Admission Prescribing Practices. (At the end of this

        All medication prescribers (physicians, dentists etc.) must be aware of what is on
         the ECRH Drug Formulary. Physicians who prescribe non-formulary drugs must
         make arrangements to treat the patient/clients with alternate therapy, if
         appropriate, until the pharmacy can procure the medication. This includes
         writing orders in the interim (if necessary) and communicating the specifics with
         the Nursing staff so that they are aware of the non-formulary order process and
         can act accordingly. The Pharmacy department will make every effort to procure
         the drug in a timely manner, however it must be acknowledged that despite the
         best efforts there will be occasions where there will be a delay in getting a drug.
         Emergency needs should be clearly understood by all parties. It is the
         responsibility of the physician and pharmacist to communicate closely in this
         process so that patient needs are met.

        Physicians may dispense consumer labeled medications from the After Hours
         Cabinet or consumer unit medications for unexpected discharge or pass.

        After Hours Emergency Procurement Procedure:

            ► MD consults the On-Call Pharmacist of necessity for non-formulary
              medication. If the On-Call Pharmacist cannot offer a formulary
              substitute, the non-formulary after hours process is initiated.

            ► On-Call Pharmacist is notified by the MD of the following: medication
              name, strength, next dose time, and expected duration of therapy and MD
              writes the order.

            ► Pharmacist contacts Medical College of Georgia Hospital (MCG)
              Inpatient Pharmacy staff to obtain the medication.

            ► ECRH and MCG Pharmacist discuss any special security methods
              required for transport of the medication (i.e. sealed envelope, plastic

    REV 01-2010                                                                           13
        sealed tote, etc.) as well as the need to label package with the location of
        delivery ( i.e. unit, Living Area).

        ► On-call ECRH Pharmacist calls the Nurse Administrator to inform
          her/him that arrangements for filling the medication order are

       ► Nurse Administrator contacts contracted cab company to pick up
         medication and notifies the Campus Security Officer and the Unit
         Nurse to expect delivery of the medication.

       ► Cab Company personnel picks up medication from MCG Pharmacy.
         MCG Pharmacy is located on second floor of the hospital. Contact
         phone number is (706) 721-4815 (MCG central Pharmacy).

       ► Contracted Cab Company delivers medication to the Campus
         Security Officer. Campus Security Officer will deliver the medication
         to the Unit Nurse.

        ►Unit Nurse will notify Nurse Administrator of medication delivery.

REV 01-2010                                                                       14
                                                               sumer evaluated and admitted.
                                     II-2 DECISION TREE FOR ADMISSION PRESCRIBING

                                                        Consumer evaluated and admitted.

                                                       Does Consumer report he/she is
     i.e. from family,                              supposed to be taking a particular med?
 previous medical record,
 medication bottles, other
   health care provider.
                                                        Yes                            No

                                      Can report be                                         Does reliable outside info indicate         No
                                  reliably confirmed?                             Consumer is supposed to be
                                                                                                 taking a particular med?                    No further action.
                    No                                Yes
              Would withholding       No                 Is med on               No
              med be medically
                acceptable?                                                                      Does Consumer report             Yes
                                                                                                                                         Fully document
                                                                                                 a medically acceptable
                                                                      No                                                                 rationale for not
                                           Yes                                                    reason for not taking
    Yes                                                                                             a particular med?
       Y                                                                                                                                   medication.
                                    Order med.                    Is a substitute
Fully document rationale                                       medically acceptable?
 for withholding med.
                                                                                                                                                     End of
                                                                                 Order med per                                                      process.
                                                   Order                   Non-formulary procedure.
        End of                                   Substitute.               (See Pharmacy Manual.)

REV 01-2010                                                                                                                                                       5


A) Pharmacists are to be registered and licensed by the Georgia Board of Pharmacy and
will abide by the Georgia State Board of Pharmacy Code of Professional Conduct.
B) Pharmacists will dispense all medications in accordance to State and Federal Law and
in accordance to standards set forth by accrediting bodies.
C) Pharmacy Technicians (under the direct supervision of a registered pharmacist) as
well as Pharmacists may enter Physician’s Orders into the patient’s electronic profile. All
orders will be verified by a pharmacist to ascertain that all aspects of the dispensing
process are properly addressed.
D) To guide appropriate drug therapy, health care providers at this hospital will be
provided with readily available consumer information. This information, at a minimum,
will contain the consumer’s Name, Age, Sex, Weight, Height, Diagnosis, Relevant Lab
Values, Drug History, Allergies, and Pregnancy/Lactation status.

A) Monitoring:

   All Physicians’ Orders will be monitored for:
               Appropriateness of Medication, Dose Range, and Schedule
               Duplication of Medication
               Drug/Drug Interactions
               Drug/Allergy Interactions
               Drug/Food Interactions

   Medications that are in question will not be dispensed until the physician clarifies the
   order. Both unit-dose and individual prescription medication dispensing systems are
   used by the ECRH Pharmacy. A unit dose system of drug delivery is predominately
   used at ECRH. The dispensing systems are modified to meet the needs of the
   consumers and the resources available to accomplish these goals. Currently all
   medication areas are filled with a 1-2 week supply of pharmaceutical blisters.

   ECRH Pharmacy staff review the appropriate drug dosing at time of order entry and
   Review the weight specific DUE monitoring. ECRH DUE committee regularly
   monitors the appropriateness of drug therapy and drug dosing of consumers less than
   50 lbs. Recommendations for medication changes are reported to Unit Physician.
   Assigned clinical pharmacists also review the appropriateness of drug dosing VIA the
   pharmacy drug regimen process.

B) Use of generics:

   Medication dispensed by the ECRH Pharmacy may be the generic equivalent of the
   proprietary name brand medication. The pharmacy reserves the right to substitute
   FDA equivalent medication. This is in accordance with Georgia State Board of
   Pharmacy rules and regulations.

     REV 01-2010                                                                              6
   C) Unit dose:

       Drugs are refilled and carts are exchanged every 14 days. Adult Mental Health
       (AMH) and Forenscis are filled every 7 days to improve medication safety
       evidenced by fewer medications in cassettes. A fill list is generated and a
       technician will place the appropriate medication, strength and amount in the
       cassette. A pharmacist will check the patient’s medication (cassette) for accuracy.
       Both the technician and the pharmacist will sign the fill list when completed.
       Items that are floor stocked, bulk dispensed i.e. liquids are normally sent in other
       ways will not be sent in the patients cassettes.

   D) Drug Education (ICF/MR Areas)

      Drug education leaflets will be issued for new medication orders when requested
      by the MD on original Rx. This information is utilized by nursing staff to monitor
      adverse effects of medication and to incorporate side effects in Nursing Health
      Care Plans. Drug Education information is accessible at all times through using
      Pharmacy One Source.com.


1 .The Pharmacy will dispense all medications packaged, appropriate to the specific drug
prescribed and according to the dispensing system (Unit Dose/Individual prescription).
These drugs must remain in the containers supplied by the Pharmacy.

2. All drug labeling will be performed by pharmacy personnel.

3. Labels must be typed or machine printed (computer generated).

4 .The labels must be legible, free from erasures and firmly affixed to the container.

5 .Appropriate ancillary labels and caution statements will be affixed to the container
where indicated.

6 .The metric system will be used whenever possible.

7 .The names and strength of the therapeutically active ingredient(s) should be indicated
on all compounded products.

8. Medications intended for dilution or reconstitution must contain specific direction for
doing so. This may be on the pharmacy generated label or on the manufacturer's label.
Whenever possible, dilution should be performed in the pharmacy. In some instances the
pharmacy will send out drugs not reconstituted due to short shelf life. The
directions for the reconstitution and a suitable diluent will be sent with the medication

9. Perishable drugs, such as antibiotics should have the expiration date clearly indicated

     REV 01-2010                                                                             7
on the label or via an ancillary label. Antibiotics that are reconstituted should have an
expiration date based on the manufacturer’s recommendations.

10. The route of administration must be indicated for parenteral drugs (IV, IM,SQ)

11. Coined names and unapproved abbreviations are prohibited ( i.e. PB).

12. Repackaged drugs used for floor stock must contain: drug name, strength,
manufacturer, lot number, expiration date and quantity on the label. Appropriate
repackaging records will be kept in the pharmacy with date of repackaging, amount
repackaged, manufacturer, lot number and signature of repackager and pharmacist.

13. The individual prescription medication container label must contain the following

   a) Client's first and last name

   b) Client's Living Area

   c) Generic or trade name of medication (whichever is appropriate) *

   d) Strength of medication

   e) Specific directions for use

   f) Identity of dispenser

   g) Name of prescriber

   h) Date of order

   i) Expiration date if dispensed in bulk bottle **

     *   If a generic equivalent is dispensed the word equivalent to brand name if
         applicable may follow the drug name on the label.

     ** Expiration dates for pharmacy prepared or packaged items will be 12 months
        from the date of dispensing (except for those perishable whose manufacturer’s
        expiration date is less than 12 months). Items that are dispensed in the original
        container will have the manufacturer's expiration date.

     REV 01-2010                                                                            8

Standard Ward Inventory will consist of drugs that are stocked in certain areas for the
use of our consumers. These drugs are stocked for the convenience of the Medical and
Nursing Staff, and require a valid physician's orders when it is medically necessary
administer the drug immediately without waiting for the pharmacy to send the
medication. Charging and replacement for items that are "ward inventory" vary upon the
type of item. The physician’s order must be sent to the Pharmacy for review. These
drugs may change from time to time as needs change. The areas where these drugs are
kept will be inspected monthly to ensure that they are being properly stored and
handled. A Monthly Medication Station inspection report will be completed by assigned
Pharmacy personnel to document compliance/noncompliance with proper procedures.
Floorstock and Standard Ward Inventory Drugs lists are approved by P&T committee
and facility CEO


1. All medication orders must be written on the physician's order form by a practitioner
licensed in the State of Georgia authorized to prescribe drugs e.g., Physician, Dentist,
Podiatrists etc.; and credentialed to write medication orders at ECRH. Each order is to
be signed and dated by the prescriber. The prescriber should use the metric system
whenever possible. Credentialed prescribers will have a signature card kept in the
Pharmacy. This card contains the following information: name, degree, DEA number,
address, Georgia license number, beeper number, signature, and date. Medication orders
sent to the pharmacy can be authenticated by comparing the signature on the order with
the signature card on file.

2. Emergency verbal orders and phone orders from authorized prescribers may be
accepted, and written on a physician’s order form by a licensed nurse or extern with the
following stipulations:

 a) The order must be recorded on the physician's order form ensuring that all
 necessary information is present (see below). The name of the prescriber giving the
 order, the time and the signature of the nurse/extern (with title) recording the order
 must be included.

 b) The nurse/extern must verbally repeat the order to the prescriber from the written
  record. Refer back to nursing documentation procedures that must be followed.

 c) If the order is received by a pharmacist, it will be recorded on a prescription blank
  and attached to the Physicians Order upon receipt.

 d) The prescriber must co-sign the order by the next regular working day, but in
  all events within 24 hours at both hospitals.

   REV 01-2010                                                                              9
   3. All Medication orders written by a prescriber must contain
   a) Date
   b) Name and dose of medication
   c) Frequency of administration
   d) Route of administration (if other than PO)
   e) Length of therapy (for special medications)
   f) Signature of prescriber with degree (MD) and provider #
   g) Drug Indication
   h) New drug information if applicable

 4. When any change occurs in a client's therapy a complete new order is required.
 Orders such as "change phenobarbital to bid" or change HS dose to 100 mg, are
 prohibited. A complete new order with all the information listed above should be

 5. This hospital does not recognize the phrase “Resume Orders.” Physicians are
 encouraged to either list all current medications when the client returns to the hospital or
 notate resume orders of a certain date (i.e. date of last Periodic Health review or last 30-
 day Renewal). Any medication changes that have occurred during that time frame must
 be addressed.

 6. A “Hold” order will be considered the same as a discontinuation order. A new order,
 containing all appropriate information, must be written to resume the medication.

 7. Only those abbreviations listed on the approved abbreviation list and approved and
 recognized by the Hospital as official can be used when writing a medication order.
 Orders with unapproved abbreviations will not be carried out, until clarified. See
 Section II-22 for a list of unapproved abbreviations.

 8. Physicians are not to use trailing zeros and to use preceding zeros when writing drug
 dosages in order to prevent medication dosing errors.

 9. The Pharmacist will monitor for therapeutic duplications, allergies, dose, indications,
 and any other apparent irregularities. Any questions arising from an order must be
 resolved with the prescriber before the drug is dispensed or administered. There should
 be no doubt as to interpretation of an order before the drug is given. It is the
 responsibility of either the pharmacist or the nurse to notify the prescriber of an illegible
 or uninterpretable order. No order should be to carried out until the question(s) is/are

 10. The pharmacist shall monitor for drug interactions prospectively when new
 medications are added to client's/patient’s medication regimen, via computer generated
 alert notes. The prescribing MD is notified and informed of such interactions.
 Documentation will be maintained on the order and to be documented in the physician
 contact log. Retrospective and concurrent reviews of drug interactions will be performed
 through clinical pharmacy reviews.

 11. All medication orders will be reviewed by a pharmacist prior to dispensing. The
pharmacist shall initial any corresponding documents i.e. medication order, refill request,
fill list, etc. The pharmacist will then place the medication in a designated area for

     REV 01-2010                                                                           10
delivery to the Living Area. When the pharmacy is not open, a health care professional
will review the medication order in the pharmacist’s absence. Being that the pharmacy is
not open 24 hours a day and 7 days a week, a pharmacist will conduct a retrospective
review of the order as soon as the pharmacy is open. Nursing and Medical staff have been
inserviced to utilize Pharmacy One Source.com as a online drug information reference if
health care staff have drug questions /issues when the pharmacy is closed.

II-7 REFILLS: Medications are normally refilled every 7-14 days in Unit Dose areas. A
refill calendar will be distributed to each Living Area/Unit monthly, designating the day
of automatic refilling. If a medication needs to refilled for any other reason, e.g. a prn, a
refill form (ECRH CLN12) must be completed and forwarded to the Pharmacy. These
forms may be used for bulk items e.g. inhalers, ointments etc., or tablets capsules, and
other dosage forms. The medication will be refilled and delivered to the area at the next
scheduled delivery.

medication and discontinued medications should be sent to the pharmacy daily. When
available, medications will be dispensed in unit dose packaging. Once returned to the
pharmacy, unit dose medications will be credited back to the consumer/patient per the
Georgia State Board of Pharmacy.

In situations where the medications can not be returned to the pharmacy that day, the
medications, remaining quantities, and appropriate consumer/patient information will be
written up on a CLN form 461 (non-controlled medications), a CLN form 462 (controlled
medications), or/and a GSSH form 312 (CII medications) and stored in a designated area
for optimal security. The unit pharmacy staff will verify the quantities of the medications
with a nurse and bring them back to the pharmacy to be returned to stock or destroyed.
Two pharmacists and a nurse will verify the count of the controlled substances and
witness the destruction of these medications. The CLN form 462 and GSSH form 312
will be retained in the Living Area for two years.

II-9 MULTI-DOSE VIALS: Multi-dose vials will expire on the manufacture date with
two exceptions. PPD and Insulins, which have a 28-day expiration date from the time it is
opened. Nurses must date these products once opened. They should be kept in the
refrigerator, unless the package insert specifically recommends against such storage. The
package insert will spell out the storage instructions and expirations of multi-dose vials.
Consult the insert prior to use. The nurse should check the medication refrigerator at least
monthly and discard any outdated vials. The pharmacist will check the expired drugs as
part of their monthly medication station inspection.

     REV 01-2010                                                                          11
    II-10 CONTROLLED DRUGS: Those drugs restricted in distribution and requiring
    special record keeping, due to their addiction and abuse potential.

    A) Schedule II - are drugs with the highest abuse potential. They cannot be refilled; a
    new written prescription is required each time they are dispensed for a consumer.
    Examples are: morphine, demerol, amphetamines, secobarbital, or combinations of
    drugs containing these types.

All schedule II drugs have a C-II noted next to them on the formulary listing. Drugs in
this class must be kept under double lock and key. A separate imprintable prescription
(ECRH form 375) is required for dispensing of these medications to ECRH consumers,
along with a regular order form. This prescription must contain the exact quantity to be
dispensed and be signed and dated by the physician. The DEA number of the prescribing
individual must be on the Rx prior to dispensing. A new signed Rx (form 375) must be
completed each time more medication is required. Schedule II drugs cannot be refilled.
The pharmacy requires a nurse to sign for these medications upon receipt on a ECRH
form 530-1.

At ECRH a controlled drug sign-out sheet (see GSSH or GRHA form 312 in appendix)
will be returned with the filled Schedule II prescription. The nurse that receives the drug
should immediately verify the count and complete the nurse verification section of this
sheet. Each dose that is given should be logged on this sheet, with the name of the person
giving the dose, date, time, amount on hand, amount given and amount remaining
columns completed. When all the doses have been given, the disposition section of the
form should be completed. If any doses are returned to the pharmacy it should be noted
here. The sign out sheet is retained in the Living Area for 2 years. The procedure for
filing is as follows:

     1. Maintain a folder for each client receiving a Schedule II drug. File the completed
     Form 312 here
     2. On discharge or death of a client, place client file in an inactive file. Indicate on
     each file a 2 year suspense date for destruction.

     3. Destroy file after 2 years time has elapsed.

    B) Schedule III- V drugs are those drugs with some degree of abuse liability (less than
    C II). These drugs may be refilled up to 5 times within a six month period. They are
    listed in the formulary with a "C" beside them. At ECRH, a GSSH form 312 may
    accompany these medications when they are delivered. All controlled drugs must be
    carefully charted on the client's medication administration record, which serves as the
    "proof of use sheet" for these drugs.

Floor stock Controlled drugs: A limited number of controlled drugs are kept as "floor
stock" in specified areas for emergencies and after hour use. A Controlled Drug Floor
Stock card will be sent along with the drug, when dispensed. Each dose that is given must
be logged on this form. The nurse must sign for these medications on the top portion of
this card when they are delivered.

       REV 01-2010                                                                              12
Ativan 2mg tubex are authorized to be floor-stocked in every Unit. This is to be used in
the event that an emergency dose of this drug is needed. The quantities are determined by
the P & T and are subject to periodic change. This drug is to be kept in the refrigerator
and its use and handling is reviewed by the pharmacy monthly.

Double count: All Schedule II drugs and other controlled drugs as required by Unit Nurse
Manager or Pharmacist must be counted between nursing shifts. All such drugs are to be
inventoried each shift, by both the nurse coming on and the nurse going off duty. Any
discrepancies should be noted immediately. Any problems with the Schedule II count
should be reported as soon as possible to both the Unit Nurse Manager and Pharmacy
Loss or waste of controlled drugs: When a controlled drug is lost or wasted i.e., part of
the dose is not administered, a GSSH form 686, Loss or Waste Report of Controlled
Drugs, must be completed in duplicate. A pharmacist must review the form for
appropriateness and completeness. The original is kept in a Living Area file and the copy
is sent to the pharmacy files (see GSSH form 686 in appendix for further details). Clinic
and Dental clinic originals will be kept in the pharmacy.

II-11 SAMPLE MEDICATION Sample drugs that are given to ECRH staff for the use
of the clients must be stored in and dispensed out of the Pharmacy. These drugs are not
usually part of the ECRH drug formulary, nevertheless the labeling and dispensing
requirements will be the same as routinely acquired drugs. For this reason, staff members
that are given or request samples for trial use by ECRH consumers should make
arrangements for these samples to be delivered to the Pharmacy. Sample drugs given to
staff members (physicians) for personal use will remain the property of the staff member.
Proper storage requirements of these drugs must be observed. They should not be stored
on the grounds of hospital. If a physician has made arrangements for samples to be left
for a trial of a medication he/she should make sure that an adequate supply is obtained to
complete the trial. To continue the patient on the medication after the sample supply is
exhausted, will require either the drug being placed on the formulary or the physician
requesting a non-formulary drug procurement.

Sample drugs that are “stored” in the Pharmacy will be recorded on a log to enable
adequate control, for the purposes of tracking, and in the advent of a recall. Provision has
been made to allow sample medication storage and distribution by medical staff assigned
the 23 Hour Observation Unit. The MD and nurse use pharmacy logs to document receipt
and issue of sample medications on this unit. Pharmacy maintains oversight (periodic
inspections) to insure adequate documentation. Sample drugs in this area are received
directly by the assigned physician and drugs are only used for NON-ADMITS.

     REV 01-2010                                                                         13
Medications available in patient care areas, but not dispensed for individual patients,
will be known as Floor Stock. Floor stock medication may include both over the counter
and prescription (legend) drugs. Floor stock will be ordered from the pharmacy,
utilizing a floor stock requisition form, (GSSH form 412 or MH 5-5 17A). Should any
component of the requisition form be omitted or improperly filled out, pharmacy
personnel will return the form for correction. When dispensing Legend drugs for floor
stock, pharmacy personnel will affix a label to the drug packaging, which will include:

               a). Unit/Living area name
               b). Name and strength of drug

These drugs are floor stocked in the patient care areas for nursing convenience. They are
for patient/client related use exclusively. A valid physician’s order is required to
administer any floor stock drug to a patient/client.

Floor stock controlled drugs:

Some of the controlled drugs used at ECRH especially those for as needed use (prn) will
be floor stocked. The determination as to what drugs will be floor stock will be made by
the ECRH Pharmacy and Therapeutics (P&T) committee. For instance, (Ativan)
lorazepam injection is floor stocked on Gracewood campus because of the frequent need
for the immediate use of this drug. Oral lorazepam as floor stock is sent to certain areas
as part of the Behavior Intervention Kit. The Pharmacy will maintain all necessary
records to satisfy all Federal and State regulations regarding the dispensing and
inventory control of controlled substances. Controlled substances will be requisitioned
on form MH 5-5 17B. Exact quantities of the drug(s) requested must be included.
Generally, the pharmacy will fill floor stock controlled drugs for the requested
quantities. Should the quantity be less than requisitioned, pharmacy personnel will
indicate quantity dispensed. The Unit pharmacist, at the time of the monthly medication
station inspection, will review the use, storage, quantities and documentation for floor
stock controlled drugs.

Accompanying each “prn” controlled drug will be a controlled substance Sign-out Card
(GRH/AUG form 12). Nursing personnel administering controlled substance have the
responsibility for documenting the proof of use for each dose on this form. Nurses
receiving the controlled substances from the pharmacy will match the ordered quantities
with the received quantities. Validation of this process will be confirmed by their
signature on the sign out card and return of the pharmacy portion.

Nursing personnel will inventory controlled substances at the close of each work shift.
Discrepancies will be immediately reported to the appropriate nursing supervisor.

II-13 RADIOACTIVE DRUGS ECRH hospitals do not handle radioactive
medications or substances that are used for diagnostic purposes. Consumers that are in
need of these substances will be sent to outside agencies for those needs.

   REV 01-2010                                                                         14

Physicians at ECRH are prohibited from prescribing methadone solely for the treatment
of a consumer’s/patient’s narcotic addiction.

Methadone may be continued for consumers/patients who are admitted to ECRH while
enrolled in methadone maintenance programs. The ECRH physician must verify
enrollment with the maintenance program treating physician. Dispensing methadone
upon discharge for consumers/patients in maintenance treatment programs is prohibited.

Methadone may be used for pain management at ECRH. Methadone may also be
dispensed for pain management for consumers/patients upon discharge.

   REV 01-2010                                                                      15
II-15. INVESTIGATIONAL DRUGS Investigational drug use will be governed by the
following policy. These drugs will be used only in patients/clients who have been
admitted to the facility on such drugs or have been placed on these drugs from another
facility. These circumstances will only occur when the use of investigational drug is
deemed to be essential for the health and well being of the involved client/patient. All
applicable laws and standards will be adhered to.

All investigational drug protocols will be followed. Drugs will be handled/dispensed
and disposed of according to the protocol and the procedures outlined by the
investigator and the drug manufacturer. Investigational drugs will be stored in the
Pharmacy under double lock and key (vault).

1. Purpose

  To provide policy and procedure and to delineate circumstances and safeguards for
  the use of investigational drugs.

2. Policy

  a. The facility will only use FDA approved investigational drugs.

  b. A client or patient admitted to the facility on an investigational drug may
     continue the drug if it is needed for his/her health and well being.

  c. The following measures, as required by State Board of Pharmacy Rule 480-13-09
     and The Joint Commission standards, shall be taken for each client/patient
     admitted to ECRH on an investigational drug:

      1] The Attending Physician will contact the Principal Investigator to establish a
         channel of communication and to obtain:

         A copy of the approved protocol for investigational drug use.

         Copies of informed consents signed by the client or his/her representative.

         Copies of past medical records relating to use of the drug.

         Information regarding the drug’s actions and adverse effects.

      2] Those who are to administer the drug shall have competency based training
         on the drug’s actions and adverse effects.

      3] A process for obtaining the drug both routinely and in emergencies shall be

   REV 01-2010                                                                         16
  d. Investigational drug use in a given consumer shall be reviewed and approved by
     the P&T Committee, Medical Executive Committee, and the CEO. The Human
     Rights Committee(s) and Medical Director, Division of MH/MR/SA shall be
     informed of the use of such drugs by the CEO.

  e. Continued use of the drug shall be monitored by the Medical Executive
     Committee. The Committee shall submit periodic reports on continued use of the
     drug to the Facility Administrator.

3. Procedure

  Responsible Person(s)               Action

  Attending Physician                  1. Discusses clients admitted on an investigational drug
                                          with the Principal Investigator and assures open
                                          channels of communication with the Principal

                                       2. Obtains copies of the approved protocol for the
                                          investigational drug, informed consent(s), past
                                          medical records, and information on the drug’s
                                          actions and side effects.

                                       3. Identifies, in conjunction with the Director of
                                          Nursing, those who are to administer the drug.
  Unit Clinical Pharmacist /
  Director of Pharmacy                 1.Reviews the approved protocol and other sources of
                                         information regarding the drug’s actions and adverse

                                       2. Provides in-service training regarding the drug’s
                                          actions and adverse effects to clinical staff involved
                                          in drug administration and providing clinical
                                          services to the client

                                       3. Assures defined procedures for obtaining the drug.

                                       4. Maintains adequate storage, control/accountability

                                       1. Refers protocol regarding use of the investigational
  Clinical Director                       drug and related information to the P&T Committee.

  P&T Committee                        1. Recommends approval/disapproval of continued use
                                          of the drug.

                                       2. Refers to the Medical Executive Committee.

  Medical Executive Committee          1. Recommends approval/disapproval of continued use.

   REV 01-2010                                                                       17
                              2. Refers to the Facility CEO.

Facility CEO                  1. Approves/disapproves continued use of the drug.

                              2. Informs the Human Rights Committee and the
                                 Medical Director, Division of MH/MR/SA, of
                                 circumstances surrounding use of the investigational

Responsible Person(s)         Action

Medical Executive Committee   11. Monitors continued use of the drug and provides
                                 periodic reports to the Facility CEO and the Human
                                 Rights Committee regarding its use.

REV 01-2010                                                               18

The following guidelines, reviewed by the ECRH Pharmacy & Therapeutics Committee
have been established by the hospital to ensure safe administration of high risk drugs.

Anticoagulants (Warfarin, LMWH-Lovenox, Fragmin)
Identify the consumer using at least two methods.
Verify the correct dose.
Verify the correct lab work (IRN, platelets, etc) has been completed.
Verify no sites of excess bleeding or bruising.

Identify the consumer using at least two methods.
Do not use the abbreviations "u" for "units."
Require two independent dose checks on all insulin orders.
Double check that the correct type of insulin is being administered.

Narcotics and Opiates
Identify the consumer using at least two methods.
Double check the correct dose.
Label medications by generic name as well as brand name.
All patients receiving opiates should be screened for allergies.
Ensure that naloxone or an equivalent is available/accessible in areas where narcotics are
Use liquid adapters and disposable syringes to insure dosing accuracy.

Psychotropics (NGAs & SSRIs)
Identify the consumer using at least two methods
Verify the correct dose.
Use dosage within established Maximum Recommended Daily Dosage (MRDD)
Dosages above MRDD must be approved by the Clinical Director.
Dispense as unit dose.
Clozapine (Clozaril) – Verify the correct lab work (ANC) has been drawn.

Neuromuscular Blocking Agents/ Paralytics (allowed only in ECT suite)
May only be given by a physician trained in airway management or a certified registered
nurse anesthetist.
Medication must be clearly labeled as a paralytic agent.
Dose must be verified by two practitioners before administration

     REV 01-2010                                                                       19
                               I CAN
                Protect My Consumers From
                    High Risk Medications
       Identify the consumer using at least two methods.
       Double check the correct type of insulin.
       All insulin doses are double checked by a second nurse.
       Never use “u” to abbreviate “units.”

Clozapine (Clozaril)
       Identify the consumer using at least two methods.
       Verify the correct dose.
       Verify the correct lab work (ANC) has been drawn.

Anticoagulants (Coumadin, Lovenox, Fragmin)
       Identify the consumer using at least two methods.
       Verify the correct dose.
       Verify the correct lab work (INR, platelets) has been drawn.
       Verify no sites of excess bleeding or bruising.

       Identify the consumer using at least two methods.
       Verify the correct dose.
       Ensure naloxone (Narcan) is accessible to the living area.

  For Questions about High Risk Medications, contact your Unit Pharmacist or call the
                               Pharmacy at 790-2496.

Approved by the ECRH P&T Committee May 13, 2010

     REV 01-2010                                                                    20
  Medication errors are one of the leading causes of injury to hospital patients,
  and chart reviews reveal that over half of all hospital medication errors occur
  at the interfaces of care. [Rozich JD, Resar RK. Medication safety: One
  organization’s approach to the challenge. JCOM. 2001;8(10):27-34.]

  Medication reconciliation is defined as a formal process of obtaining a complete
  and accurate list of each patient’s current home medications — including
  name, dosage, frequency and route — and comparing admission, transfer,
  and/or discharge medication orders to that list. Discrepancies are brought to
  the attention of the prescriber and, if appropriate, changes are made to the
  orders. Any resulting changes in orders are documented.

  The process involves three steps:
      1. Verification (collection of medication history)
      2. Clarification (ensuring that the medications and doses are
      3. Documentation (changes to orders or reason for differences)

   Clinical staff (Physicians, Pharmacists, Registered Nurses and Social Workers)
will interview the consumer, or family member to ascertain an accurate listing of all
medication (Rx, OTC and herbal products) currently used at time of admission. Staff
may also review prescription containers submitted at admission to ascertain the
medication history. If medication history information is not available at admission,
the physician should treat symptomatically and the social worker should contact
family representative for information/follow-up. If medication history is not
available, medical staff should specify symptomatic treatment on admission orders.
This information should be faxed to the pharmacy as soon as possible for
 Clinical staff will document current list of medications on ECRH Pre- Admission
Assessment (CLN 040- pg 3) report or ECRH Admission Evaluation Form
(MH001-pg2) report.
Admission history reports will be faxed daily to the pharmacy by admitting personnel
designated by the Clinical Director.
Clinical Pharmacist will compare drugs ordered using physician admission orders

with information documented in admission history report for said consumer. This

  REV 01-2010                                                                       21
should occur within 24 hours of receiving the physician admission medication orders.
Attending physician should be notified ASAP of prescription drug omissions or
dosage discrepancies, which could be harmful to the consumer. The reviewing
clinical pharmacist will not notify the physician if another drug in the same
therapeutic class was ordered (i.e. Seroquel ordered –but admission history indicates
consumer was previously on Risperdal).
Clinical Pharmacist will document on the admission history report that reconciliation
was completed, sign and date. Documentation of all discrepancies will be annotated
on said medication history report.
Pharmacy will maintain a Reconciliation notebook of all admissions /reconciliations.
Clinical Pharmacist will note on the admission report any discrepancies and
document physician contact responses relative to reconciliation.
Medication reconciliation should be completed daily.
Using the automated renewals that retrieve current medication list from Worx
computer system automatically completes consumer Transfer- Reconciliation.
Receiving physician should run report when consumer transferred into designated
Consumer Discharge-Reconciliation is automatically completed by using the
automated physician discharge report that retrieves current medication list from Worx
computer system Physician should run report when consumer discharged from
ECRH. Physician admission history (H&P), admission orders, transfer orders and
discharge orders are available in consumer chart for staff to review to insure
medication reconciliation is complete at ECRH. Note, the consumer receives the
printed list of discharge medications upon discharge for reference/submission to next
provider of service. Additionally the next provider of service receives a continuity
care plan and a discharge summary report from ECRH which further promotes
compliance with NPSG 8A &8B(Medication Reconciliation).

  REV 01-2010                                                                       22

A.      Discharge medications:

The ECRH Pharmacy provides medications for its patients/clients that are discharged or
go on pass. There are specific policies about the amounts and other things as they relate
to the type of consumer that is being served. These will be discussed in their specific
All discharge and pass medications orders must contain complete dispensing instructions,
including patients name, drug name, strength, form, quantity, and directions. The
physician must sign and date the order. A separate prescription with a DEA number is
needed to dispense Schedule II medication to discharged patients. Patients will be offered
counseling on their medication and medication information leaflets will be sent along
with the medication.

     Discharge medications at ECRH: Medications must be written on a patients discharge
     form (MH 5-5-410 in appendix). A maximum of 5 days supply can be dispensed for
     Augusta Campus patients. To receive schedule II medications a separate prescription
     including the physicians DEA number, must be written. Liquid psychotropic
     medications are not dispensed to patients without careful counseling of the patient or
     caregiver to prevent medication errors. Prior arrangements must be made with the
     pharmacy for this type of medication to be dispensed. A progress note must be entered
     into the patients record stating the necessity for dispensing this dosage form.

B. Pass medications:

Consumers who are not being discharged from an ECRH hospital but are temporarily
leaving the campus may receive pass medications. Medication orders must be written on
the physicians order form with complete dispensing information. The date and time of
departure and return must be included on the order. To receive schedule II medications a
separate prescription including the physicians DEA number, must be written.

In the long term care areas (MR) the following procedures must be followed:

1) The parent/guardian must notify the appropriate Living Area at least 3 days in advance
of departure. Each Living Area should assign a person to notify and coordinate with the
Physician the vacation drug needs of the client. The Physician will determine which
medications the client must have during the stay and which they may do without. An
order properly completed with the client name, drug name and strength and amount to be
dispensed must be filled out. The physician must sign the order. A regular physician's
order form should be used for this purpose. An addressograph should be used at the top
of the form. The exact date and time of the client's departure and return should be on the

       REV 01-2010                                                                      23
Topical preparations should be sent home with the client from the client's living area drug
supply (i.e. the client's own filled prescription labeled from the pharmacy). These items
must have a pharmacy label on them, the nurse should request that the family return the
topicals when the client returns to the hospital

2) The pharmacy will prepare the pass medications and send them to the client's living
area. Such medication will be dispatched one day prior to the departure of the client or on
Friday, if the client is to leave the institution on the weekend. The medication will be
delivered in a separate paper bag entitled "Pass Medication" with the name of the client
written on the bag. The nurse must check the medication upon receipt against the client's
records for corrections.

3) The nurse will be responsible for giving the medication to parents/guardians or others
having responsibility for the client while away from the institution and for instructing
them in its proper use. The nurse will document this activity on appropriate form(s).

4) Unexpected departures – The pharmacist on call will be notified by the appropriate
personnel when clients are going home unexpectedly, when the Pharmacy is not open.
The physician on call must write the order for the client's medication. The pharmacist
will return to Pharmacy, fill and dispense the medication, and verify with nursing
personnel or other personnel the medications being furnished. The OD on the Augusta
Campus may send properly labeled prescription medication from consumer’s cassette
when the pharmacy is closed and time does not permit the Pharmacist to return to the
facility and dispense the medications.

5) Upon receipt from the pharmacy, a nurse may open the prescription bottle of
take-home medications to verify that the contents of the bottle are the same as ordered. If
there is any question, as to whether the count of individual doses is correct, the
medication shall be returned to the pharmacy for recount. A nurse that verifies the count
of a pass medication should take care not to contaminate the medication.

 C.     Off-Campus Trip Medication

    The living area nurse is to be notified of proposed off-campus trips by sponsoring
    department or individual. At the discretion of the living area nurse, routinely prepared
    medications may be taken off campus in drug cabinets (for large groups) or drug
    baskets (for small groups) or the living area nurse may request the pharmacy to
    specially prepare trip medications.

      REV 01-2010                                                                        24
 1) Use of drug cabinets/baskets

            (a) Use of drug cabinets/baskets to take routinely prepared medications off
                campus is encouraged for those trips where use of cabinets or baskets is

            (b) The cabinets or baskets should be secured either by locking or utilization
                of the seals as provided by the Pharmacy. They should be maintained in a
                locked vehicle or in a secure environment.

 2) Pharmacy preparation of trip medication

            (a) If the living area/unit nurse determines that specially prepared trip
                medication are needed, a trip medication request GSSH Form 397, will be
                submitted to the Pharmacy at least five (5) days ahead of time.

            (b) The pharmacy will prepare trip medication for the required doses. The
                label for these medications shall contain the name of the client, name and
                strength of the drug, name of the doctor and directions for administration.

             c) Should a medication order be changed or discontinued between the time
                the medications are filled and the time the client actually leaves for the
                trip, the living area nurse shall return the trip medications to the pharmacy
                for appropriate adjustment and relabeling.

 D.     Birth Control Pills

If the consumer is on birth control pills when leaving the institution, the package of birth
control tablets originally dispensed from the pharmacy will be sent with the client on
vacation or trips. This is to ensure that the cycle will not be altered. If the cycle of tablets
will be completed before the client returns to the hospital, then the Living Area nurse will
fill out a refill Form 612 and write on the Form "pass". Return this package and the form
for an extra cycle of birth control pills.

      REV 01-2010                                                                            25
     (Medication Renewal Orders, Physician Discharge Reports, Pharmacy
Discharge Reports, Vacation Medication Orders, Transfer Medication Orders)

    Physician renewal orders are rewritten every 30 days for consumers in
       SNF and Mental Health areas of our facility and every 90 days for
                                consumers in ICF areas.
The automation process allows designated ECRH staff to print renewals, transfer orders,
vacation orders and discharge reports from computers at nursing stations, nursing offices
and physician offices as well as the pharmacy. These reports use the pharmacy WORx
computer system to retrieve accurate prescription information and BHIS-consumer
identification information to create template designed medication orders.

Benefits of automation :

   1. To prevent transcription errors on renewal orders. These reports retrieve real time
      information from the WORx computer system. Physicians can be assured that the
      renewal orders submitted at periodic health reviews are accurate relative to the
      date and time printed in the header of the renewal orders, or discharge reports.
   2. To save manpower hours (nursing, physician, and pharmacist time). A nurse
      using automation now only has to insure that medication orders for new start
      medication are accurate according to label on container received from the
      have to insure medication orders are up-to-date at time of the Periodic Health
      Review (PHR). This process is automated. Clinical Pharmacists will work with
      nursing staff and physicians to streamline the process. PHR implementation will
      consist of two primary components.
          a) PHR orders (area maintained) consisting of the following: diet, dietary
              measures, medication/indications, treatments, lab study frequency,
              supervision/privileges, and other non-medication parameters.
          b) Automated renewal orders (retrieved from WORx) containing
              medications, dosages, directions and indications.
   3. Renewal reports can also be used as consumer specific vacation/off campus
      medication requests or as transfer medication orders. In the past nurses and
      physicians have had to rewrite medication orders for vacations/trial visits.
      Automated Concept – Print consumer renewal, check vacation box, check drugs
      for pharmacy to dispense (check the box next to drug name). Fill in number of
      days for the vacation; fill in effective date (at bottom of renewal order). Sign and
      send to pharmacy (fax or order pick-up).
   4. Physician Discharge Medication Orders: This report retrieves correct medications
      and displays in ECRH consumer information template. Physician inputs name of
      consumer, prints report, checks appropriate boxes (indicates meds to dispense).
      Enter C if coupon is given to consumer, Rx if prescriptions given, checked box

     REV 01-2010                                                                       26
   indicates pharmacy to dispense. Physicians will check consumer drug
   information precautions, referral information, and disability information. Area is
   available for comments, consumer signature, physician signature and nursing
   signature. Previous method involved staff writing out this information (time
   consuming and method has increased possibility for errors).
5. Pharmacy Discharge Report: This report retrieves the same information as the
   physician discharge report relative to medications and consumer education topics
   with additional information concerning drug counseling. The automated reports
   create a checklist for the counseling pharmacist. Previously the counseling
   pharmacist has had to rewrite medications ordered by physician (labor intensive
   and increased possibility of errors).
6. Compliance with patient Joint Commission safety goal 8: Reconciliation of
   medications between providers of service. The physician discharge reports
   provide a method to comply with the safety goal.
7. Physicians can utilize their computers to access comment medication profiles
   from multiple medications, therefore improving the scope and delivery of

 REV 01-2010                                                                       27
 II-20 Unapproved Abbreviations

                                     DANGEROUS ABBREVIATIONS-DO NOT USE
                              Intended Meaning             Misinterpretation                                       Correction
MS                            magnesium sulfate            Confused for one another.                               Write “morphine sulfate”
MgSO4                         morphine sulfate             morphine sulfate                                        or “magnesium sulfate”
MSO4                                                       magnesium sulfate

Q.D., q.d., QD, qd            every day                    QID                                                     Write daily or qday
Q.O.D., q.o.d., QOD,          every other day              QID                                                     Write every other day
U or u                        unit                         Read as a zero (0) or a four (4), causing a             “Unit” has no acceptable
                                                           10-fold overdose or greater (4U seen as                 abbreviation. Use “unit.”
                                                           “40” or 4u seen as 44”).
IU                       international unit                Misread as IV (intravenous).                            Use “units.”
Zero after decimal point 1 mg                              Misread as 10 mg if the decimal point is not            Do not use terminal zeros
(1.0) Trailing zero*                                       seen.                                                   for doses expressed in
                                                                                                                   whole numbers.
No zero before decimal 0.5 mg                              Misread as 5 mg.                                        Always use zero before a
dose                                                                                                               decimal when the dose is
(.5 mg)                                                                                                            less than a
                                                                                                                   whole unit.
* Exception: A trailing zero may be used only where required to demonstrate the level of precision of the value being
reported, such as for laboratory results , imaging studies that report the size of lesions ,or catheter/tube sizes. Trailing
zero may not be used in medication orders or other medication-related documentation.
Reference: JCAHO Do Not Use List

       REV 01-2010                                                                                                        28

 The ECRH Pharmacy abides by the Department’s policy on informed consent for
 psychotropic drugs. Informed consent is obtained from either the consumers or a next of
 kin (as appropriate). Except for in the case of emergency, this consent is obtained prior
 to dispensing of the drug. The Pharmacy will hold the physician responsible for
 obtaining informed consent as per hospital policy.

The following is a table of the "maximum dose" for the major psychoactive medication
used at the consolidated pharmacy at ECRH. This table is for informational purposes
only, as a means of tracking, normally by graphical means of client’s dose of
psychoactive medications over time. There may be occasions where the dose may exceed
the "max" in this table, depending upon the use of the medication, the size or weight of
the client, or other factors. Please obtain authorization from the Clinical Director to
exceed maximum recommended dose.

Brand Name            Generic Name                ECRH Max Dose      References

Adapin, Sinequan      Doxepin HCl                 300 mg/day         2,3
Celexa                Citalopram                  60 mg/day          1,2
Cymbalta              Duloxetine                  120 mg/day         2,3
Desyrel               Trazodone HCl               600 mg/day         2,3
Elavil                Amitriptyline HCl           300 mg/day         2,3
Effexor XR            Venlafaxine XR              375 mg/day         2,3
Lexapro               Escitalapram                20 mg/day          1,2
Tofranil              Imipramine HCl              300 mg/day         2,3
Luvox                 Fluvoxamine Maleate         300 mg/day         2,3
Pamelor               Nortryptyline               150 mg/day         2,3
Paxil                 Paroxetine                  60 mg/day          2,3
Prozac                Fluoxetine                  80 mg/day          1,2,3
Remeron               Mirtazapine                 60 mg/day          2,3
Wellbutrin            Bupropion HCl               450 mg/day         2,3
Zoloft                Sertraline HCl              200 mg/day         2,3

Abilify               Aripiprazole                30 mg/day          2,3
Clozaril              Clozapine                   900 mg/day         1,2
Geodon                Ziprasidone HCl             160 mg/day         1,2
Geodon IM             Ziprasidone HCl             40 mg/day          1,2,3
Haldol                Haloperidol                 100 mg/day         1,2
Haldol Decanoate      Haloperidol decanoate       100 mg first       1,2

    REV 01-2010                                                                        29
                                                450 mg/month     1,2
Invega               Paliperidone               12 mg/day        2,3
Loxitane             Loxapine Succinate         200 mg/day       2,3
Mellaril             Thioridazine HCl           800 mg/day       2,3
Navane               Thiothixine HCl            60 mg/day        2,3
Orap                 Pimozide                   10 mg/day        2,3
Phenergan            Promethazine HCl           100 mg/day       2,3
Prolixin             Fluphenazine               40 mg/day        2,3
Prolixin Decanoate   Fluphenazine Decanoate     100 mg/month     2
Risperdal            Risperidone                16 mg/day        2,3
Risperidal Consta    Risperidone Consta         50 mg/ 2 weeks   2,3
Seroquel             Quetiapine                 800 mg/day       2,3
Thorazine            Chlorpromazine HCl         2000 mg/day      2,3
Trilafon             Perphenazine               64 mg/day        2,3
Zyprexa              Olanzapine                 40 mg/day        2,3

Brand Name           Generic Name               ECRH Max Dose    References

                     Stimulants: Cerebral and Respiratory
Adderall             Dextroamphetamine sacch,   60 mg/day        2,3
                     Amphetamine aspartate
                     Amphetamine sulfate
Ritalin              Methylphenidate HCl        60 mg/day        2,3

Ativan               Lorazepam                  10 mg/day        2,3
Restoril             Temazepam                  30 mg/day        2,3
Valium               Diazepam                   40 mg/day        2,3
Xanax                Alprazolam                 10 mg/day        2,3
Klonopin             Clonazepam                 20 mg/day        2,3

                     Anxiolytics, Sedatives, & Hypnotics
Ambien               Zolpidem                   10 mg/day        1,2,3
Atarax               Hydroxyzine HCl            400 mg/day       2,3
Benadryl             Diphenhydramine HCl        300 mg/day       2,3
Buspar               Buspirone HCl              60 mg/day        2,3
Vistaril             Hydroxyzine Pamoate        400 mg/day       2,3

    REV 01-2010                                                               30
                      Anticonvulsants & Antimanics
                      Valproic Acid/ Divalproex
Depakote/Depakene     Na                            60 mg/kg/day    2,3
Lamictal              Lamotrigine                   400 mg/day      2,3
Lithotabs             Lithium Carbonate             2400 mg/day     2,3
Tegretol              Carbamazepine                 1600 mg/day     2,3
Trileptal             Oxcarbazepine                 2400 mg/day     2,3

Calan, Isoptin        Verapamil HCl (ext. agents)   480 mg/day      2,3
Catapres              Clonidine HCl                 2.4 mg/day      2,3
                      Propranolol HCL (ext.
Inderal LA            agents)                       640 mg/day      2,3

Reference Code
                  1   Package Insert
                  2   Facts and Comparisons
                      Lexi-Comp Drug
                  3   Information

**Approved by the ECRH P&T Committee June 24, 2010**

Multiple Psychotropic Drugs:

ECRH Pharmacy monitors the use of multiple psychotropic drugs as part of the clinical
pharmacy drug regimen review process (Compliance with Medicaid indicators).
Additionally therapeutic duplication information is an essential part of pharmacy annual
assessments for DD consumers. Monthly Rational Drug Therapy (QA/CQI) reports
identify multiple psychotropic drug use for DD/MH consumers.



 Automatic stop orders provide a system for reevaluating a consumer’s need for specific
 medications after a specified period of time. This procedure aids greatly in preventing
 ECRH clients and patients from receiving drugs beyond the appropriate duration of

 The Pharmacy computer will limit the time a drug can be dispensed based on the time
 specified by the automatic stop order procedure. This is accomplished through the order
 entry process. After the stop order has taken effect, the pharmacy will stop sending the
 medication without a new order. No drug will be sent from the pharmacy beyond the
 stop order date until the pharmacist has received a new order.

    REV 01-2010                                                                        31
 The Automatic Stop Order Procedure for the drugs indicated below may be overridden
 by the physician if:

 1. The physician writes an order for the drug to be given for a specific length of time.
    The drug will then be automatically discontinued after the specified time has
    elapsed. The physician's order will supersede the automatic stop order when it is
    written for a specified length of time.

 2. The physician write an order for the drug on the thirty/ninety day
    recertification/reorder; the drug will then be dispensed continuously as written until
    the physician writes an order to discontinue the drug.

 3. The physician writes an order for the drug and desires to add it to the next
    thirty/ninety day order. The physician must indicate this desire by writing "add to
    thirty/ninety day order" after the drug, dose and directions for use.

The following specific stop orders are to be in effect at ECRH:

       1. Schedule II Narcotics: If no duration is specified, 1 day; otherwise 7 days
       maximum (unless terminal, 30 days).

       2. Schedule II Non-narcotics 30 days.

       3. Schedule III Narcotics 7 days

       4. Schedule IV

          Lorazepam PRN (Augusta Campus) 7days
          Clonazepam (scheduled) (Augusta Campus) 30 days

       5. Schedule V 7 days.

        6. Other drugs with stop orders:

        DRUG TYPE                                          STOP ORDER

        Coumadin                                                7 days

        Antibiotics (oral and parenteral)                       14 days

        Anti-emetics                                            7 days

        Antihistamines (for cough, cold, or allergy)            10 days

        Cold and cough preps                                    10 days
        Hypnotics                                               30 days

 7.   Order which reads “apply until healed” will be automatically stopped in 30 days.

      REV 01-2010                                                                           32
**** The pharmacist will notify the prescriber regarding any orders that need to be
rewritten because they are past the automatic stop date. The physician may then review
this information and decide whether or not to continue the therapy. To continue the
therapy, a new order must be written.


  To establish an effective method of rapidly handling all types of drug and biological

 The Pharmacy will keep records of all drugs that are procured. This record will consist
 of a card file or other appropriate system(s) with the following information. Drug name
 and strength, manufacturer, lot or batch number, date received, quantity received, and
 expiration date. This information will be kept for a minimum of two years for any drug
 procured. Upon notification by the manufacturer, FDA or other authority of a drug
 recall, the Pharmacy Director or his designee, will determine the applicability of the
 recall. This will be accomplished by review of the card file to see if any of this specific
 drug ( including lot #) is recorded. If we have not purchased this particular item, then no
 further action is needed.

 If we have purchased this brand and lot of the recalled drug; the following steps will be
 taken immediately.

 1. All stock of recalled item(s) currently in pharmacy inventory is removed from the
    shelves and quarantined.

 2. All areas where drugs are stored throughout both institutions will be inspected. All
    stock of recalled drug is to be returned to pharmacy. The Unit Pharmacist and Nurse
    Manager will coordinate.

 3. Medical Staff and other affected parties will be notified of the recall.

 4. Drug use will be discontinued until another source or an alternate drug can be

 5. A special inspection of the medication areas (including DC box) will be conducted by
    unit pharmacists to assure all recalled drug is removed.

 6. New drug supplies will be ordered through regular channels. Replacement drugs will
    be ordered as soon as practical.

 7. A file of drug recalls will be maintained in the Pharmacy for either internal or
    external review.

 Review of effects of recalled drugs

    REV 01-2010                                                                           33
 The unit physician(s) should review all adverse effects that are thought to be caused by
 the recalled drug. It is the responsibility of the unit physician and Director of Pharmacy
 to report suspected adverse effects to the FDA or other authority through an FDA Med
 Watch report.



The purpose of this policy is to establish uniform methods for the control, use and
disposition of all drugs introduced by and/or accompanying consumers at the time of
admission to a State Hospital or state-operated Crisis Stabilization Program (CSP).

Admitting/Attending physicians are responsible for the use and disposition of drugs
accompanying consumers to the State Hospital or CSP.

Medications introduced by and/or accompanying consumers at the time of admission are
controlled, accounted for, disposed of properly, and under most circumstances, not
utilized for treatment purposes.

A. Control of medications brought by consumers:

The admitting/attending physician is advised of the presence of any drugs accompanying
consumers at the time of admission.

All prescription medication, non-prescription medication, and illegal drugs
accompanying consumers to the hospital are identified by admitting staff and
documented in the Consumer Medication Brought from Home form.

When the consumer’s family is present during the consumer’s admission process, the
physician or other designated staff sends the medication home with the family. If the
medication can not be returned to the consumer’s family, two staff members identify and
count the medication at the time of admission (this can be done by any direct care staff
and does not have to be done by nurses). The drugs are bagged, dated, and sealed.
Packages are marked with the consumer’s name, identification number, and assigned
unit. Staff documents their count of the medication on the Consumer Medication
Brought from Home form. The sealed bag is sent to the pharmacy.

Pharmacy staff identifies and counts the medication and verifies this information on the
Consumer Medication Brought from Home form until discharge or destruction. The
original form is filed in the pharmacy. Once the Pharmacist receives medication, the
patient's name will be entered into a log book and the medication will be stored

     REV 01-2010                                                                         34
alphabetically according to the patient's last name until destroyed or returned to the

These medications are handled as personal property and placed on the Valuables List
established at the time of admission.

B. Use and storage of consumer medications brought from home:

Consumers use the medication dispensed from the hospital pharmacy. Home medication
not used for treatment purposes is stored in the pharmacy until discharge or destruction.

NOTE: Exceptions are determined by the admitting/attending physician. Drugs that the
consumer brought with them are not administered unless they are precisely identified and
verified to be stable based on visual examination for particulates or discoloration by
either the admitting/attending physician or a pharmacist.

Home medications may be sent to the unit, for use, only when the medication is not
available from the Hospital or CSP Pharmacy. When prescribing non-formulary
medication that is available from the consumer’s supply of medication brought from
home, the physician sends an order to the pharmacy, stating, “May use consumer’s home
medication”. The order also includes the name(s) of the medication. The pharmacy
identifies and labels the medication and sends it to the consumer’s unit for use and

 Nursing/medical staff can use Pharmacy One Source drug identification resource to
assist in drug identification when the pharmacy is not open. Simply go to the drug
information screen, highlight identification on left toolbar; enter specific drug
markings or scroll down and enter specific drug name –images will appear.
Pharmacy staff can also use Identify a drug reference to assist in identification.
Weekends and holidays, the pharmacy may be contacted by phone for identification
from 9am-1pm. On call pharmacist via phone can use their drug id reference after
hours to identify drugs. If the medication cannot be identified, it will be obtained from
another source via consultation with ECRH on call clinical pharmacist. Drug
identification reference book will be available for on duty staff to use in after hours
medication room.

C. Disposition of consumer medication brought from home:

     REV 01-2010                                                                         35
Upon written orders of the attending physician, medications may be returned to the
consumer at the time of discharge, provided the consumer is released from the hospital
within thirty (30) days following admission.

The process of returning medication to the consumer is handled the day of discharge
during normal pharmacy hours. Medications can be picked up from the pharmacy or
delivered to the consumer’s unit. If this is not possible, the consumer/representative may
return to the pharmacy during normal pharmacy hours to obtain these medications.

A notation is made and signature of person receiving medication is made on the
Consumer Medication Brought from Home form.

E. Disposal:

Hospitals dispose of all medications after 30 days that have not been authorized for return
to the consumer. Medications are disposed in accordance with Georgia Drugs and
Narcotics Agency guidelines. A record of the disposal is maintained in the Pharmacy for
two years. Disposal is noted on the Consumer Medication Brought from Home form.

F. Handling Illegal Drugs:

The police are notified if suspected illegal drugs are found. The drugs are released to the
police for disposition in compliance with each hospital’s standard procedure for handling
illegal drugs.

     REV 01-2010                                                                         36

The purpose of this policy is to establish uniform methods for the control, use, and
disposition of all drugs introduced by and/or accompanying consumers at time of
admission to the 23 hour unit of ECRH.

Admitting/Attending physicians are responsible for the use and disposition of drugs
accompanying consumers to the 23 hour unit of ECRH.

Control of Medications Brought by Consumers to the 23 Hour Unit

The admitting/attending physician is advised of the presence of any drugs accompanying
consumers at the time of admission.

All prescription medication, non-prescription medication, and illegal drugs
accompanying consumers to the hospital are identified by admitting staff and
documented in the Consumer Medication Brought from Home form.

When the consumer’s family is present during the consumer’s admission process, the
physician or other designated staff sends the medication home with the family. If the
medication can not be returned to the family, two staff members identify and count the
medication at the time of admission (this can be done by any direct care staff and does
not have to be done by nurses). The drugs are bagged, dated, and sealed. Packages are
marked with the consumer’s name, identification number, and 23 hr unit. Staff document
their count of the medication on the Consumer Medication Brought from Home form.
The sealed bag is then stored in Room 138, personal storage, to be returned to the
consumer upon leaving the 23 hour unit.

If the consumer is admitted to a living area within ECRH, the living area to which the
consumer is being admitted is to be written clearly on the package. The sealed package is
then moved to Room 137 where the patients name, living area, and signature of who
transferred the medication is documented in the Patient’s Personal Medications Log
Book. The pharmacy courier will pick up the sealed package, sign it out of the Patient’s
Personal Medication Log Book, and bring it to the pharmacy.

From this point the statewide inpatient procedure for Patient’s Personal Medications,
Policy #6805-102, (found in the Pharmacy Manual III-5) will be followed.

                                                Approved by the ECRH P&T Committee 8/12/2010

     REV 01-2010                                                                         37
                UNIT______________________________ DATE____________
              CONSUMER’S NAME:________________________________________

                                                Description                        Pharmacy
         Medication Name               (i.e. blue tablet or capsule)   Quantity   Verification
                                                                                  of Quantity















Admission Staff Name/Signature____________________________________ Date/Time______________

Ward/Living Unit Nurse Name/Signature______________________________ Date/Time______________

Name/Signature of Nurse Sending Med to Pharmacy_____________________ Date/Time______________

Quantity verified in Pharmacy by_____________________________________ Date__________________

DATE RETURNED TO LIVING UNIT____________AUTHORIZING M.D._______________________

DATE PICKED UP BY CONSUMER_____________ AUTHORIZING M.D._______________________

Name and Signature of Person Receiving Medication(s)
DATE MAILED TO CONSUMER_______________ AUTHORIZING M.D.________________________
DATE DESTROYED BY PHARMACY___________ PHARMACIST_____________________________

      REV 01-2010                                                                            38

 Supervision of drug storage is the responsibility of the Pharmacy Director or designee.
 Every month a pharmacist or specially trained pharmacy personnel will inspect all areas
 where drugs are stored and complete a Inspection Report of Medication Stations. The
 after hours cabinets will be inspected by pharmacy personnel at least weekly, and an
 inspection sheet will be signed. The nursing personnel in the Units/Living Areas are
 responsible to ensure that medications are properly stored, and that procedures are
 properly carried out. Keys to the drug storage areas are to be separate from any other
 keys i.e. grand master etc. Nursing personnel will be responsible for these keys and
 should pass the keys onto the next shift. Deficiencies will be reported to the Nursing
 Supervisor and must be corrected immediately.

1. Medication storage and work areas must be functional and provide:

           a. Adequate lighting.

           b. Adequate work space protected from traffic and noise.

           c. Hot and cold running water.

           d. Refrigeration space.

           e. Sufficient equipment and supplies in readily usable form.

           f. Adequate security.

           g. A clean environment.

2. Medication cabinets and medication carts must be secured by lock and key except
   when authorized personnel are preparing medications. These areas are the
   responsibility of the designated Nursing personnel. They should limit accessibility to
   these areas at all times.

3. Disinfectants and drugs for external use must be stored separately from medications
   intended for internal or injectable use.

4. Poisons, cleaning agents, general disinfectants and antiseptics must be stored
   separately from all medications in a locked storage area.

5. Medications requiring special conditions for storage to assure stability are properly
   stored i.e. refrigerator.

6. Only drugs and equipment for their preparation and administration shall be stored in
   medication cabinets and carts.

7. Discontinued and outdated drugs are disposed of properly according to procedures
   outlined in this manual. Outdated drugs are not stocked.

     REV 01-2010                                                                           39
8.   Containers with worn, illegible or missing labels must be returned to the pharmacy
     for proper disposition.

9.   Distribution and administration of controlled drugs are properly stored and

10. Drugs and medication orders that are being transferred between the Living Areas
    and the Pharmacy are to be placed in a locked cabinet or drawer, designated for only
    this purpose and located in the Living Area. This must be locked and assessable to
    only designated Nursing and Pharmacy personnel.


 1. General rules

     a. Only licensed nursing personnel or physicians/dentists can administer

     b. Provide for the maximum safety throughout the preparation, administration and
        recording process.

     c. Never give a medication from an unlabeled bottle or one that is, illegibly labeled.
        Never re-label medications.

     d. Ensure that medications are given only upon a written order of a physician.

     e. All medication orders must be clearly defined before drug administration is to
        occur. Question any order that is not completely clear.

     f. Know:

      1.Class of the drug

      2.Usual dosage range

      3.Dosage forms

      4.Methods and techniques of administration

      5.Expected effects and side effects

      6.Symptoms of overdose

      7.Purpose of drug

      8. If the drug is compatible with other drugs the client receives.

      9. If client has history of allergy or reaction to drug

     REV 01-2010                                                                         40
  g. Medications are to be prepared, administered and charted by the same person.

  h. Never leave medications unattended.

  i. Safely discard all items used in the preparation/administration of a drug
     (syringes/needles) disgard needles in the sharp box container.

  j. Medications cannot be used for a client other than the one they were dispensed

2. Care in the preparation of medications.

  a. Review current physician's orders and check against Medication Administration
     Record (MAR) to detect discrepancies.

  b. Avoid conversation and distractions during the entire process.

  c. Check the label of the medication container 3 times.

      1. When removing it from it's storage location.

      2. When removing the medication from its container.

     3. Before returning the container to its storage location.
  d. Check all drugs for signs of deterioration.

  e. Oral liquid medication

      1. Before pouring shake all suspensions and emulsions.

      2. Measure the exact amount by holding the container at eye level, or use liguid
         measured adapters.

      3. Pour with the label upward to avoid soiling it.

      4. Wipe "rim" of bottle with paper towel prior to closure.

  f. Tablets and capsules

      1. Remove medication from the container or packaging without contaminating it.

  g. Injections

      1. Use aseptic technique when removing drug to prevent contamination.

      2. Use multi dose vials expiration date on vial except for PPD and Insulin which
         receive 28 days after penetration by needle.

   REV 01-2010                                                                        41
     h. Never mix drugs unless specifically ordered.

3.      Care in administration

     a. Administer only those medications you prepare and chart only those medications
        you give.

     b. Give medications at the ordered time of administration.

     c. Assist client/patient in assuming a comfortable position prior to administration of

     d. Identify drug and client.

     e. The person administering the drug should stay with the client/patient until the
        medication has been taken, making sure that the drug is swallowed properly.

4.      Recording of medications

        All administered medications or medications omitted must be properly recorded
        on the Medication Administration Record (MAR) as soon as possible after
        administration by the person giving the medication.


     REV 01-2010                                                                          42
 In order to provide some continuity to patient care for each hospital, a system of
 standardized administration times was developed. These times are individualized to
 each hospital because of differing patient populations and staffing schedules. A
 medication may be administered ONE HOUR before or after the standard time.
 Administration outside of this one hour window would be considered a medication

 These standardized times should be followed if at all possible based on living area as to
 what times.. The physicians, pharmacists, and nurses must be aware of the standardized
 times. Should the physician desire non standard times, the order must clearly state the
 time(s). Any order written with standardized terminology will be given at the standard
 time. For example, an order written to give a drug at HS (bedtime) at 2300 hours is
 ambiguous if the standard time for HS at the hospital 2100. Orders written ambiguously
 must be clarified prior to administration.

                      Medication Administration Times for ECRH

              GRACEWOOD                                  AUGUSTA

DAILY          8:00 AM                                 8:00 AM
AM            8:00 AM                                  8:00 AM
AMHS          8:00 AM, 8:00 PM                         8:00AM, 9:00 PM
AMPM           8:00 AM, 4:00 PM                       8:00 AM, 5:00 PM
BID        8:00 AM, 8:00 PM                           8:00 AM, 9:00 PM
TID        8:00 AM, 4:00 PM, 8:00 PM                  8:00 AM, 5:00 PM, 9:00PM
*BIDCC     8:00 AM, 5:00 PM                           8:00 AM, 5:00 PM
*TIDCC    8:00 AM, 12:00 PM, 5 PM                     8:00 AM, 12 PM, 5 PM
QID        8:00 AM, 12 PM, 4 PM- 8 PM                 8:00AM, 1 PM-5 PM-9 PM
HS         8:00 PM                                    9:00 PM
PM        4:00 PM                                     5:00 PM
Q4H       4A-8A-12N-4P-8P-12MN                        4A-8A-12N-4P-8P-12MN
Q6H       6A-12N- 6P-12MN                             6A-12N-6P-12MN
Q8H       6A-2P-10P                                   6A-2P-10P
Q12H      Q12H will be the same as BID

* CC = with meals

    REV 01-2010                                                                         43

 The State of Georgia has elected to use the Minnesota Multistate Contracting Alliance
 for Pharmacy (MMCAP), as the agency contracting drug purchases. The State of
 Georgia, Department of Administrative Services (DOAS) is responsible for all State of
 Georgia purchasing contracts, including the MMCAP. MMCAP is responsible for
 bidding the drug contract annually and obtaining addendum, as requested by the
 various State agencies during the contract year.

 The MMCAP reviews each bid by evaluating the following:

 (1)     Bioavailability material file on each product as deemed necessary:

 (2)     Vendor liability insurance coverage:

 (3)     Files and reports containing problems submitted by state agencies utilizing the
         products (therapeutic failures, defective products, supply problems and prime
         vendor complaints from manufacturers):

 (4)     Return good procedure from vendor of the product:

 (5)         Recall history of the vendor or FDA problems:

   The contract is awarded to the product with the lowest price that is FDA approved.
   FDA approval is determined by reference to the "Approved Drug Products with
   Therapeutic Equivalence Evaluations" or the most recent FDA Database.

   When the FDA approved product with the lowest price does not meet one or more of
   the above criteria, it may be dual-awarded. Dual-awarding is then made to the
   product with the lowest price, as well as the product with the lowest price which
   meets the required criteria.


1. Introduction

       Clients who are anxious or unable to cooperate for necessary diagnostic tests and
       treatments may benefit from low doses of medications to alleviate anxiety and
       improve the individual’s ability to cooperate. These medications should be
       administered on the living units prior to transport to the appointment. In general,
       these medications are not administered in the clinics and clients requiring heavier
       sedation, including IV procedures must be managed under a Moderate Sedation

       REV 01-2010                                                                           44
2. Purpose

     The purpose of this policy is four-fold: 1) to define minimal sedation acceptable for
     clinic appointments and procedures; 2) to identify the persons who are authorized to
     prescribe and administer these medications; 3) to establish the evaluation and
     monitoring requirements for clients receiving these medications; and 4) to outline
     prescribing requirements and provide a table of approved medications which may
     be used.

3. Definition

     Minimal sedation is defined as a drug-induced state during which the individual
     client responds normally to verbal commands. The client whose mental status is
     initially abnormal should respond as usual to verbal and tactile stimulation.
     Although cognitive function and coordination may be impaired, ventilatory, and
     cardiovascular functions are unaffected.

4. References

   JCAHO CAMH Standards
   JCAHO CAMBHC Standards
   Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists
     Anesthesiology, 1996; 84:459-71

5. Evaluation

     The physician/dentist must evaluate the client’s physical/medical status including
     age and weight, current medication regimen, and previous experience with these
     medications in order to select an appropriate medication, dose of medication and
     route of administration.

     The nurse must check the client's vital signs and look for any contraindications to
     the prescribed medication prior to administration. Should the nurse identify a
     potential problem, the medication must be held until the physician/dentist is notified
     and further orders are obtained. Examples in which the nurse should hold the
     medication and notify the physician include, but are not limited to; abnormal vital
     signs, a change in the client’s general physical condition, a change in the client’s
     drug regimen since the order was written and a recent prn medication which could
     potentate the effect of the prescribed medication.

6. Application
   This procedure is applicable to both campuses.

    REV 01-2010                                                                           45
7. Monitoring

   7.1. Prior to clinic/diagnostic appointment

       The administering nurse should measure and record vital signs before
       administration of any sedative medication. A staff member must continually
       observe the client following administration to insure the client remains fully
       conscious. Fully conscious is defined as easily aroused with normal response to
       verbal commands. Since cognitive function and coordination may be impaired, a
       staff member should assist any client who has received any sedative medication
       until the effects are no longer noticeable. Such assistance would include aiding
       with ambulation, particularly in the transition from sitting or lying to standing and
       walking. Any unusual findings or response to the medication must be
       immediately reported to the nurse for evaluation. The nurse should inform the
       physician/dentist of significant abnormal findings such as vomiting, labored
       respirations, cyanosis, aspiration, not arousable to verbal or tactile stimulation,
       blood pressure less than 90/60, pulse rate less than 60 or respiratory rate less than

   7.2.   Intra appointment monitoring

       Clinics/diagnostic areas receiving clients who have been pre-medicated must have
       internal policies and procedures which provide for acceptable client monitoring
       and emergency medical response. Clinics/diagnostic areas should have immediate
       access to emergency drugs approved by the ECRH Pharmacy and Therapeutics
       Committee. A positive pressure emergency oxygen source should be available.
       Clinic staff should be trained in early recognition of medical emergencies and
       should be prepared to provide basic life support and activate Emergency Medical

   7.3.   Post appointment dismissal and monitoring

       Following completion of the clinic/diagnostic appointment and after the attending
       staff (medical or dental) has determined that the client is stable, the client may
       return to his or her living area.

       Upon arrival at the living area, the nurse will evaluate the client and record the
       vital signs. The nurse should inform the physician/dentist of significant abnormal
       findings such as vomiting, labored respirations, cyanosis, aspiration, not arousable
       to verbal or tactile stimulation, blood pressure less than 90/60, pulse rate less than
       60 or respiratory rate less than 12. Any clinic orders are reviewed and appropriate
       action taken. The client is monitored in accordance with facility protocol until the
       client has returned to baseline coordination and cognitive function. The client
       whose mental status was initially abnormal should have returned to his or her
       baseline. For example, the client should respond as usual to verbal and tactile
       stimulation. Since cognitive function and coordination may be impaired, a staff

    REV 01-2010                                                                           46
      member should assist any client who has received any sedative medication until
      the effects are no longer noticeable. Such assistance would include aiding with
      ambulation, particularly in the transition from sitting or lying to standing and

8. Prescribing Requirements

   The smallest dose required to achieve the desired level of relaxation should be
   prescribed. The dose may be titrated up as needed over subsequent clinic
   appointments provided minimal sedation levels and maximum doses are not
   exceeded. A table of approved medications that includes typical and maximum
   dosages is included in this policy. Typical doses are based on average healthy adults
   and should be adjusted accordingly to insure only minimal sedation is achieved.
   Whenever possible, the oral route should be selected as it is less invasive to the client.

   Combinations of these drugs should be used only after the single medications have
   proven to be ineffective in achieving minimal sedation appropriate for the clinical
   evaluation or procedure to be done.

               A physician/dentist may exceed the maximum recommended dose only with
               the clinical director’s approval. In these situations the prescribing physician
               must write a progress note justifying the higher dose and the record must
               reflect previous attempts at the maximum dose resulting in little or no
               sedative affect. The clinical director (or designee) must make a similar
               supporting progress note. Subsequent appointments for that client will not
               require additional notations.

   A physician/dentist may prescribe a medication not on the approved list only with the
   clinical director’s approval. In these situations the prescribing physician must write a
   progress note justifying the alternative medication and the record must reflect little or
   no sedative affects with the approved medications. The clinical director (or designee)
   must make a similar supporting progress note. Subsequent appointments for that
   client will not require additional notations.

   Table 1. Approved Sedative Medications
  Generic Name           Route           Typical Dose                    Maximum Dose
    Alprazolam             PO              0.5 mg                               2 mg
  Chloral Hydrate          PO              500 mg                            1000 mg
 Chlorpromazine            PO               25 mg                              50 mg
    Diazepam               PO                5 mg                              20 mg
 Diphenhydramine           PO               50 mg                             100 mg
    Haloperidol        PO or IM              5 mg                               5 mg
 Haloperidol plus          IM       5 mg Haloperidol plus              5 mg Haloperidol plus
    Lorazepam                          2 mg Lorazepam                    4 mg Lorazepam
   Hydroxyzine         PO or IM             50 mg                             100 mg
    Lorazepam          PO or IM              2 mg                               4 mg

    REV 01-2010                                                                             47
    Midazolam              IM                   2 mg                        5 mg
    Meperidine           PO or IM              50 mg                       50 mg
   Promethazine          PO or IM              25 mg                       50 mg
    Butabarbital           PO                  50 mg                      100 mg

PO includes through the gastrostomy tube.
The dose of medication must be modified for the elderly and infirmed and based on

9. Scheduled Review

     Month/Year:      March 11,2005

     Responsibility: Pharmacy and Therapeutics Committee

10. Effective Date       1-1-01

11. Approval                                              Date
               Chair Pharmacy and Therapeutics Committee



       1. To monitor incidents related to medication administration, i.e., recording,
          transcribing, dispensing, or prescribing, which are recognized before
          medication reached the patient/consumers, also known as potential medication

       2. To monitor the medication process and subsequent errors which are identified
          as discrepancies between what is ordered by the physician and what is actually
          administered to the patient/consumer, also known as actual medication

       3. To ensure implementation of appropriate corrective follow-up actions in order
          to prevent recurrence of the error or discrepancy.


       Given the relatively high incidence of medication use among consumers and the

    REV 01-2010                                                                      48
     high potential for adverse outcomes of medication-related errors, tracking of such
     errors and subsequent identification of causal factors is an essential component of
     the performance improvement process in organizations providing health care.


  A. A Medication Variance Report (MVR) is completed whenever a medication
     variance is discovered.

     i) Section 1 of the MVR (General Information) is completed by the
        discovering practitioner (nurse, pharmacist, or physician), or by the
        practitioner to whom the variance is reported. The report is then
        forwarded for completion of Section 2.

     ii) Section 2 of the MVR (Investigation/Analysis) is completed by the
         Clinical Supervisor (or Clinical Supervisor Designee) of the discipline
         from which the variance most likely originated. The report is then
         forwarded to the Medication Surveillance Committee (MSC).

     iii) Section 3 of the MVR (Review/Analysis) is completed by the MSC.

  B. The MSC is called to order the first week of each month to review all
     MVRs submitted in the previous month.

     i) The MSC uses the Medication Variance Worksheet (Worksheet) to
        perform monthly data counts.

     ii) The MSC uses the Medication Variance Tracking Form (Tracking
         Form) to track monthly data counts.

     iii) The MSC completes an Intensive Analysis of Medication Variance to
          further analyze:
          a) Any medication variance episode of outcome E, F, G, H, or I; or
          b) Any trend or cluster observed in the data of actual variance
              episodes or potential variance episodes.

  C. Suggested process for the MSC review of MVRs:

     i) Collect all MVRs submitted during the previous month.

     ii) Review each MVR for completeness. If additional information is
         required, return to sender with explanation.

     iii) Review each MVR for correctness. For instance, If an actual variance
          episode is marked as a potential medication episode, make
          corrections, explain corrections on the MVR, and initial corrections

   REV 01-2010                                                                       49
   iv) As the MVR is being reviewed:
       a) Capture MVR data on the Worksheet:
           Insert tally mark in the proper count section for the variance
              episode identifier;
           Insert tally mark in the proper count section for outcome
              category; and
           Insert tally mark(s) in the proper section for breakdown point(s).
       b) Complete MVR Section 3:
           Initiate Intensive Analysis of Medication Variance for reports
              with outcome category = E, F, G, H, or I;
           Indicate the critical breakdown point and critical breakdown
              point subcategory;
              (i) Insert tally mark in the proper section of the worksheet for
                   critical breakdown point.
           For actual variance episodes only:
              (i) Indicate the type of NRI error (Complex, Administration Only,
                   Prescribing Only, or Dispensing Only).
              (ii) Insert tally mark in the proper section of the Worksheet for
                   NRI error type
           Capture Signature and Date of the Medication Surveillance
              Committee Chairperson.

   v) Total all tally counts made so far on the worksheet.

   vi) Separate out all MVR forms concerning actual variance episodes.
          Select only those MVRs concerning actual variance episodes to
             complete the NRI section of the worksheet.
             (i) Count the total number of distinct clients (no client counted
                  twice) for all MVRs involving actual variance episodes, and
                  enter the total value in the corresponding cell of the
             (ii) Count the total number of doses (administered or omitted)
                  for all MVRs involving actual variance episodes and enter
                  the total value in the corresponding cell of the Worksheet.
             (iii) From the Worksheet, count the total number of outcomes =
                  (B or C), (D, E, or F), and (G, H, or I) and enter the total
                  values into the corresponding NRI section of the Worksheet.

   vii) Transcribe Worksheet totals to the Tracking Form.

D. All information collected by the Medication Surveillance Committee (MVRs
   and associated reports/forms) is maintained by the Medication
   Surveillance Committee, the Chief Medical Officer, or by Designee of the
   Chief Medical Officer.

 REV 01-2010                                                                50
     E. Additional processes (creating quarterly reports, graphs, and reporting to
        NRI, etc.) is the responsibility of the Medication Surveillance Committee,
        the Chief Medical Officer, or Designee of the Chief Medical Officer.

     For more detailed information please refer to State Policy # 03-505

     The Medication Variance Report can be found on the ECRH shared drive
     under CLN for CLN445.


DEFINITION OF MEDICATION REACTION: Any undesired response to a
medication which requires intervention or change in therapy.

A common expected side-effect (e.g. drowsiness due to an antihistamine; GI upset due to
NSAID) need not be reported unless it is deemed significant. If in doubt, report it. Side
effects, if observed, should be recorded on the patients progress notes.

APPROVED BY: Pharmacy and Therapeutics Committee/Medical and Dental
Staff/Nursing Executive Committee

Nursing Staff/Physicians/Dentists/Clinical Pharmacists


1.      To improve client/patient care.

2.      To provide a viable medication reaction reporting process.

3.      To provide the P&T Committee reports concerning the incidence, types, and
        severity of medication reactions occurring at ECRH, and to report necessary
        information to the manufacturer and/or FDA.

GENERAL GUIDELINES: The process for monitoring and addressing potential
medication reactions is interdisciplinary and involves the physician, dentist, nurse,
pharmacist, and any staff observer. It is the responsibility of the staff member observing
or recognizing a potential medication reaction to immediately inform the nurse caring for
the client. The nurse will notify the attending physician or designee (hereafter referred to
as the physician) who will evaluate the client and take appropriate action. The nurse,
physician/dentist and pharmacist will document the incident on the Medication Reaction
Report GRHA form 5-5-552/GSSH form 457.


      REV 01-2010                                                                         51
Initiator of Action   Action

Any Staff Member      1)       Observes potential medication reaction and
                               Immediately notifies the nurse caring for the

Nursing Personnel     1)       Takes immediate action as indicated.

                      2)       Notifies the physician and Unit Nurse
                      3)       Records signs and symptoms of suspected
                               medication reaction, action taken, and
                               notification of physician in the client’s

                      4)       Initiates Medication Reaction Report, fills
                               out discipline-specific section and forwards
                               report to the physician.

Physician             1)       Evaluates client and takes action as

                      2)       Fills out discipline-specific section on
                               Medication Reaction Report and forwards
                               report to the Nurse Manager.

Unit Nurse Manager    1)       Reviews report and forwards it to the
                               Assigned clinical pharmacist.

Clinical Pharmacist   1)       Fills out discipline-specific section on
                               Medication Reaction Report. Forwards
                               original report to the Unit Nurse Manager
                               and a copy of the report to the Pharmacy
                               Director and the Nursing Director.

Unit Nurse Manager    1)       Reviews report.

                      2)       Ensures that the physician reviews
                               pharmacist’s comments on the report.

                      3)       Forwards original report to the Pharmacy

Pharmacy Director     1)       Presents a copy of the report to the P&T

    REV 01-2010                                                            52
P & T Committee                    1)     Evaluates the report to determine the nature,
                                          cause, and the severity of the reaction.

                                   2)     Addresses any necessary changes in
                                          Medication procedures in order to prevent
                                          future reactions.

                                   3)     Determines whether or not the event should
                                          reported to the manufacturer and/or the

                                   4)     Notifies the clinical pharmacist and
                                          physician/dentist as to the outcome of their
                                          evaluation of the report and the necessary
                                          action to be taken. A copy of the report will
                                          be forwarded to the Performance
                                          Improvement Director.

P & T Representative               1)     Records action taken by the P & T
                                          Committee on the original Medication
                                          Reaction Report. Forwards the report to the
                                          Living Area Secretary.

Living Area/Unit Secretary         1)     Files original report in the client’s medical

Performance Improvement/           1)     Enters the information from the report into
Quality Management Director               the computer database for medication

Clinical Pharmacist and            1)     Jointly report the necessary information to
Physician/Dentist                         the manufacturer and/or the FDA.


SUBJECT:                     In-Patient Monitoring for Food-Drug Interactions

AREA:                        Physician/Nursing/Pharmacy/Clinical Dietitian

APPROVED BY:                 Pharmacy and Therapeutics Committee/Medical Staff/
                             Nursing Executive Committee/Clinical Nutrition

    REV 01-2010                                                                         53
RESPONSIBILITY:              Clinical Dietitians

PURPOSE:              To provide for a process that addresses the potential for drug/food
                      interactions and to mitigate any negative consequences resulting
                      from these interactions.

                      In addition, this procedure provides for a mechanism that will aid
                      the health professional in assuring that the client’s and patient’s
                      diet and drug therapy are optimized for positive outcomes.

GUIDELINES:           The process for monitoring and addressing drug/food interactions
                      is interdisciplinary and involves the physician, pharmacist, nurse,
                      and dietitian. A list of drugs that have the potential for food
                      interaction was developed and agreed upon by representatives of
                      each of these disciplines. This list will serve as the basis for a
                      computerized program that will screen for any client who has been
                      given a drug on this list. A Pharmacy computer program will be
                      run in the Pharmacy each day. This program will list the
                      client/patient, Living Area (Unit), drug name, and order date. This
                      program will serve as the basis for the food/drug interaction

GUIDELINES:           List of drugs; additionally food drug information will be sent
                      concurrently with some medications such as Cipro and Levaquin.
                      This information is necessary to prevent food absorption problems.
                      Additionally grapefruit products have been found to increase drug
                      concentrations by inhibition of metabolism. A grapefruit drug
                      information education leaflet is sent with discharge and vacation
                      medications to prevent such reactions.


Initiator of Action                          Action

       Physician                     1.      Writes the order for the identified

       Nurse                         2.      Forwards the drug order to the Pharmacy.

       Pharmacy                      3.      Receives orders. A Pharmacy Report is run

    REV 01-2010                                                                         54
                                  And any drug(s) that are determined to have
                                  potential to interact with food will printout
                                  on sheets by living areas/Unit.

                            4.    These reports are distributed to the dietitians
                                  in a timely manner.

 Dietetic Program Manager   5.    Checks the potential food-drug interaction
                                  list and/or the Food Medication Handbook
                                  for any nutrition interventions needed.

                            6.    Contact Nurse Manager/Living Area Nurse
                                  and Physician if a potential food-drug
                                  interaction is identified or any recommended
                                  diet or other change is needed.

                            7.    Documents the recommended change on the
                                  Food Drug Report and in the medical record
                                  progress notes (GSSH form 650-H; GRH
                                  form MH 5-5-102).

 Physician                  8.    Writes order for recommended diet or other
                                  change. If not in agreement for diet change,
                                  will document reason on progress notes
                                  (GSSH form 650-H; GRH form MH 5-5-

 Nurse                      9.    Transcribes the order for the diet or other
                                  change and forward a copy of the order to
                                  the Unit Dietitian or Pharmacist as

 Dietitian                  10.   If a change or nurse/physician contact is not
                                  needed, the dietitian documents this on the
                                  Food Drug Report.

                            11.   Files Food Drug Reports in the Food-Drug
                                  Interactions file in the Unit Dietitian’s office
                                  and be retained for a period of six months.

 Nurse/Unit Dietitian       12.   Monitors for any observable altered
                                  response to medication and client
                                  compliance with modifications and follow-
                                  up accordingly.

REV 01-2010                                                                     55
                  Clinical Dietetic Program           13.      Collects data from daily reports and prepares
                  Manager                                      summary reports for review (P&T, etc.).


         To establish a process for identifying, developing, and providing services and supports to
         clients to facilitate and maximize each consumer’s participation and independence with
         managing their own medications. This process is one of normalization in which there is
         an evolving partnership between the client and provider.
          The Self Administration of Medication Program was developed to achieve the above
         purpose. It consists of a step continuum of skill development for consumer self-
         medication management. The process begins with nursing staff assessing consumer
         ability to self-administer medications using the Consumer Medication Management Skill
         Assessessment. The interdisciplinary team will then review these assessments to
         determine and implement appropriate programming to teach and support consumers’
         independence with taking their medications. Each consumer will be enrolled in the Self
         Administration of Medication Program at that level or phase congruent with the their
         current skill level and potential.

         Consumer:         _______________________________                       Location: _________

                             Instructions: Nurse will complete assessment form based on observation of consumer
                             and input from direct case staff. Use the following rating scale: Not capable of
                             performing=0; No=1; Capable of learning=2; Yes=3.

 Sensory- motor
Acknowledges presences of others through touch, sound or sight
Tracks objects with eyes or head
Opens mouth with cues
Basic physical and cognitive skills
Grasps or holds small objects w/hand w/out dropping it.
Lifts hand to mouth.
Drinks w/ minimum spillage.
Follows, cooperates w/simple instructions with either gestures, sign or verbal prompts
Advanced physical skills
Pours beverages with minimum spillage.
Washes hands
Removes caps/lids of bottles
Recaps lids/bottles
Advanced cognitive skills
Counts objects up to 5.

               REV 01-2010                                                                                    56
 Knows time of day (morning, afternoon, lunch, evening) associates time of day with daily activities
 Is able to differentiate between colors
 Is able to differentiate between simple shapes
 Able to read
 Communicates in full sentences
 Able to follow compound and if/then type instructions
 Scoring               Phase Level       Skill Readiness
 6-9*                  I                 Responsive, ready to initiate partnership in process
 10-20                 II                Ready to form active and reciprocal partnership
 21-32                 III               Able to establish and build upon partnership
 33-40                 IV                Able to take initiative, the first steps
 41-43                 V                 Able to assume responsibility for rule in process
 45-54                 VI                Shows capacity for independence and ownership of process
* SNF consumers placement phase is primarily subject to team recommendation rather than dictated by placement
          Team, to determine appropriate skill development phase in ECRH Self Administration
                                               Program, will use assessed score.
          Nurse Signature: _______________________________________                                               Date: ____________


          Phase I       Initiating Partnership
                                   a.        Consumer will be told, or signaled that its medication time.
                                   b.        He will be encouraged and reinforced to attend to and track nurses actions.
                                   c.        He will be prompted to open his mouth, to receive medications.
                                   d.        Nurse will reinforce compliance.

            Phase II:            Forming Partnership
                                 a.         HST will instruct client to wash his hands using interaction pattern.
                                 b.         HST or nurse will invite client to come for medications.
                                 c.         Nurse will pour drink in cup for client.
                                 d.         Nurse will hand client his/her medication.
                                 e.         Nurse will use the interaction pattern to teach client to take medications and to ingest medications.
                                 f.         Nurse will watch to ensure ingestions, will thank and praise client for efforts.
           There should be 100% compliance by the consumer for a minimum of three months before progressing to next Phase. RN will
          counsel client and in-service nursing staff relative to next phase.

          Phase III Establishing partnership
                                  a.        HST will prompt client as needed to wash hands
                                 b.         HST or nurse will invite client to come for medications.
                                 c.         Nurse will instruct client using the interaction pattern to pour juice/water into cup.
                                 d.         Nurse will hand client his medications and prompt to ingest
                                 e.         Nurse will praise, thank client for his assistance.
          There should be 100% compliance by the client for a minimum of three months before progressing to next Phase. LCA RN will
          counsel client and in-service nursing staff relative to next phase.
          Phase IV       Taking initiative
                                 a.         The client continues to report to the medication nurse at proper
                                 b.         Nurse requests client to wash hands.
                                 c.         The medication nurse hands the medication container(s) to the consumer.
                                 d.         The consumer uncaps medication container.
                                 e.         Nurse reinforces proper number of tablets/capsules to place in med. cup.
                                 f.         Nurse places tablets/capsules in medication cup and ensures proper administration by client.

          There should be 100% compliance by the client for a minimum of three months before progressing to next Phase. LCA RN will
          counsel client and in-service nursing staff relative to next phase.
          Phase V: Continuing initiative
                                 a.        IDT will develop and implement skill building programs to address

                 REV 01-2010                                                                                                                    57
                                   Any existing skill deficit identified in the client’s Medication Management Assessment that would
                                   prevent successful completion of Phase VI.
                        b.          The client continues to report to the medication nurse at proper
                        c.          Nurse requests consumer to wash hands.
                        e.          The medication nurse hands the medication container(s) to the consumer.
                        f.          The consumer uncaps medication container.
                        g.          Under the direct supervision of the medication nurse, the consumer is allowed to select and take
                                    medication. He/she is probed at least weekly as to the proper medication administration technique.
                        h.          Consumer recaps medication container and returns it to nurse.
There shall be 100% compliance for a minimum of three months before progressing to
next phase. Unit RPH will counsel client and in service nursing staff relative to next phase. Pharmacist will monitor monthly.
 Phase VI: Taking responsibility
           a.           Consumer comes to pharmacy for refills weekly.
                        b.          Consumer locks refilled medication in medication cabinet (if available) in Living Care Area under
                                    nursing supervision.
                        c.          Pharmacist ensures client knowledge of medication dosages, frequency of administration, and
                                    focuses on building awareness of drug name, color, shape, use,
                        d.          Pharmacist ensures adequate and accurate compliance achieved during previous week.
                        e.          Consumer returns meds to nurse or locks medication containers in designated cabinet LA.
                        f.          Consumer takes medication at proper time.
                        g.          Consumer selects correct medication and dose for appropriate time of administration.
                        h.          Consumer recaps and returns medication containers to cabinet or nurse.
There shall be 100% compliance for a minimum of six months before progressing to Phase VII. Unit RPH will counsel client and in
service nursing staff relative to next phase. Pharmacist will monitor monthly
Phase VII       Establishing independence
                        a.          Consumer comes to pharmacy for refills weekly and will
                                    1. identifies purpose of medications.
                                    2.identify side effects of medications.
                        b.          Consumer locks refilled medication in medication cabinet (if available) in Living Care Area under
                                    nursing supervision.
                        c.          Pharmacist ensures client knowledge of medication dosages, frequency of administration, and
                                    focuses on building awareness of drug name, color, shape, use,
                        d.          Pharmacist ensures adequate and accurate compliance achieved during previous week.
                        e.          Consumer returns meds to nurse or locks medication containers in designated cabinet LA.
                        f.          Consumer takes medication at proper time.
                        g.          Consumer selects correct medication and dose for appropriate time of administration.
Consumer recaps and returns medication containers to cabinet or nurse
Pharmacist will monitor monthly.

                            SKILL DEVELOPMENT FOR SELF-ADMINISTRATION PROGRAM                                                            PHASE
               (dellac nehw eman ot dnopser ro ezingocer nac) noitacifitnedi fles remusnoC ‫ٱ‬                                                 1
               .ssecorp .mda .dem ni noitca sesrun skcart remusnoC ‫ٱ‬                                                                         1
               Opens mouth with cues                                                                                                         1
               (gnikeehc on) yletairporppa snoitacidem stsegnI ‫ٱ‬                                                                             1

               cifitnedi fles remusnoC ‫ٱ‬ation (can recognize or respond to name when called)                                                 2
               sdnah hsaw ot tseuqer ffats htiw seilpmoC ‫ٱ‬                                                                                   2
                ffats yb demrofni nehw aera noitacidem ot stropeR ‫ٱ‬                                                                          2
               esrun morf puc noitartsinimda ni snoitacidem stpeccA ‫ٱ‬                                                                        2
               ppa snoitacidem stsegnI ‫ٱ‬ropriately (no cheeking)                                                                             2

               (dellac nehw eman ot dnopser ro ezingocer nac) noitacifitnedi fles remusnoC ‫ٱ‬                                                 3
               sdnah hsaw ot tseuqer ffats htiw seilpmoC ‫ٱ‬                                                                                   3
                ffats yb demrofni nehw aera noitacidem ot stropeR ‫ٱ‬                                                                          3
               i snoitacidem stpeccA ‫ٱ‬n administration cup from nurse                                                                        3

       REV 01-2010                                                                                                                  58
   seciuj ro retaw sruoP ‫ٱ‬                                                          3
   (gnikeehc on) yletairporppa snoitacidem stsegnI ‫ٱ‬                                3

   (dellac nehw eman ot dnopser ro ezingocer nac) noitacifitnedi fles remusnoC ‫ٱ‬    4
   sdnah hsaw ot tseuqer ffats htiw seilpmoC ‫ٱ‬                                      4
    ffats yb demrofni nehw aera noitacidem ot stropeR ‫ٱ‬                             4
   esrun morf puc noitartsinimda ni snoitacidem stpeccA ‫ٱ‬                           4
   seciuj ro retaw sruoP ‫ٱ‬                                                          4
   reniatnoc noitacidem spacnU ‫ٱ‬                                                    4
   ‫ ٱ‬Recaps medication container                                                    4
   rporppa snoitacidem stsegnI ‫ٱ‬iately (no cheeking)                                4

   (dellac nehw eman ot dnopser ro ezingocer nac) noitacifitnedi fles remusnoC ‫ٱ‬    5
   sdnah hsaw ot tseuqer ffats htiw seilpmoC ‫ٱ‬                                      5
    ffats yb demrofni nehw aera noitacidem ot stropeR ‫ٱ‬                             5
   da ni snoitacidem stpeccA ‫ٱ‬ministration cup from nurse                           5
   seciuj ro retaw sruoP ‫ٱ‬                                                          5
   reniatnoc noitacidem spacnU ‫ٱ‬                                                    5
   .tinu egakcap/reniatnoc fo tuo noitacidem sekaT ‫ٱ‬                                5
   S ‫ٱ‬elects correct dosage units                                                   5
   ‫ ٱ‬Recaps medication container                                                    5
   etairporppa snoitacidem stsegnI ‫ٱ‬ly (no cheeking)                                5
   .noitacol reward ro esrun ot reniatnoc dem snruteR ‫ٱ‬                             5

   (dellac nehw eman ot dnopser ro ezingocer nac) noitacifitnedi fles remusnoC ‫ٱ‬    6
   .ylkeew sllifer rof ycamrahp ot semoC ‫ٱ‬                                          6
   ,ekat ot stinu) segasod tcerroc sweiveR ‫ ٱ‬adm times) with RPh                    6
   ecnailpmoc ylkeew etaruccA ‫ٱ‬                                                     6
   .noitacol reward ro esrun ot reniatnoc dem snruteR ‫ٱ‬                             6
    ffats yb demrofni nehw aera noitacidem ot stropeR ‫ٱ‬                             6
   sdnah sehsaw ylreporP ‫ٱ‬                                                          6
   S ‫ٱ‬elects correct dosage units                                                   6
   bal sdaeR ‫ٱ‬el instructions                                                       6

   .ylkeew sllifer rof ycamrahp ot semoC ‫ٱ‬                                          7
   hPR htiw (semit mda ,ekat ot stinu) segasod tcerroc sweiveR ‫ٱ‬                    7
   snoituacerp gurd/stceffe edis/snoitacidni swonK ‫ٱ‬
   ecnailpmoc ylkeew etaruccA ‫ٱ‬                                                     7
   ro esrun ot reniatnoc dem snruteR ‫ ٱ‬drawer location.                             7

REV 01-2010                                                                    59
                       ffats yb demrofni nehw aera noitacidem ot stropeR                ‫ٱ‬                                                7
                      sdnah sehsaw ylreporP ‫ٱ‬                                                                                            7
                      S ‫ٱ‬elects correct dosage units                                                                                     7
                      snoitcurtsni lebal sdaeR ‫ٱ‬                                                                                         7

                      MISC Skills to develop
                      sepahs setaitnereffiD ‫ٱ‬                                                                                    ANY
                      emit slleT ‫ٱ‬                                                                                               ANY
                      seitivitca yliad htiw ssap noitacidem fo semit setaicossA ‫ٱ‬                                                ANY
                      koob noitacidem ni teehs dem snruT ‫ٱ‬                                                                       ANY
                      .ecalp reporp ni koob dem stuP ‫ٱ‬                                                                           ANY

                      sdem sekat ehs/eh yhw swonK ‫(-ٱ‬indications)                                                                ANY
                      at ehs/eh noitacidem fo seman swonK ‫ٱ‬kes                                                                   ANY
                      noitingocer lobmys yb tenibac ni skcap dem nwo setacoL ‫-ٱ‬with med sheet                                    ANY
                      snoitacidni gurd setatS ‫ٱ‬                                                                                  ANY
                      seman gurd setatS ‫ٱ‬                                                                                        ANY

       ECRH Service Health Care Plane Plan

Client Name                   Originator: Pharmacist       Entered: Target Date:
                                                                        Health Care Status Codes:      (1) Progress
       Satisfactory        (2) Goal/Objective Met
                                                                                                       (3) Failure to Progress
                 (4) New Goal/Objective/Method Needed
 Reference            Pharmacy Diagnosis                Expected Outcome                    Pharmacy Interventions                       Person
   Code                      Goal                           Objective                               Method                             Responsible

              REV 01-2010                                                                                                 60
             Will increase knowledge of   Will participate in a medication       MEDICATION                            Pharmacist
             medications                  review with pharmacist weekly.         EDUCATION PLAN
                                                                                   1) Encourage knowledge
                                          Ability to read label directions to            of medication names
                                          RPH ---YES ---NO
                                          Ability to relate when to take med
                                                                                    2)   Educate to ensure
                                                                                         knowledgeable of
                                          to RPH    ---YES ---NO                         doses administered
                                                                                         each medication pass.
                                          Knows quantity to take each med           3)   Counsel client on
                                          pass. ---YES ---NO                             applicable significant
                                          Ability to relate med indication use           side effects such as:
                                          to RPH    ---YES ---NO                    a) Risk of orthostatic
                                          Responds correctly to questions                hypotension
                                          relating to how to get up from a          b)    Risk of sunburn
                                          sitting or lying down position.           c)    Anticholinergic SE
                                          ---YES ---NO                                    thirst, etc.
                                          Responds correctly to questions           4)   Counsel to educate
                                          relating to use of sunscreen                   knowledge of
                                                                                         medication uses.
                                          ---YES ---NO
                                          Responds correctly to questions           5)   Counsel to ensure
                                          relating to specific side effects
                                          ---YES ---NO
                                          Responds correctly to questions
                                          relating to compliance.
                                          ---YES ---NO

GSSH FORM 677-A (Revised 12/03) CPR

        Prior to referral to the Pharmacy Drug Education Plan, a client must be capable of
        telling time, differentiating colors, and reading (subject to discretion of Pharmacist).
        The client must also be behaviorally and physically capable of self-administering
        medications. Additionally the client should have successfully completed the Pharmacy
        Self Medication Program (Phase VI) Consumers will be maintained non-
        programatively in Phase VI. Pharmacist will educate clients relative to drug pre-cautions,
        adverse effects, and dosing information. Consumers will come to the Pharmacy Weekly
        for medication refills and drug information.
        Objective information – 100% compliance is recommended in order to encourage optimal
        safety and compliance relative to drug administration. If a client fails to meet the
        objective in the specified time period, the Unit Pharmacist or RN may elect to extend the
        maximum period of each phase or discontinue to program secondary to poor
        performance. However, if a client meets 100% compliance consistently of the program
        phase, but due to physical or other limitations the client should not progress to the next
        phase, then the skills learned are to be maintained through non programmatic means and
        the formal program discontinued. Prior to this, the Unit Pharmacist and QMRP must
        substantiate skill and document accordingly. These skills should then be placed on
        client’s strength list.

              REV 01-2010                                                                                         61

Poison control information must be posted in all Medication Stations. This should
include the phone number of the local Poison Control Information Center. On
Gracewood Campus there are Poison Control Cabinets located in the General Clinic on
A-Wing which is open from 7 a.m. until 4:30 p.m., Monday thru Friday, and in the After
Hours Clinic in 76 Building. The extension is 2164 or 2392 respectively. The cart in the
Clinic is locked, the key can be secured from the nurse.

Antidote charts are located in all nursing medication areas.

In case of poisoning or suspected poisoning of any client/patient, the Unit Physician, the
Nurse or the Physician-On-Call (MOD) or his/her designee on-call will be notified

              MEDICATIONS                    MEDICATIONS
(1) Baking Soda 16 oz.         (1) Milk of Magnesia 16 oz.
(3) Charcoal 25 gm             (1) Peroxide 16 oz.
(2) Citrate of Magnesia 10 oz. (2) Salt 2 oz
(1) Epson Salt 16 oz.          (1) Sodium Chloride for Irrigation 1000ml
                               (2) Vegetable Oil 16 oz.
                               (2) Vinegar 16 oz


1.     Stomach tubes                               3.      60cc irrigating syringes,
       (Sizes: 14, 16, 18, 28, 32, 36)                             catheter tip

2.     Mouth prop                                  4.      Gloves, sterile
                                                           (Size 7 ½ & 8)

NOTE: For further information, please contact the POISON CONTROL
CENTER, UNIVERSITY HOSPITAL…………phone number 724-5050
 (if no answer, call 722-9011) or POISON CONTROL CENTER – HOT LINE, GRADY MEMORIAL HOSPITAL, Atlanta,
                             GA…...phone number   1-800-222-1222.

     REV 01-2010                                                                                   62
 Purpose: To identify strategies to prevent medication errors secondary to problematic look alike, sound
 alike drugs.
 Current Strategies:
      1. ECRH Pharmacy utilizes upper and lower case letters in certain problematic drug names on
          facility labels to highlight syllables to differentiate.
      2. ECRH Pharmacy Staff separates certain drugs which have been problematic in the past.
      3. Pharmacy Staff will place look alike drug alerts on storage shelves for drugs approved by the P&T
          Committee as problematic look alike, sound alike drugs.
      4. Nursing, Medical and Pharmacy Staff will utilize read back procedure for verbal orders.
      5. Medical Staff will write precise indication for look-alike, sound-alike drugs for name for drugs
          approved as problematic (see list).
      6. Problematic drug list will be placed in front of consumer charts.
      7. Drug indications should be included in all orders.
      8. Automated medication order, vacation, discharge medication, renewal process eliminates
          handwriting errors relative to look alike names.
      9. Clinical Pharmacist and Nursing Staff will separate look alike drug packages on Living Care Area
     Look Alike Drug Name                                                                                                   Alternative
                              Look Alike Drug Name Misinterpretation               Correction
       Misinterpretation                                                                                                    Correction
Avandia                       Coumadin                                 Include precise indication on every   Use the non-offending brand or generic
(rosiglitazone)               (warfarin)                               order                                 name in prescriptions.
Celebrex                      Cerebrex                                 Include precise indication on every   Use the non-offending brand or generic
(celecoxib)                   (fosphenytoin)                           order                                 name in prescriptions.
Celebrex                      Celexa                                   Include precise indication on every   Use the non-offending brand or generic
(celecoxib)                   (citalopram)                             order                                 name in prescriptions.
Clonidine                     Clonazepam                               Include precise indication on every   Use the non-offending brand or generic
(Catapres)                    (Klonopin)                               order                                 name in prescriptions.
Lamictal                      Lamisil                                  Include precise indication on every   Use the non-offending brand or generic
(lamotrigine)                 (terbinafine)                            order                                 name in prescriptions.
Serzone **                    Seroquel                                 Include precise indication on every   Use the non-offending brand or generic
(nefazodone)                  (quetiapine)                             order                                 name in prescriptions.
Zyprexa                       Zyrtec                                   Include precise indication on every   Use the non-offending brand or generic
(olanzapine)                  (cetirizine)                             order                                 name in prescriptions.
Chlorpropamide                Chlorpromazine                           Include precise indication on every   Use the non-offending brand or generic
(Diabinese)                   (Thorazine)                              order                                 name in prescriptions.
Prilosec                      Prozac                                   Include precise indication on every   Use the non-offending brand or generic
(omeprazole)                  (fluoxetine)                             order                                 name in prescriptions.
Zantac                        Xanax                                    Include precise indication on every   Use the non-offending brand or generic
(rantidine)                   (alprazolam)                             order                                 name in prescriptions.
Zantac                        Zyrtec                                   Include precise indication on every   Use the non-offending brand or generic
(ranitidine)                  (cetirizine)                             order                                 name in prescriptions.
Acetohexamide                 Acetazolamide                            Include precise indication on every   Use the non-offending brand or generic
(Dymelor)                     (Diamox)                                 order                                 name in prescriptions.

Darvocet                      Percocet                                 Send white schedule ll Rx for         Use on non-offending brand or
(propoxyphene/APAP)           (oxycodone/APAP)                         Percocet to differenciate.            generic name.

Topamax                       Toprol XL                                Include precise indication on every   Rx the non-offending brand or generic n
(topiramate)                  (metoprolol)                             order

        REV 01-2010                                                                                                 63
Hydroxyzine                           Hydralazine (Apresoline)                       Include precise indication on      Rx the non-offending brand or
                                      Hydrochlorothiazide (hydroDiuril)              every order                        Generic name

**Precise diagnosis is not Serzone for psychiatric disorder; but is Serzone for Depression                   Reference-JCAHO
  The P&T Committee will review, update, and approve the Look Alike – Sound Alike drug list at
  least annually.

III-17 Anticoagulant Management
                            Anticoagulation Management

Policy: Protocol/Guideline for Anticoagulation Management Service

Anticoagulation management is directed by a Physician with input from Pharmacists, Dietitians
and Registered Nurses with specific knowledge in anticoagulation therapy. Oral anticoagulant
care is managed under the supervision of the attending physician at ECRH. This process is
monitored monthly by the Clinical Director.

    To manage oral anticoagulant therapy by evaluating the Prothrombin time/INR and
      instructing patients or family/caregiver of appropriate dosages of anticoagulant
    To assess patients for possible complications related to anticoagulant therapy and ensure
      effective and safe therapy.
    To provide education to patient and/or family members about anticoagulation therapy
      with specific attention to signs and symptoms to report.


           1. Physicians, Pharmacists, Dietitians, Registered Nurses will utilize the following
              resources available on ECRH intranet (files on the employee homepage under
              PHARMACY) to monitor patients on Anticoagulant therapy.
              A. Effective Anticoagulant Management
              B. Anticoagulant Therapy (Self Instructional Packet)
              C. Anticoagulant Program Expectations
              D. Anticoagulant Competency Quiz
           2. Above referenced staff has to pass the Anticoagulant Quiz – results forwarded to
              Human Resources Development.
           3. Medical staff will utilize Anticoagulant resources available on the intranet for
              educational resources.
           4. Physicians will order INR’s for Coumadin dosing and monitor platelets for Lovenox
              or Fragmin.
           5. Lab will forward INR results to ECRH Pharmacy.
           6. Pharmacists will contact MD if Anticoagulant dosing adjustments are needed
              secondary to INR/or platelets count.
           7. Pharmacist will compile a monthly Anticoagulant report monthly and send to Clinical
           8. Pharmacy will notify dietary staff when patients are placed on Anticoagulant therapy
              via Food-Drug Interaction Reports.

       REV 01-2010                                                                                                             64
        9. Pharmacy, Dietary, Medical Services will provide discharge drug education.

General Guidelines

The Pharmacist is to provide drug education to the patient/consumer and family.
Gracewood Campus clients are provided drug education primarily through the self-
administration of medication program. At Augusta Campus patients are given drug
information classes by the Clinical Pharmacist. These procedures are outlined in the
Pharmacy Manual under the self-administration of medication and clinical pharmacy

The family will be provided drug education/information by the Pharmacy staff in two
ways. The Unit Pharmacist will provide drug information leaflets as a part of the annual
team “conference” process. The family will also be provided drug information sheets
with pass medications and discharge when the patient/client leaves campus with their
family members. The Nurse will provide education to family members via the drug
leaflets whenever the patient/client leaves campus, with the family.

The information sheets used are from the Facts and Comparisons, Patient Drug Facts
program. They contain considerable information including: Type or class of drug;
normal use; precautions or what to consider before using the drug; proper use of the drug
including dietary considerations; instructions on how to correctly take the drug; what to
do if you miss a dose; special precautions while taking the drug; possible side effects
(both more common and less common); and a discussion about those side effects that
usually do not require medical attention.



INITIATOR OF ACTION                                   ACTION

Family member                          Family calls to inform staff that they intend to take
                                       client/patient off campus.

Social Worker, Team Leader, etc.       Informs nurse that patient/client is to go off campus
                                       for specified time period.

Nurse                                  Notifies MD to obtain order for visit and pass

Physician                              Writes pass medication orders for client’s/patient’s
                                       visit with family. Dates and times for departure and
                                       return to must be specified on the order. Order
                                       must be complete with all information, including

    REV 01-2010                                                                            65
                         directions for administration for each medication
                         ordered. All verbal orders must be signed with 24
                         hours. Pharmacy recommends nursing/medical staff
                         to use the automation pass medication/physician
                         discharge reports.

Nurse                    Sends order to Pharmacy for filling.

Pharmacy Staff           Fills vacation medications. Generates drug
                         information “leaflets” from computer database.
                         Sends pass/discharge medication and drug leaflets
                         to Living Area/Unit. *Note: Drug information
                         leaflets will be sent for any drug that is in the
                         database. Some drugs may not be available in the
                         database and therefore no information will be sent.

Nurse                    1.     Reviews pass medications and drug leaflets
                                prior to Patient’s/Client’s departure.

                         2.     Gives pass medication and drug leaflets to
                                family. Discusses medication
                                administration and monitoring with family.
                                Answers Families’ questions about
                                medication, etc. At Gracewood Campus:
                                Documents on GSSH Forms 842, 843, and
                                the 650-H.



INITIATOR OF ACTION                            ACTION

Unit Pharmacist          Prepares annual assessment for client. Generates
                         and gathers drug information leaflets for
                         medications client is currently taking. Sends drug
                         leaflets with Pharmacist’s assessment to QMRP.

                         1.     If family and Pharmacist both attend

                                        QMRP will bring drug leaflets to the
                                        staffing. Pharmacist reviews drug

    REV 01-2010                                                            66
                                                     leaflets with family, answers
                                                     questions from family members, and
                                                     provides counseling concerning the
                                                     proper use of the medications.
                                                     Documents teaching on GSSH Form
                                                     843 (Teaching Flow Sheet) and 650-
                                                     H. **Documentation on 650-H must
                                                     include a complete list of the drug
                                                     leaflets that are being supplied.

                                      2.     If Pharmacist does not attend staffing but the
                                             family does attend:

                                                     Prior to staffing, Pharmacist gathers
                                                     leaflets and sends to QMRP. Team
                                                     Leader give leaflets to family.
                                                     Physician or Nurse will answer
                                                     questions from family members.
                                                     Pharmacist documents on 650-H and
                                                     GSSH Form 843 that leaflets are
                                                     being provided to QMRP or designee
                                                     (at time of assessment). MD or
                                                     Nurse will document on 843 form
                                                     that leaflets are being given to
                                                     Family and whether or not any
                                                     further teaching has occurred.

                                      3.     If family does not attend staffing:

                Pharmacists gather leaflets and gives them to QMRP to send with post-
                staffing package to family. Documents on GSSH Form 843 (Teaching Flow
                Sheet) and 650-H that drug leaflets are being sent. ***If Pharmacist does
                not attend staffing will document at time of Pharmacist assessment. If
                Pharmacist attends staffing will document at the staffing if entry not made
                when annual assessment is completed.

Social Worker                         1.     If family does not attend staffing:

                                                     Documents on 650H and GSSH
                                                     Form 843 that leaflets are being sent
                                                     to family with post-staffing package.

Physician                             1.             Discusses medication questions with
                                                     family members either in person via
                                                     telephone or written correspondence.

    REV 01-2010                                                                          67



CRU/Unit Staff                Calls and notifies Pharmacist that client and
                              family are available to give drug history.

Pharmacist                    Obtains drug history from family. Provides
                              drug leaflets for appropriate drugs to family.
                              Answers any questions regarding drug
                              therapy. Documents on 650-H the client’s
                              current medications and dosages, a list of the
                              medication sheets provided, and any other
                              information as deemed appropriate by the

    REV 01-2010                                                          68


        To provide guidelines for clinical pharmacy services at the ECRH.


        Pharmacy Services will employ Clinical Pharmacists to provide a variety of
        clinical services to ECRH. The Clinical Pharmacist assigned to a particular Unit
        will serve as the Pharmacy representative in that Unit and shall be made
        responsible by the Director of Pharmacy for overseeing that their area(s) are in
        compliance with all policies and standards as set forth by all regulating bodies,
        ECRH policies, and Georgia Pharmacy Law. The Clinical Pharmacist, or
        pharmacy designee, will conduct monthly inspections of medication stations and
        file a written report to the Pharmacy and Nursing Departments.


        A)     Drug Regimen Reviews and Team Meetings

               The Clinical Pharmacist will participate on patient/client teams (as
               appropriate to Area). He/she will conduct periodic drug regimen reviews
               on a monthly basis. These reviews may include, but are not limited to,
               pharmacotherapy reviews (drug/drug, drug/disease, drug/allergy),
               pharmacokinetic reviews (renal/hepatic function, lab reviews,
               cultures/sensitivities), and pharmacoeconomic reviews.

        B)     Consultation

               The Clinical Pharmacist will be available for medication consults either as
               a part of their daily responsibilities or when requested by the physician (or
               other staff as appropriate). These consults may include but are not limited
               to the following.

               1.      Pharmacokinetics (or other drug dosing issues)
               2.      Drug interactions
               3.      Drug selection and efficacy issues
               4.      Drug information or drug use issues
               5.      Drug availability, storage, distribution and control issues
               6.      Medication error and reaction investigation and reporting
               7.      The Clinical Pharmacist will be available for one-on-one patient
                       counseling by request of the attending physician.

       REV 01-2010                                                                        69
 C)     Committees

         A Clinical Pharmacist will serve on various committees such as, but not
 limited to:

        1.     P & T Committee
        2.     Risk Management Sub-Committee
        3.     Patient/Family Education Committee
        4.     Behavior Support Plan Review
        5.     Human Right s Committee (Human Right’s BSP Subcommittee)
        6.     Clinical Review Panel
        7.     Drug Utilization Evaluation
        8.     Medical Executive Committee
        9.     Others as assigned

 D)     Patient Education

        The Clinical Pharmacist will provide patient medication education through
        classes, discharge counseling, and consultation to patients and staff.

        Patient Education Classes:

        Patient education classes are provided routinely for consumers/patients at
        AMH and Forensics. The classes consist of medication education as well
        as information about the importance of compliance, medication storage,
        over-the-counter medicines, and the dangers of alcohol and street drugs.
         Documentation of the education is completed on the Patient Medication
        Education Form (Form MH 390).

        Patient Discharge Counseling

        Patients will be given Medication Handouts with their discharge

        Patient will be given the opportunity to be counseled about their
        medication by a Registered Pharmacist.

        All Discharge Medication Counseling will be documented on the
        Physicians Discharge Medication Counseling Record. These automated
        reports extract current drug regimens from the Pharmacy Worx computer
        system, has patient education information, relative to drug uses, as
        directions typed in easy to read format and contains as disclaimer relative
        to counseling with ECRH Pharmacist via and access phone number.

REV 01-2010                                                                        70
 E)    Performance Improvement (PI)

       The Clinical Pharmacist will participate with P.I. as designated by the
       Director of Pharmacy.

 F)    Laboratory Values

       The Clinical Pharmacist will review appropriate lab values, including
       culture and sensitivities, as a routine part of their clinical duties. Any lab
       values that the Clinical Pharmacist deems significant will be
       communicated to the physician for review.

 G)    Drug/Food Interactions

       The Clinical Pharmacist will coordinate Drug/Food Interactions issues
       with the Clinical Dietitian. They will review all potential food drug
       interactions and assist the Clinical Dietitians as appropriate. See
       Food/Drug procedure in this manual.

 H)    Adverse Drug Reactions (ADR)

       All adverse drug reactions will be reported to Pharmacy Service using the
       Medication Reaction Report Form. The Clinical Pharmacist will report
       any ADR’s to the Pharmacy and Therapeutic Committee for evaluation. If
       deemed necessary after P&T review, the Clinical Pharmacist will process
       the necessary forms for reporting to FDA through the Mediwatch

 I)    Medication Room Inspection

       The Clinical Pharmacist, or pharmacy designee, will inspect all areas
       outside the Pharmacy where drugs are stored. The findings of this
       inspection will be reported on a Monthly Inspection Report. This form
       will be reviewed by each Nurse Manager or their designee. Any serious
       irregularities must be reported immediately to the Director of Pharmacy.

REV 01-2010                                                                         71

A. Applicable Standards and Requirements

      Clinical Pharmacists at ECRH are required to review the record of each client
      receiving medication(s) monthly. Notation, as appropriate, is made in the client’s
      record, and observations of response to drug therapy, adverse reactions, and
      over/under utilization of drugs are communicated to the Unit Physician.

B.    Requirements

      The Unit Pharmacist reviews each client’s medication regimen at least monthly.
      Formal Drug Regimen Reviews are to be conducted in skilled nursing areas
      monthly and ICF areas quarterly. In addition to drug reviews, the pharmacist will
      complete an Annual Pharmacist Assessment. This assessment should be available
      to the Living Area staff (on shared drive) at least 2 weeks prior to the Annual
      Conference (Staffing).

C.    Procedure

      1.     The Pharmacy Medication Review (CLN Form 681), ECRH Form DD683
             and Indicator Comment sheets are used to document reviews.

      2.     Pharmacy reviews are dated and may include:

             *       Client response to drug therapy

             *       Drug allergies

             *       Adverse drug reactions and/or significant drug interactions

             *       Observations of over/under drug utilization

             *       Follow-up of clients receiving behavior modifying medications.

             *       Follow-up of clients receiving anticonvulsive medications

                 Potential drug therapy indicators (list may be found in the Department
                  of Pharmacy)

      3.     Completion of Forms

     REV 01-2010                                                                      72
          Pharmacy Medication Review (CLN Form 681) and Consultant
           Pharmacist’s Drug Regimen Review Comments (DD 683) are
           identified using the client identification label. Each client receiving
           medications has these forms in their record in the direct medical care
           section. This form contains documentation of drug reviews with
           applicable comments/recommendations for quick reference.

       *      The front of the Pharmacy Medication Review, CLN Form 681,
              lists medications. PRN medications are listed in the bottom spaces
              of the form. Review dates are entered at the top of the form. An
              arrow drawn in a block between review dates indicates medication
              continuation. Diagonal lines indicate discontinued drugs.
       *      Special medications, i.e., those prescribed for a limited time for an
              acute condition, are not listed unless in the opinion of the
              pharmacist, comment is needed regarding usage.
       *      The reverse side of the Pharmacy Medication Review, CLN Form
              681, lists known drug allergies. The blocks for the pharmacist’s
              signature and date are completed at each review. All applicable
              monitoring parameters, including required laboratory data, are
              completed also. After the review, the medications block is
              checked as “appropriate” or “see form DD 683 for comments”
       *      Comments are sent in memorandum form to the Unit Physician on
              an Indicator Comments sheet, accompanied by a Checklist for
              Drug Reviews. Copies are distributed to the Pharmacy Director,
              Assistant Pharmacy Director, Clinical Director, and Nursing
              Manager. The Pharmacist goes no further than identification of
              possible irregularities and notification of the Unit Physician. It is
              not necessary for the Pharmacist to ascertain the outcome of the
              recommendation. The Pharmacist need not repeat the
              documentation each review if the apparent irregularity continues

              a)      It has been deemed insignificant by the Pharmacist.

              b)      It has been deemed significant by the Pharmacist, but the
                      identification of possible irregularity has been rejected by
                      the individual having authority to correct it. Under these
                      circumstances, the Pharmacist may document that he/she
                      identified an apparent irregularity and notified a person
                      having authority to correct the potential problem.
                      Notification is required on an annual basis.


REV 01-2010                                                                      73
 PURPOSE: To provide written documentation of medication usage relative to
 disease state and efficacy to members of the client’s Interdisciplinary Team.

 POLICY: The Clinical Pharmacy Department shall perform an annual
 pharmaceutical assessment on all clients. Drug therapy, which has the maximum
 potential to develop side effects or be contra-indicated in various clinical disease
 states, should be emphasized. These assessments must be prepared and submitted
 by the Clinical Pharmacist to meet the Hospital’s predetermined deadline.


 1.     The following information can be derived from each client’s record for
        inclusion in annual assessment or from pharmacy resources:

        a)      Pertinent data base includes age, weight, diagnosis, diet, ideal
                weight range and allergy information.

        b)      Current medication therapy (include drug, dosage, and initiation
                date if applicable).

        c)      Analysis, description of seizures and/or inappropriate behaviors.
                Parameters to monitor secondary to current drug therapy (include
                potential adverse/side effects and precautionary use of selected
                medications in various disease states. (Optional)

        d)      Lab test frequency guidelines according to current therapy.

        e)      Drug interaction evaluation of current therapy; food drug
                interactions profile.

        f)      Recommendations to be considered secondary to current therapy.

        g)      Therapeutic duplications

 2.     The above assessment criteria may be modified by the Clinical Pharmacist
        to include additional information determined to be of value to the
        medical/nursing staff.

 3.     Pharmacy Annual Assessments are forwarded to the pharmacy secretary
        (four weeks prior to team conference) for a computer-generated copy of
        Pharmacy Assessment (GSSH Form 721). The secretary will place
        completed annual assessment on the shared drive (j-drive) in the pharmacy

REV 01-2010                                                                        74
              folder. This information is available on line for ECRH staff to review.
              Yearly revisions of Annual Assessment must be submitted to the secretary
              to update files and assessments.

       4.     A hard copy of the Pharmacy Annual Assessments are sent to the
              consumer’s Living Area to be added to the consumer’s record.

       5.     Drug Education Leaflets will be submitted to QMRP with the Annual

       6.     A copy of the consumer’s Drug Education Leaflets are sent to the patient’s
              family by the social worker for Family Education and documented in the
              Teaching Flow Sheet (GSSH 843).

       7.     Recommendations for participation in the Pharmacy Self Administration
              Program should be included in the Assessment with program objectives.


Clinical Pharmacists may attend the annual IDT “staffing” for those clients who meet the
following criteria: Attendance is not mandatory unless requested by Unit Physician .


1.     Administration of one anticonvulsive medication.

2.     Administration of one behavior medication.

3.     Complex medication problems based on the judgement of the pharmacist.

4.     A specific written request from the Unit Physician or Interdisciplinary Team
       Leader for any client who does not meet any of the first three criteria.

     REV 01-2010                                                                      75
                        DIVISION OF HEALTH SUPPORTS
                           PHARMACY DEPARTMENT

                   IMPLEMENTED    FISCAL YEAR 2003

IV.    Important Aspects of Care:

1.     All drugs dispensed by the Pharmacy shall be screened to ensure that they are
       being used in a rational manner, with factors such as age, allergies and
       interactions given adequate consideration prior to administration to ECRH
       patients. All stop order procedures shall be followed and unnecessary therapeutic
       duplication of medications minimized.

2.     All medication orders written by a physician or dentist are filled, dispensed and
       profiled accurately. A Registered Pharmacist reviews the “filled prescription”
       prior to dispensing. (Per State Board of Pharmacy Rules)

3.     Drug regimen reviews are conducted according to the rules governing ICF/MR
       and SNF facilities.

4.     All drug are stored in the Pharmacy according to State Board of Pharmacy
       regulations, to ensure no drug, that is expired, mislabeled, contaminated,
       deteriorated, or without the container intact, is dispensed to ECRH consumers and

5.     All drugs are properly labeled according to State Board of Pharmacy, Joint
       Commission (JCAHO), and HCFA requirements.

V.     Indicators:

       Indicator: Rational Drug Therapy

1.     All drugs, dispensed by the Pharmacy, shall be screened to ensure that they are
       being used in a rational manner; with factors such as age, allergies and
       interactions given adequate consideration prior to administration to ECRH
       clients/patients. All stop order procedures shall be followed and unnecessary
       therapeutic duplication of medications minimized.

      REV 01-2010                                                                          76

       1)     Doses are appropriate for client’s age.                      95%

       2)     No contraindicated drugs on profile.                         99%

       3)     No significant drug-drug or drug-food                        94%
              interactions are found.

       4)     No chemical or therapeutic duplications are                  90%
              found in current drug therapy.

       5)     No unauthorized continuation of drugs beyond                 95%
              stop dates are found.

Indicator: Profiling and Dispensing

2.     All medication orders written by a physician or dentist are filled, dispensed and
       profiled accurately. A Registered Pharmacist reviews the “filled prescription”
       prior to dispensing (Per State Board of Pharmacy Rules).


       1)     Pharmacy profile agrees with physician’s orders.             99%

       2)     A pharmacist initials the physician’s order.                 85%

       3)     Discontinued medications are clearly indicated.              90%
              (where applicable)

       4)     Medication(s) dispensed are correct.                         99%

Indicator: Drug Regimen Review Monitoring

3.     Drug regimen reviews are conducted according to the rules governing ICF/MR
       and SNF facilities.


       1)     Client’s chart reviewed as required.                         95%

       2)     Flow chart updated.                                          90%

       3)     GSSH 650-H Form is properly annotated.                       90%

     REV 01-2010                                                                           77
Indicator: Pharmacy Stock Integrity

4.     All drugs are stored in the Pharmacy according to State Board of Pharmacy
       regulations, to ensure no drug, that is expired, mislabeled, contaminated,
       deteriorated, or without the container intact, is dispensed to ECRH

       1)     Oral solids
       2)     Oral liquids
       3)     Injectable
       4)     EENT preparations
       5)     Topicals
       6)     Refrigerated drugs

               *The integrity of each drug is determined by the following criteria:


       1)     Drug not expired.                                             95%

       2)     Drug not recalled.                                            95%

       3)     Drug not contaminated.                                        95%

       4)     Drug not visibly deteriorated.                                95%

       5)     Drug not improperly packaged.                                 95%

       6)     Container intact                                              95%

Indicator: Labeling and Packaging

6.     All drugs are properly labeled according to State Board of Pharmacy, Joint
       Commission, and HCFA requirements.


       1)     Correct drug name on label?                                   99%

       2)     Correct drug strength on label?                               95%

     REV 01-2010                                                                      78
        3)      Directions for administration on label?                            95%

        4)      Expiration date on label?                                          80%

        5)      Correct client name on label?                                      100%

        6)      Current client Living Area on label?                               99%

        7)      Manufacturer’s lot number on label?                                90%
                (if applicable)

        7)      Manufacturer’s name on label?                                      90%
                (if applicable)

VI.     Data Collection:

A. Data collection:

        Data collection will be done by pharmacy personnel assigned by the Pharmacy Director.
        The collection process will by necessity be individualized for each indicator. The
        following is a description of the data collection process for each indicator.

        1.      Rational Drug Therapy:

                Twenty client’s profiles will be reviewed by a Registered Pharmacist monthly.
                These will be selected at random. Those selected will not be chosen again for
                review for at least 6 months. Records will be kept to ensure that all Units will be
                represented in the sample at least once every 6 months.

        2.      Profiling and Dispensing:

                Twenty client’s profiles will be reviewed monthly by the assigned personnel.
                These will be selected at random. Records will be kept to ensure that all units
                will be represented in the sample at least once every 6 months.

        3.      Drug Regimen Reviews:

                Thirty client’s charts will be reviewed by the assigned personnel each month.
                Five charts from each Unit, will be selected at random. The charts will be
                reviewed back one calendar year.

        4.      Pharmacy Stock Integrity:

                Five items of pharmacy stock, selected at random from each category, will be
                reviewed by the assigned personnel each month.

        5.      Labeling and Repackaging:
                Twenty drugs dispensed to ECRH clients/patients will be selected at random by
                the assigned personnel and reviewed and documented monthly.

      REV 01-2010                                                                                 79


1.    After-Hours Cabinets
      Rationale and General Guidelines:
      To provide for availability of medications during those hours when the Pharmacy
      is closed each campus we will have an After Hours cabinet. Contents of these
      cabinets vary from time to time and are tailored to the role and function of the
      particular hospital. A list of the current contents is included in this manual. Drugs
      are divided into three major sections:1-Cardiovascular Drug Cabinet also contains
      drugs for Cholesterol, Thyroid ,EPS and Diabetes, 2- Psychiatric Drug Cabinet,
      and Medical Drug Cabinet. Drugs are sorted in these cabinets secondary to
      primary indication and secondarily by the generic names within the indication
      grouping. Upper /lowercase letters are used on the individual labels and in the
      nursing reference databases to highlight certain name syllables to prevent the
      possibility of medication selection error due to look a like names. Color coding
      has also been added on labels to highlight drug names. This coding also specifies
      primary indication grouping in the cabinets as referenced in drug databases.

      a.    Drugs placed in the after-hours cabinets shall be packaged and labeled
            appropriately. Whenever possible, only the full prepackaged containers
            should be removed.
      b.    www.pharmacyonesource.com should be placed on every
            computer that medical staff utilizes to retrieve medication
            information (esp. when the pharmacy is closed). This site can be
            used to check drug id, side effects, dosage, food-drug interaction,
            drug-drug interactions, print drug information monographs, etc.
            Additionally this site provides updated interaction information such
            as the cranberry juice warfarin interaction potential via email. This
            will help us meet elements of performance for MM4 .10(all
            prescription or medication orders are reviewed for
            appropriateness-even when the pharmacy is closed). Note
            information links to pharmacyonesource.com have been
            placed on our intranet under Clinical Director, Nursing and
            Pharmacy sections on our facility homepage

      c.     Withdrawals from the after-hours cabinet shall be made only by
             authorized persons. Authorized persons include physicians (including
             MOD/OD) and nurses. In addition, the ECRH Pharmacist “on call” is
             authorized to remove medications, either in person, or through a third
             party (e.g. Nurse). A physician’s order (either a new order or an existing

     REV 01-2010                                                                        80
 d.    order in the chart) is required to remove drugs from the after-hours
       cabinet. All withdrawals shall be recorded, by the individual removing the
       drug(s), on an After-Hours Sign Out document. The following
       information is required on the sheet: date, time, patient’s name, Living
       Area/Unit, name and strength of medication, and nurse removing and
       giving drug. A copy of the After-Hours sign out sheet is to be forwarded
       to the Pharmacy each regular working day. Only nursing personnel,
       physicians, and pharmacy personnel are authorized to enter the after-hours
       cabinet. This staff should have an “after-hours cabinet” orientation in-
       service, to become familiar with the proper procedures.
       The next day, the Living Area/Unit should send the medication taken from
       the after-hours cabinet to the Pharmacy for appropriate labeling and
       review by a pharmacist.

  c.    All medication orders will be reviewed by a pharmacist prior to
       dispensing. The pharmacist shall initial any corresponding documents i.e.
       medication order, refill request, fill list, etc. The pharmacist will then place
       the medication in a designated area for delivery to the Living Area.
       When the pharmacy is not opened, two health care professional will review
       the medication order in the pharmacist’s absence. When the pharmacy is
       not open 24 hours a day and 7 days a week, the pharmacist will conduct a
       retrospective review of the order as soon as the pharmacy is open.

 d.    Orders for medication taken from after-hours cabinets must be sent to the
       Pharmacy the next working day. Pharmacy personnel will review the
       after-hours sign out sheets and the orders to assure that they are in
       agreement. Medications used from the after-hours cabinet will be
       profiled, charged to the appropriate client/patient, and replaced in the
       cabinet. All drugs in the cabinets are inventoried no less than once weekly
       by pharmacy personnel. Such reviews shall be documented and this
       record is to be retained for a period of two years for inspection by
       authorized agents of the Board of Pharmacy.

 e.    Access to the pharmacy: When a drug is needed that is not available from
       the after-hours cabinets and is required, a Registered Pharmacist will be
       on-call to come to the institution, open the pharmacy, and dispense the
       medication. Pharmacists will communicate with requesting nurse where
       medications will be delivered after hours. Deliveries will either be made
       to the area or after hours cabinet (pharmacist preference). The
       Pharmacist will insure appropriate nurse is aware of drop off site.

 f.    The after-hours cabinets are located in the 76 Building (After Hours
       Treatment Room) for Gracewood Campus and Admitting Office (23 Hour
       unit) for Augusta Campus.

 g.    Refer to the Decision Tree (Section II-2) and Nursing Procedure Manual
       (Section VI.3) for after hours drug procurement and Emergency After Hours
       procurement procedure (Section II-2).

REV 01-2010                                                                         81
                     V-2AFTER HOURS CABINET
                        GRACEWOOD CAMPUS
                                                               * BOTTOM SHELF
                            * REFRIGERATOR                      ** TOP SHELF
Indication             Generic name                                Trade name Peg         Qty
Analgesic Supp.           Acetaminophen Suppositories 650mg Tylenol                 ***                10
                    Albuterol for Inhalation 2.5ml             Ventolin             127                12
Bronchodilator      Albuterol Oral Inhaler                     Ventolin             128                  1
Misc-EPS            Amantadine, 100mg                          Symmetrel            80               1x12
Infection           Amoxicillin, 250mg                         Amoxil                1               2x12
Infection           Amoxicillin, 500mg                         Amoxil                2               2x12
Infection           Amoxicillin, 250mg/5ml                     Amoxil               TS          2x150ml
Infection           Amoxicillin/Clavulanate, 250mg/125mg       Augmentin             3            1 x 12
Infection           Amoxicillin/Clavulanate, 250mg/125mg/5ml   Augmentin            TS          2x150ml
Infection           Amoxicillin/Clavulanate, 400mg/57mg/5ml    Augmentin            TS          1x100ml
Infection           Amoxicillin/Clavulanate, 500mg/125mg       Augmentin             4               1x12
Infection           Amoxicillin/Clavulanate, 875mg/125mg       Augmentin             5               1x12
Psychosis           Ariprazole 9.75mg/1.3ml                    Abilify              144               2x1
Infection           Azithromycin, 250mg                        Zithromax             6                2x6
Mania/Seizures      Carbamazepine 200mg                        Tegretol             88               1x12
Infection           Ceftriaxone, 1gm                           Rocephin             132               4x1
Infection           Cephalexin, 250mg                          Keflex                7               1x12
Infection           Cephalexin, 500mg                          Keflex                8               2x12
Infection           Cephalexin Susp., 250mg/5ml                Keflex               TS          1x100ml
Hynoptic            Chloral Hydrate, 500mg/5ml                 Noctec               TS           3x5ml
Infection           Ciprofloxacin, 250mg                       Cipro                 9                4x6
Infection           Ciprofloxacin, 500mg                       Cipro                10                4x6
Infection           Clindamycin, 150mg                         Cleocin              11               2x12
Infection           Clindamycin Pediatric 75mg/5ml             Cleocin              TS          1x100ml
Heart/BP            Clonidine, 0.1mg                           Catapres             81                2x6
Anti-fungal         Clotrimazole Cream                         Lotrimin             119                  1
Anti-fungal         Clotrimazole/Betamethasone Dipro           Lotrisone            121                  1
Misc-EPS            Diphenhydramine 50mg/1cc Vial              BenADRYL             141               3x1
Misc-EPS            Diphenhydramine, 12.5mg/5ml                BenADRYL             BS          1x120ml
Misc-EPS            Diphenhydramine, 25mg                      BenADRYL             83               1x12
Mania/Seizures      Divalproex,250mg                           Depakote             89            2 x12
Mania/Seizures      Divalproex, 500mg                          Depakote             90               2x12
Mania/Seizures      DivalPROEX ER 250MG                        DepaKOTE ER          91               2X12
Mania/Seizures      DivalPROEX ER 500MG                        DepaKOTE ER          93               2X12
Anticoagulant       Enoxaparin Sodium Inj. 100mg/1ml           Lovenox              133               1x2
Allergic/Med Rxn    Epinephrine 1:1000 1mg/ml Amp                                   134           4X1
Infection/OPTH      Erythromycin OPTH                          ILOTYCIN OPTH        11           2X1
Infection           Erythromycin, 250mg                        E-Mycin              12           2x 12
Infection           Erythromycin, 400mg/5ml                    E-Mycin               R      2x100ml

      REV 01-2010                                                                               82
Seizures                Fosphenytoin 50mg/ml 2ml Vial               CereBRYX                  R                  5
Diuretic/BP             Furosemide 20mg (10mg/cc) 2cc Vial          Lasix                    142                3x1
Diuretic/BP             Furosemide, 40mg                            Lasix                     84                2x6
Seizures                Gabapentin 300mg                            Neurontin                 93              1x12
Infection               Gentamicin Opth. Oint.                      Garamycin                111                2x1
Diabetes                Glucagon 1 unit (1mg) Vial                                           135                 1
Diabetes                Glutose Oral Gel                            Glucose Oral Gel          **                 3
Constipation            Glycerin Suppository- Adult                                           R                 10
Psychiatric             Haloperidol, 5mg                            Haldol                    94              2x12
Psychiatric             Haloperidol Injection 5mg/ml                Haldol                   145                 3
Hemorrhoids             Hemorrhoidal HC Supp                        Anusol Hc                 R                 12
Hemorrhoids             Hemorrhoidal Supp                           Anusol Hc                 R                 12
Diuretic/BP             Hydrochlorothiazide, 25mg                   HydroDiuril              85                 2x6
Anti-Inflammatory,topical Hydrocortisone 1% Cream                                            120                 1
Anxiety                 Hydroxyzine 100mg/2cc Vial                  Vistaril                 148          2x1
Indication              Generic Name                                Trade Name         Peg         Qty
Anxiety                 Hydroxyzine, 10mg/5ml                       Vistaril                 BS      1X 3OZ
Anxiety                 Hydroxyzine, 25mg                           Vistaril                  97         1X12
Analgesic:NSAID         Ibuprofen, 400mg                            Motrin                    13              3x12
Analgesic:NSAID         Ibuprofen, 600mg                            Motrin                    14              2x12
Analgesic:NSAID         Ibuprofen, 800mg                            Motrin                   15               1x12
Diabetes                Insulin Glargine                            Lantus                    R                  1
Diabetes                Insulin Humalog                                                       R                  1
Diabetes                Insulin NPH U-100 (Human) 10ml                                        R                  1
Diabetes                Insulin Reg U-100 (Human) 10ml                                        R                  1
Antidote, Potassium     Kayexalate 15gm/60ml                                                 TS           4x60ml
Hypokalemia             KCL 10% 20meq/15ml                          K-lor                    TS            2x3oz
Bronchodilator          Ipratripium 0.5mg/2.5ml                     Atrovent                 129                 8
Constipation            Lactulose Solution 10gm/5ml                 Chronulac                TS            1x8oz
Infection               LevoFLOXACIN, 250mg                         Levaquin                  16                2x6
Infection               LevoFLOXACIN,, 500mg                        Levaquin                  17                2x6
Infection               Linezolid, 600mg                            Zyvox                     18                2x6
Anesthetic,topical      Lidocaine 1%, 10cc Vial                     Xylocaine                136                3x1
Infection               Linezolid, 600mg                            Zyvox                     19                2x6
Mania                   Lithium Carbonate, 300mg                    Lithinate                 98              2x12
Misc-Diarrhea           Loperamide, 2mg                             Imodium                   20              2x12
Misc-Allergies          Loratadine, 10mg                            Claritin                  22           1 x 12
Infection               Mupirocin Oint. 2%                          Bactroban                122                2x1
Infection/OPTH          Neomycin-Polym B Gramic Opth Soln.          Neosp. Opth Sol.         112                2x1
Infection/OPTH          Neomycin-Polymycin B-Bacit. Opth Oint.      Neosporin                113                2x1
Infection/OTIC          Neomycin-Polymyxin B, HC Otic Susp.         Cortisporin OTIC         126                2x1
Infection/OPTH          Neomycin-Polymyxin B. Bac, HC Opth. Oint.   Cortisporin Opth         108                 1
Infection/OPTH          Neomycin-Polymyxin B-HC opth. Susp.         Cortisporin Opth         109                2x1
Infection               Nitrofurantoin, 50mg                        Macrodantin               24              1x12
Cardio-active           Nitroglycerin, 0.4mg tablets                Nitrostat                 87           2 x 25
Allergies               Normal Saline Spray                         AYR                      131                 1
Infection,topical       Nystatin-Triamcinolone Cream                Mycolog                  123                2x1

        REV 01-2010                                                                                      83
Psychosis                Olanzapine, 5mg                             Zyprexa                    98             4x6
Psychosis                Olanzapine Zydis, 5mg                       Zyprexa-Zydis              99             1x6
Misc-Allergies           Oxymetazoline hydrochloride 0.05%           Afrin Nasal Spray     TS                   2
Infection                Penicillin VK, 250mg                        Pen-Vee K                  25           1X12
Seizures                 Phenytoin 100mg/2ml Amp                     Dilantin                   137           3x1
Seizures                 Phenytoin, 50mg                             Dilantin                   28            1x12
Seizures                 Phenytoin,100mg                             Dilantin                   27           2x12
Injection/OPTH           Prednisolone Acetate Opth. Susp.            Pred-Forte                 114              1
Anti-Inflammatory        Prednisone, 5mg                             Deltasone                  29     1x12
Misc-Nausea/Vomiting     Promethazine 25mg/cc Amp                    Phenergan                  138    4X1
Misc-Nausea/Vomiting     Promethazine Suppositories 25mg             Phenergan                   R             12
Misc-Allergies           Pseudoephrine,30mg                          Sudafed                    30     1x12
Psychiatric              Quetiapine, 25mg                            Seroquel                   100   2x12
Psychiatric              Quetiapine, 100mg                           Seroquel                   101   2x12
GERD                     Ranitidine, 150mg                           ZanTAC                     32     2x6
Psychiatric              Risperidal, 0.5mg                           Risperdal                  102            2x6
Psychiatric              Risperidal, 1mg                             Risperdal                  103            2x6
Psychiatric              Risperidal, 2mg                             Risperdal                  105            2x6
Infection/OPTH           Sulfacetamide Sod./Prednisolone 10%/ 0.2%   Blephamide                 115             1
Infection/OPTH           Sulfacetamide Opth Sol. 10 %                Sodium Sulfamyd            116             1
Burns/Infection          Sulfadiazine Cream                          Silvadene                  124             1
Infection                Sulfamethaxazole/ Trimethoprim              Septra                     33       2x6
Infection                Sulfamethaxazole/Trimeth, 800/160mg         Septra DS                  34       2x6
Infection                Sulfamethaxazole,Trimethoprim Susp.         Septra                     TS 1x4oz.
Infection, topical       Three-In-One Cream                          Triamcinolone              TS              2
Tetanus                  Tetanus Immune Globulin Human 250U                                      R              1
Seizures                 Topiramate, 25mg                            Topamax                    36            2x12
Psychiatric              Trazodone, 50mg                             Desyrel                    106           2x12
Anti-Inflammatory,topical Triamcinolone Cr .1%                       Kenalog                    118             1
Seizures                 Valporic Acid 250mg/5ml Syrup               Depakene Syr               BS    1x16oz
Anti-Coaulant            Warfarin, 1mg                               Coumadin                   86    2x12
Psychosis                Ziprasidone Mesylate 20mg/ml                Geodon                     150            3x1
Psychosis                Ziprasidone Mesylate 20mg Capsules          Geodon                     107            2x6

       REV 01-2010                                                                                      84
            V-3. (AUGUSTA CAMPUS)- AFTERHOURS CABINET(Generic Sorted)3/06
            Augusta Campus After Hours Cabinet(Generally sorted).
                       TS-Top Shelf
                       NO-Nursing Office
                       BS-Bottom Shelf
                                                                      BS-Bottom Shelf
                                                                          Ro PE
INDICATION                     GENERIC NAME                               w    G   BRAND NAME
Diuretic/BP                    AcetaZOLamide, 250mg                        2   14   DiaMOX
                                                                          2    22
Infection,Anti-Viral           Acyclovir, 200mg                           6     6   Zovirax
EPS                            Amantadine, 100mg                          10   82   Symmetrel
Depression                     Amitriptyline, 25mg                        11   93   Elavil
Depression                     Amitriptyline, 50mg                        11   94   Elavil

Heart/BP                       Amlodipine, 5mg                             3   20   Norvasc
                                                                          2    19
Infection                      Amoxicillin, 250mg                         3     9   Amoxil
                                                                          2    20
Infection                      Amoxicillin, 500mg                         3     0   Amoxil
Infection                      Amoxicillin/Clavulanate, 250mg/125mg       23    1   Augmentin
Infection                      Amoxicillin/Clavulanate, 500mg/125mg       23    2   Augmentin
Infection                      Amoxicillin/Clavulanate, 875mg/125mg       23    3   Augmentin
Psychosis                      Aripiprazole 10mg                          16    7   Abilify
Psychosis                      Aripiprazole 15mg                          16    8   Abilify
Heart/BP                       Atenolol, 50mg                              3   21   Tenormin

Cholesterol                    Atrovastin 10mg                             8   64   Lipitor
Cholesterol                    Atrovastin 40mg                             8   65   Lipitor
                                                                          2    20
Infection                      Azithromycin, 250mg                        3     4   Zithromax
EPS                            Benztropine Mesylate Inj                  S          Cogentin Inj
EPS                            Benztropine, 0.5mg                         10   83   Cogentin

    REV 01-2010                                                                       85
EPS               Benztropine, 1mg                10   84   Cogentin
EPS               Benztropine, 2mg                10   85   Cogentin

Depression        BuPROPION, 100mg                11   96   Wellbutrin

Depression        BuPROPION, 75mg                 11   95   Wellbutrin

Depression        BuSPIRONE, 5mg                  11   97   Buspar

Depression        Buspirone, 10mg                 11   98   Buspar
Heart/BP          Captopril, 25mg                 3    22   Capoten
Mania/Seizures    Carbamazepine 100mg             15    7   Tegretol
Mania/Seizures    Carbamazepine 200mg             15    8   Tegretol

Cardio-active     Carvedilol 12.5mg               1     6   Coreg

Cardio-active     Carvedilol 3.125mg              1     5   Coreg
                                                  2    20
Infection         Ceftriaxone, 1gm                3     5   Rocephin
                                                  2    20
Infection         Cephalexin, 250mg               3     6   Keflex
                                                  2    20
Infection         Cephalexin, 500mg               3     7   Keflex
Diabetes          ChlorproPAMIDE, 250mg           7    55   Diabinese
                                                  2    20
Infection         Ciprofloxacin, 250mg            4     8   Cipro
                                                  2    20
Infection         Ciprofloxacin, 500mg            4     9   Cipro
Depression        Citalopram 20mg                 1    99   Celexa
                                                  2    21
Infection         Clindamycin, 150mg              4     0   Cleocin
Heart/BP          Clonidine, 0.1mg                3    23   Catapres
 Anti-coagulant   Clopidogrel Bisulfate           1     4   Plavix
Hormone           Conjugated Estrogens, 0.625mg   26    1   Premarin
                                                  2    23
Muscle Relaxant   Cyclobenzaprine, 10mg           6     3   Flexeril
Infection         Dicloxacillin, 250mg            2     1   Dynapen

    REV 01-2010                                               86
                                                    2    19
GI Motility       Dicyclomine 10mg                  2     8   BenTYL
Cardio-active     Digoxin, 0.125mg                  1     7   Lanoxin
Cardio-active     Digoxin, 0.25mg                   1     8   Lanoxin
Heart/BP          Diltiazem CD, 120mg               3    24   Cardizem
Heart/BP          Diltiazem CD, 180mg               3    25   Cardizem
Heart/BP          Diltiazem CD, 240mg               3    26   Cardizem

EPS               Diphenhydramine, 25mg             10   86   BenADRYL

EPS               Diphenhydramine, 50mg             10   87   BenADRYL
Mania/Seizures    Divalproex 500mg                  15    0   Depakote
Mania/Seizures    Divalproex 250mg                  15    9   Depakote
Mania/Seizures    Divalproex ER 250mg               20    9   Depakote
Mania/Seizures    Divalproex ER 500mg               20    0   Depakote

Heart/BP          Doxazosin, 2mg                    4    28   Cardura
Depression        Doxepin, 25mg                     12    0   Sinequan
                                                    2    21
Infection         Doxycycline, 100mg                4     2   Vibramycin
Depression        DULoxetine 30mg                   12    1   Cymbalta

Heart/BP          Enalapril, 5mg                    4    30   Vasotec

Heart/BP          Enalapril, 10mg                   4    31   Vasotec
                                                    2    21
Infection         Erythromycin, 250mg               4     3   E-Mycin
Depression        Escitalopram 10mg                 12    2   Lexapro
                                                    2    19
GERD              Esomerprazole, 20mg               2     0   Nexium
                                                    2    19
GERD              Esomerprazole, 40mg               2     1   Nexium
Cholesterol       Ezetimibe10 mg,Simvastatin 10mg   8    67 Vytorin 10/10
Cholesterol       Ezetimibe10 mg,Simvastatin 20mg   8    68 Vytorin 10/20

    REV 01-2010                                                87
Cholesterol          Ezetimibe10 mg,Simvastatin 40mg    8   69   Vytorin 10/40
                                                       2    19
GERD                 Famotidine, 20mg                  2     2   Pepcid
                                                       2    21
Infection            Fluconazole, 150mg                4     4   Diflucan
Depression           FLUoxetine, 10mg                  12    3   Prozac
Depression           FLUoxetine, 20mg                  12    4   Prozac
Psychosis            FluPHENAZINE, 10mg                16    4   Prolixin
Psychosis            FluPHENAZINE,5mg                  16    3   Prolixin
                                                       2    23
Vitamin Supplement   Folic Acid, 1mg                   7     8   Folvite
Diuretic/BP          Furosemide, 20mg                   2   15   Lasix
Diuretic/BP          Furosemide, 40mg                   2   16   Lasix
Mania/Seizures       Gabapentin 100mg                  15    1   Neurontin
Mania/Seizures       Gabapentin 300mg                  15    2   Neurontin
Cholesterol          Gemfibrozil, 600mg                 8   66   Lopid

Diabetes             GliPIZIDE, 5mg                     7   56   GlucoTROL
Hypoglycemia         Glucagon 1mg(unit)                S         Glucagon
Hypoglycemia         Glutose 15                        S         Oral Glucose
Diabetes             GlyBURIDE, 2.5mg                   7   57   Glynase
Diabetes             GlyBURIDE, 5mg                     7   58   Glynase
Psychosis            Haloperidol, 1mg                  17    5   Haldol
Psychosis            Haloperidol, 2mg                  17    6   Haldol
Psychosis            Haloperidol, 5mg                  17    7   Haldol
Psychosis            Haloperidol,10mg                  17    8   Haldol
Diuretic/BP          Hydrochlorothiazide, 25mg          2   17   HydroDiuril

Anxiety              Hydroxyzine, 25mg                 11   91   Vistaril

Anxiety              Hydroxyzine, 50mg                 11   92   Vistaril

    REV 01-2010                                                    88
                                                2    18
Analgesic:NSAID   Ibuprofen, 400mg              1     2   Motrin
                                                2    18
Analgesic:NSAID   Ibuprofen, 600mg              1     3   Motrin
                                                2    18
Analgesic:NSAID   Ibuprofen, 800mg              1     4   Motrin
Depression        Imipramine, 25mg              12    5   Tofranil
                                                2    18
Analgesic:NSAID   Indomethacin, 25mg            1     5   Indocin
                                                2    22
tuberculosis      Isoniazide, 300mg             5     4   Laniazid
Cardio-active     Isosoribide Dinitrate, 10mg   1     9   Isordil
Heart/BP          Labetalol, 100mg              4    32   Normodyne
                                                2    24
Seizures          Lamotrigine, 100mg            8     5   LaMICTAL
                                                2    24
Seizures          Lamotrigine, 150mg            8     6   LaMICTAL
                                                2    24
Seizures          Lamotrigine, 25mg             8     4   LaMICTAL
                                                2    19
GERD              Lansoprazole Solutabs. 30mg   2     3   Solutabs
                                                2    24
Seizures          Levetiracetam, 250mg          8     7   Keppra
                                                2    24
Seizures          Levetiracetam, 500mg          8     8   Keppra
                                                2    21
Infection         LevoFLOXACIN, 250mg           4     5   Levaquin
                                                2    21
Infection         LevoFLOXACIN, 500mg           4     6   Levaquin
Thyroid           LevoTHYROXINE, 0.025mg        9    73   Synthroid
Thyroid           LevoTHYROXINE,, 0.05mg        9    74   Synthroid
Thyroid           LevoTHYROXINE,, 0.075mg       9    75   Synthroid
Thyroid           LevoTHYROXINE,, 0.1mg         9    76   Synthroid
                                                2    21
Infection         Linezolid 600mg               5     7   Zyvox
Heart/BP          Lisinopril, 10mg              4    34   Prinivil
Heart/BP          Lisinopril, 20mg              4    35   Prinivil

    REV 01-2010                                             89
Heart/BP          Lisinopril, 5mg               4    33   Prinivil
Mania             Lithium Carbonate CR, 450mg   15    3   Eskalith
Mania             Lithium Carbonate, 150mg      15    4   Lithinate
Mania             Lithium Carbonate, 300mg      15    5   Lithinate
Mania             Lithium Carbonate, 600mg      16    6   Lithinate
                                                2    23
Diarrhea          Loperamide, 2mg               6     0   Imodium
                                                2    22
Allergies         Loratadine, 10mg              6     8   Claritin

Heart/BP          Losartan, 25mg                5    37   Cozaar

Heart/BP          Losartan, 50mg                5    38   Cozaar
Psychosis         Loxapine, 25mg                17    9   Loxitane

Diabetes          Metformin, 500mg              7    59   GlucoPHAGE

Diabetes          Metformin, 850mg              7    60   GlucoPHAGE
                                                2    19
GI Drug,Misc      MetoCLOPRAMIDE 10mg           2     7   Reglan
Heart/BP          MetoPROLOL 25mg               5    39   Lopressor

Heart/BP          MetoPROLOL, 50mg              5    40   Lopressor
                                                2    21
Infection         MetroNIDAZOLE, 250mg          5     8   Flagyl
Depression        Mirtazepine, 15mg             12    7   Remeron
Depression        Mirtazepine, 30mg             12    8   Remeron
                                                2    18
Anti-Asthma       Montelukast,10 mg             1     9   Singular
                                                2    18
Analgesic:NSAID   Naproxen, 250mg               1     6   Naprosyn
Heart/BP          Nifedipine XL, 30mg           5    41   Procardia XL
Heart/BP          Nifedipine XL, 60mg           5    42   Procardia XL
Heart/BP          Nifedipine XL, 90mg           5    43   Procardia XL
Heart/BP          Nifedipine, 10mg              5    44   Procardia

    REV 01-2010                                             90
                                                       2    21
Infection            Nitrofurantoin, 50mg              5     9   Macrodantin
Cardio-active        Nitroglycerin Transdermal 0.1mg   2    10   Transderm-Nitro
Cardio-active        Nitroglycerin Transdermal 0.2mg   2    11   Transderm-Nitro
Cardio-active        Nitroglycerin Transdermal 0.4mg   2    12   Transderm-Nitro
Cardio-active        Nitroglycerin, 0.4mg tablets      2    13   Nitrostat
Depression           Nortriptyline, 25mg               13    0   Pamelor
Psychosis            Olanzapine Zydis, 10mg            17    1   Zyprexa-Zydis
Psychosis            Olanzapine Zydis, 5mg             17    0   Zyprexa-Zydis
Psychosis            Olanzapine, 10mg                  17    2   ZyPREXA
Psychosis            Olanzapine, 15mg                  17    3   ZyPREXA
Psychosis            Olanzapine, 2.5mg                 18    4   ZyPREXA
Psychosis            Olanzapine, 5mg                   18    5   ZyPREXA
                                                       2    19
GERD                 Omeprazole, 20mg                  2     4   Prilosec
                                                       2    25
Seizures/Mania       OXcarbazepine, 150mg              9     3   TriLEPTAL
                                                       2    25
Seizures/Mania       OXcarbazepine, 300mg              9     4   TriLEPTAL
                                                       2    25
Seizures/Mania       OXcarbazepine, 600mg              9     5   TriLEPTAL
                                                       2    23
Neurogenic Bladder   Oxybutynin, 5mg                   7     5   Ditropan
Psychosis            Paliperidone, 3mg                 13    1   Invega
Psychosis            Paliperidone, 6mg                 13    2   Invega
Psychosis            Paliperidone, 9mg                 13    3   Invega
Depression           PARoxetine, 10mg                  13    4   Paxil
Depression           PARoxetine, 20mg                  13    5   Paxil
                                                       2    22
Infection            Penicillin VK, 250mg              5     0   Pen-Vee K
Psychosis            Perphenazine, 2mg                 18    6   TriLAFON
Psychosis            Perphenazine, 8mg                 18    7   TriLAFON

    REV 01-2010                                                    91
                                                             2    23
UTI Analgesic          Phenazopyridine 100mg                 7     6   Pyridium
                                                             2    23
Seizures               Phentyoin, 30mg                       7     9   Dilantin
                                                             2    25
Seizures               Phenytoin, 100mg                      8     0   Dilantin
                                                             2    24
Seizures               Phenytoin, 50mg                       8     9   Dilantin

Diabetes               Pioglitazone 15mg                     7    61   Actos

Diabetes               Pioglitazone 30mg                     7    62   Actos
Potassium Supplement   Potassium Chloride SR,10meq (750mg)   27    7   K-dur
                                                             2    18
Anti-Inflammatory      Prednisone, 20mg                      1     8   Deltasone
                                                             2    18
Anti-Inflammatory      Prednisone, 5mg                       1     7   Deltasone
                                                             2    25
Seizures               Primidone, 250mg                      8     2   Mysoline
                                                             2    25
Seizures               Primidone, 50mg                       8     1   Mysoline
                                                             2    23
Nausea/Vomiting        Promethazine, 25mg                    6     4   Phenergan

Heart/BP               Propranolol, 10mg                     6    46   Inderal
Heart/BP               Propranolol, 40mg                     6    47   Inderal
                                                             2    22
Allergies              Pseudoephrine,30mg                    6     9   Sudafed
Psychosis              Quetiapine, 100mg                     18    0   SeroQUEL
Psychosis              Quetiapine, 200mg                     18    1   SeroQUEL
Psychosis              Quetiapine, 25mg                      18    8   SeroQUEL
Psychosis              Quetiapine, 300mg                     18    2   SeroQUEL
Psychosis              Quetiapine, 400mg                     18    3   SeroQUEL
Psychosis              Quetiapine, 50mg                      18    9   SeroQUEL
Psychosis              Quetiapine, 50mg XR                   16   13   Seroquel XR

    REV 01-2010                                                          92

Psychosis         Quetiapine, 200mg XR                         16    0   Seroquel XR
Psychosis         Quetiapine, 300mg XR                         16    1   Seroquel XR
Psychosis         Quetiapine, 400mg XR                         16    2   Seroquel XR
                                                               2    19
GERD              Ranitidine, 150mg                            2     5   ZanTAC
                                                               2    22
tuberculosis      Rifampin, 300mg                              5     5   Rifadin
Psychosis         Risperidone M tab, 0.5mg                     18    4   Risperdal M
Psychosis         Risperidone M tab, 1mg                       19    5   Risperdal M
Psychosis         Risperidone M tab, 2mg                       19    6   Risperdal M
Psychosis         Risperidone, 0.5mg                           19    7   Risperdal
Psychosis         Risperidone, 1mg                             19    8   Risperdal
Psychosis         Risperidone, 2mg                             19    9   Risperdal
Psychosis         Risperidone, 3mg                             19    0   Risperdal
Psychosis         Risperidone, 4mg                             19    1   Risperdal
Depression        Sertraline, 100mg                            13    7   Zoloft
Depression        Sertraline, 50mg                             13    6   Zoloft

Cholesterol       Simvastatin, 20mg                            8    70   Zocor

Cholesterol       Simvastatin, 40mg                            8    71   Zocor
                                                               2    19
GERD              Sucralfate, 1gm                              2     6   Carafate
                                                               2    22
Infection         Sulfamethoxazole/Trimethoprim, 800mg/160mg   5     2   Septra DS
                                                               2    22
Infection         Theophylline SR, 100mg                       5     3   THEOdur
Psychosis         Thiothixene, 5mg                             19    2   Navane
                                                               2    25
Seizures/Mania    Topiramate, 100mg                            9     7   ToPAMAX
Seizures/Mania    Topiramate, 200mg                            2     8   ToPAMAX

    REV 01-2010                                                            93
                                                          2    25
Seizures/Mania         Topiramate, 25mg                   9     6   ToPAMAX
                                                          2    18
Analgesic:NSAID        Tramadol, 50mg                     1     1   Ultram
Depression             Trazodone, 100mg                   14    9   Desyrel
Depression             Trazodone, 50mg                    14    8   Desyrel
                       Triamterne/ Hydrochlorothiazide;
Diuretic/BP            37.5mg/25mg                         2   18   Maxzide
EPS                    Trihexyphenidyl, 2mg               10   88   Artane
Depression             Venlafaxine XR, 150mg              14    2   Effexor XR
Depression             Venlafaxine XR, 37.5mg             14    0   Effexor XR
Depression             Venlafaxine XR, 75mg               14    1   Effexor XR
Heart/BP               Verapamil SR, 120mg                6    49   Calan
Heart/BP               Verapamil SR, 180mg                6    50   Calan
Heart/BP               Verapamil SR, 240mg                6    51   Calan
 Anti-coagulant        Warfarin Sodium, 1mg               1     1   Coumadin
 Anti-coagulant        Warfarin Sodium, 2.5mg             1     2   CouMADIN
 Anti-coagulant        Warfarin Sodium, 5mg               1     3   CouMADIN
                                                          2    22
Infection,Anti-Viral   Zidovudine, 100mg                  6     7   Retrovir
Psychosis              Ziprasidone, 20mg                  20    5   Geodon
Psychosis              Ziprasidone, 40mg                  20    6   Geodon
Psychosis              Ziprasidone, 60mg                  20    7   Geodon
Psychosis              Ziprasidone, 80mg                  20    8   Geodon

                       Top Shelf / Refrigerator Items*

AIDS DRUGS             Didanisine, 100mg                             Videx
AIDS DRUGS             Lamivudine, 150mg                             Epivir
AIDS DRUGS             Nelfinavir, 250mg                             Viracept

    REV 01-2010                                                       94
AIDS DRUGS            Emtrict/Tenofovir/Disopr.                                    Truvada
AIDS DRUGS            Efavirenz, 600mg                                             Sustiva
AIDS DRUGS            Teno/Dis/Fumarate 300mg                                      Viread
AIDS DRUGS            Lopin/Ritonavie 250/50mg                                     Kaletra
Antidote, Potassium   Sodium Polystyrene 15g/60ml                              K   Kayexalate
Anti-fungal           Ciclopirox Cream 1%                                          Loprox
Anti-fungal           Clotrimazole Cream 1%                                        Lotrimin
Anti-fungal           Miconazole 7 Vaginal Cream,                                  Monistat
Anti-fungal           Nystatin Oral Suspension                                     Mycostatin
Anti-fungal           Nystatin/Triamcinolone Cream, 0.1%                           Mycolog
iflammatory,topical   Triamcinolone Cream, 0.1%                                    Kenalog
Anti-parasitic        Permethrin Cream Rinse, (Nix)                                Nix
Anti-parasitic        Permethrin Cream, 5% (Acticin)                               Acticin
Bronchodialator       Albuterol Inhaler                                            Ventolin
Bronchodialator       Albuterol Solution                                           Ventolin
Bronchodialator       Beconase AQ Nasal Spray                                      Vancenase AQ
Bronchodialator       Fluticasone Nasal Spray, 50mcg                               FloNASE
Bronchodialator       Fluticasone Oral Inhaler, 110mcg                             FloVENT
Bronchodialator       Fluticasone Oral Inhaler, 44mcg                              FloVENT
Bronchodialator       Budesonide 160mcg/formoterol fumarate dihydrate 4.5mcg       Symbicort 160/4.5
Bronchodialator       Ipratropium Bromide Inhaler                                  ATROvent
Bronchodialator       Ipratropium Bromide Solution, 0.02%                          ATROvent
Burns/infection       Silver Sulfadiazine Cream, 1%                                Silvadene
Constipation          Lactulose 10gm/15ml                                          Chronulac
Diabetes              *Insulin 70/30
Diabetes              *Insulin, NPH
Diabetes              *Insulin, Regular U-100 (Human)
Diabetes              *Insulin, Humalog
Diabetes              *Insulin, Lantus
Glaucoma              *Latanoprost Opht. Solution, 0.005%                          Xalatan
Glaucoma              Alphagan Ophthalmic Solution, 0.2%                           Alphagan

    REV 01-2010                                                                    95
Glaucoma                  Timolol Ophthalmic Solution, 0.5%                           Timoptic
Analgesic                 Hemorrhoidol Ointment 1%                                    Dibucaine
Hemorrhoids               Hemorrhoidal Suppository                                    Anusol
Hypo-Glycemia             Glucagon Emergency Kit                         Glucagon
Hypo-Glycemia             Glutose Oral Gel                                            Glutose
Hypokalemia               Potassium Chloride Liquid, 10%                              K-lor
I.V. SOLUTION             Dextrose 5%/Water                                           Crash Cart
I.V. SOLUTION             Normal Saline 0.9%                                          Crash Cart
Infection                 Neomy/Poly B/Hydroc. Susp                                   CORTIsporin
Infection                 Neo/Poly B/Hydr Otic Sol                                    CORTIsporin
Infection                 Neomy/Poly B/Hydro. Otic Susp                               CORTIsporin
Infection,Topical         Mupirocin Ointment, 2%                         Sol          Bactroban
                                                                                      NEOsporin Oph
Infection,Topical         Neosporin Ophthalmic Solution                               Sol.
Infection,Topical         Ofloxacin Ophth Solution, 0.3%                              Ocuflox
Mania                     Lithuim Citrate 300mg/5ml                                   Lithium Citrate
Poison Management         Charcoal, Liquid                                            Activated Charc
Poison Management         Ipecac                                                      Ipecac
Psychosis                 Haloperidol Conc. 2mg/ml                                    Haldol
Seizures/Mania            Valporic Acid Syr 250mg/5ml                                 Depakene
                          Lactinex tablets (refrigerator on
Supplement.Misc           Magnolia)                                                   Lactinex
Suture Aid                Dermabond                                                   Dermabond
Tetanus prevention        *Tetanus Toxoid
Topical Anti-
inflammatory              Hydrocortisone Cream 1%                                     Hydrocortone
Psychosis                 Olanzapine 10mg/ vail                                       Zyprexa
Anti-coagulant            Enoxaparin Sodium Inj. 100mg/1ml                            Lovenox


To provide for accessibility of drugs that may be needed in emergency situations, crash
carts and kits have been established. The contents of the kits have been approved by the
Medical Staffs and the Division Medical Executive Committee as stated per Policy 03-

    REV 01-2010                                                                        96
205-EC. They must be readily available to the staff but not accessible to the
clients/patients. Medications may not be removed from a crash cart or an emergency kit
without the order of a physician. After the kit has been opened and the drug(s) is
removed, the kit should be sent to the Pharmacy with a copy of the physician’s order, for
review. Mediations will be replaced and kits re-sealed, in the Pharmacy (with the receipt
of a physician’s order). All crash carts and emergency kits will be inspected monthly by
a qualified pharmacy staff member and every ninety (90) days the kits will be opened and
the contents checked and restocked, as needed. (See individual listing for each kit in
Table of Contents.)

                         EAST CENTRAL REGIONAL HOSPITAL
                         EMERGENCY EQUIPMENT LOCATIONS

   Adult Mental Health – Room 92
   Forensic - Room 69
   Admissions/EATO – Room 153
   Central Kitchen – Room 14
   Gym – Room 21
   Treatment Mall – Bldg 13 Resource Room 60
   Forensic Treatment Mall Annex – Room -91
   Work Therapy – Room 6
   General Mental Health Bldg 16 Treatment Room 44 Side A

GRACEWOOD CAMPUS                                                 C – Wing Room 07
 1. Camellia Unit                                                E – Wing Room 18
           Living area 1- Room 128
           Living area 2- Room 274                3.   Birch Unit
           Living area 3 – Room 322                   18-2 Chart Room
           Living area 4 – Room 422                   18-3 Room 317
           Living area 5 – Room 528                   18-4 Room 401
                                                       18-5 Room 518
 2.   Redbud                                           Living area 10 – Chart Room
              J – Wing Room J16                       House 2 – Room 1
              15-H Room H11                           House 3 – Dining Room
              D – Wing Room 17

      REV 01-2010                                                                     97
       House 57/58 – Closet off kitchen in 58       5.   Building 11 DLC – Room 4
        (door labeled)                               6.   Building 19 DLC – Room 18
       House 17 – Dining Room                       7.   Building 22 DLC – Room 5 (kitchen area)
       House 87 – Dining Room                       8.   Central Kitchen – Food Service storage
                                                          room(Dining room)
 4.     Azalea Unit                                  9. Gym – Kitchen area off Main Court
          . Magnolia Bldg 72- in the Dining Room     10. Laundry Dept. – Room 1
      (Room 3)                                       10. Dental Clinic – Outside of Room 15
          . Holly Bldg 71-Dining Room (Room 8)       11. Building 70- located in the OT Module DLC
          . Spruce Bldg 12/12x-Dining Room         (Room 6)
      (Room 30)                                    12. Forensic Step Down Unit – House 60

                                 Crash Cart Medication Contents
                                  (Aug. 2010 Policy 03-205-EC)

Aspirin 325 mg Tablets
Benadryl 50 mg/ml Injection
Epi-pen 0.3 mg Auto Injector
Narcan 1 mg/ml Injection
Nitroglycerin 0.4 mg Sublingual Tablets
Oral Glucose 30 gm Tube
Glucagon 1 mg Injection Vial

Automated External Defibrillator (with             Ambu Bag and tubing
razor)                                             Sphymomanometer-Regular and Large
CPR Backboard                                      Adult sized (Pediatric size where
Airway, Oral Small                                 indicated)
Airway, Oral Medium                                Stethoscope
Gloves, Examination, Small, Medium,                Suction Device
Large                                              Bandage Scissors
Oxygen Cylinder and Regulator                      Face Mask (MicroShield)
Mask, Oxygen with tubing                           Person Protective Equipment: Aprons
Mask, Rescue (Barrier Mask)                        (Plastic) goggles/Facemasks (2), Gowns
Sponges, Alcohol                                   (2)
Sponges, 4x4 gauze                                 Red Biohazard Bag
Suction Catheter, Yonkers, and 14                  Emesis Basin
French,                                            Extension Cord (If indicated)
Tape, Adhesive, 1”                                 Forms and Clipboards
Tube, Oxygen, Connecting

       REV 01-2010                                                                              98


  PROCEDURE- Nursing staff can take these kits to other areas (TREATMENT MALL, GYM,
  ETC) as a portable unit. Kits are to be returned to AMH when nurse returns.






  #1- Morphine 10mg /ml
  # 1 Meperidine Inj. 50 mg/ml

  Process when pharmacy is open (7AM-4PM M-F; 9AM-1PM;SS& Holidays) CALL 790-2497 to speak
  with a Pharmacist.
   Process (after hours of pharmacy operation)
  Call the on call Pharmacist ( beeper 732-0720. RPh will give you the keypad combination to access
  The pink controlled substance form must be completed when the medication is removed from the cabinet
  with the consumer’s first and last name; date and time administered; and the signature of the person
  admistering the medication. The pink card must be placed in the After Hours Book for pickup by the
  The on call Pharmacist provided the keypad combination will be responsible to make sure the medications
  are replaced when the Pharmacy reopens.

  Nurse to administer prescribed medication dosage.
  Pharmacist will replace medication and reprogram cabinet (with different combination
  Purpose:   To improve quality of life for clients at ECRH Gracewood Campus by
             promoting prompt medication intervention for acute behavioral
Medications                                                    Dosage Form               Quantity
Hydroxyzine (Atarax) 25mg                                      PO                        25

       REV 01-2010                                                                                     99
Hydroxyzine (Atarax) 100mg/2ml                          Inj.                5
Lorazepam (Ativan) 1mg                                  PO                  25
Lorazepam Inj. (Ativan) 2mg/ml                          Inj.                5 (In Refrigerator)
Haloperidal (Haldol) 5mg                                PO                  5
Haloperidal Inj.; 5mg/ml (Haldol)                       Inj.                2
Diphenhydramine Inj.; 50mg/ml (Benadryl)                 Inj.               5
Zyprexa Zydis                                            PO                 2
  Process of Implementation: Subject to approval by the P & T Committee, the kits will be
  located in designated areas by discretion of Unit MD, Nurse Manager, and Clinical
          Kit Locations 8/07: Unit 2         Unit 4
                               10              15-C        18-1, 18-3, 18-4

                              *These areas have ECRH Gracewood Campus After Hours
  Cabinet centrally located to access all above medications.

  Behavior Intervention Kit : Kits will be kept in Living Care Area medication rooms. The
  Living Care Area nurse will be responsible for contents of the kit. The area nurse should
  inventory the control meds (Ativan PO and IM) 3 times daily (each shift). Note this is
  already being done for Ativan IM which is kept in the refrigerator in designated areas.

  Unit Pharmacist will inventory these control items during monthly medication inspections.

  Medications will be supplied to designated areas via unit dose (blister card) or individual
         injection units.
  A proof of use form will be supplied each medication. These forms will be sent from the
         Pharmacy with medication to designated areas .
  Once MD has authorized usage of medication, the area nurse will sign med out according to
         ECRH Gracewood Campus Proof of Usage Form provided.
  Medications will be kept in the medication room in a specified kit with Proof of Usage
  Upon completion, these forms will be returned to the Pharmacy for refilling to par level.
  Pharmacy staff will replenish medications to appropriate levels.
  Nursing staff should inventory all meds for replenishing on Thursday.

      DRUG & STRENGTH                                                      EXPIRATION

  1x Bottle/Aspirin 325mg tablet                                       ______________
  1x Atropine 0.1mg/ml injection                                       ______________
  2x Atropine Sulfate 1mg/ml vial                                      ______________
  6x Clonidine 0.1mg tablets                                           ______________
  1x Diazepam 10mg/2ml injection                                       ______________
  1x Diphenhydramine 50mg/ml injection                                 ______________

       REV 01-2010                                                                         100
1x Epinephrine 1:1000 injection                               ______________
1x Furosemide 10mg/ml injection                               ______________
1x Glutose 40% gel                                            ______________
1x Naloxone 0.4mg/ml injection                                ______________
1x Bottle/Nitroglycerin 0.4mg SL tablets                      ______________
1x Phenobarbital 130mg/ml injection                           ______________
1x Romazicon 0.1mg/ml                                         ______________

Available at Augusta Campus location of kits: AMH1, AMH2,Forensics, Magnolia,
Spruce and Holly

1 1% Lidocaine without Epinephrine
1 Tube Silver Nitrate
1 Ethyl Chloride Spray


                                                                    Exp. Date:

      1      Acetaminophen 325mg Tablet              100/btl.       __________
      1      Acetaminophen 650mg Supp.               12/box         __________
      1      Epipen 0.3mg Auto-Injector              1 kit          __________
      1      Aspirin 325mg Tablet                    100/btl.       __________
      6      Benadryl 25mg Capsule                   cap            __________
      1      Benadryl Elixir 12.5mg/5ml              4oz            __________
      1      Benadryl Injection                      50mg/ml        __________
      2      Diastat (Diazepam Rectal Gel)           10mg/unit      __________
      2      Glutose 15gm Tube                       tube           __________
      1      Ibuprofen 200mg Tablet                  100/btl.       __________
      2      Ipecac                                  30cc/btl.      __________
      1      Pepto Bismol Susp.                      6oz btl.       __________
      6      Lorazepam (Ativan)                      1mg tab.       __________
      2      Maalox ES                               12oz btl.      __________
      1      Nitroglycerin Tab 1/150 (0.4mg)         25tb/btl.      __________
      6      Phenobarbital 130mg/ml                  1ml vial       __________
      2      Thorazine 25mg/ml                       2ml/amp        __________
      12     Triple Antibiotic Ointment               0.9g pk       __________
      1      Hydrocortisone Cream 1%                  1oz           _________
      2      Geneye Opthalmic Drops (Visine)          15ml/btl.     __________

      Additional items to be taken by nurse:

      1       Betadine Scrub                          32oz          __________
      1       Betadine Solution                       32oz          __________

    REV 01-2010                                                                  101
          2      Calamine Lotion                                  4oz       __________
          2      Sunscreen SPF 30                                16oz       __________
          1      Alcohol                                         16oz       __________

Seal #: ____________________                             Exp. Date:_________________

Prepared by:________________


2         Epinephrine 1:1000                   1 mg amp
1         Aminophyllin 250mg Inj.              10 ml amp
1         Vasopressin 20 units                 10 ml vial (25)
1         Aropine Sulfate 1mg                  10 ml syringe
2         Benadryl (diphenhydramine) 50mg      1 ml amp
1         Solu-Medrol 125mg                    2 ml vial
2         Adalet (Procardia)                   10 mg cap
12        Anectine 20mg/ml (Refrigerator)      10 cc amp
1         Dextrose 50%                         50 ml syringe
3         Diazepam 5mg/ml                      2 ml amp
1         Epinephrine 1:10,000; 1mg/ml         10 ml syringe
1         Lidocaine 2%                         5 ml syringe
2         Naloxone 0.4mg/ml                    1 ml vial
1         Nitrostat 0.4mg tab                  1 bottle
2         Promethazine 25mg/ml                 1 cc amp
2         Glutose 15, oral glucose gel         15 gm tubes
2         Ammonia Inhalants                    Amps


To obtain meds for new physician orders:
     A)       During normal operating hours (M-F; 8 am -3:45 pm).

              Fax order to pharmacy and pharmacy will deliver a plastic safety capped vial
              with a 48 hour supply of bulk medication. Since the consumer can only
              remain in the hospital for 23 hours, this two day supply of medication will
              serve as both unit med and a 24 hour supply of discharge meds.

     REV 01-2010                                                                        102
   B)        During evening hours, 3:45PM – 8AM, Sunday Night thru Thursday Night,
             the nurse will fax the order to the pharmacy and obtain the meds from the
             night cabinet. Please remove only the meds you must have for the night doses
             only. All AM doses will be delivered the next morning at 8:45AM. The meds
             removed from the night cabinet must be given to the pharmacy courier on the
             8:45AM delivery. A labeled plastic vial with the directions and the proper
             quantity will be returned to the unit on the 11:15AM delivery. There is one
             exception to this procedure. If the consumer is to be discharged prior to
             11:15AM, you must keep the med which will be used as his/her discharge
             med supply.

   C)        During the evening hours, weekends, and holidays (3:45PM Friday thru
             Sunday), fax the order to the pharmacy and obtain the meds from the night
             cabinet. If the consumer is discharged before the pharmacy opens, the
             physician will have to dispense the night cabinet meds bags to the consumer
             for their discharge meds. These bags generally contain a three (3) day supply
             of medication. Thus, the consumer will be receiving a two day supply of
             discharge medication. We will supply blank labels for the physician to
             instruct the consumer as to dosage and times of administration. (The
             physician, not the nurse, must do this since it is considered dispensing.)

Transfers: If the consumer is transferred from the 23 hour program to another ECRH unit
(i.e. AMH), please transfer the medication with the consumer. No bulk medication (Not
unit dose) can be returned to stock and must be destroyed therefore to avoid waste, it
must be used on the receiving unit.

Floor Stock: There will have to be a minimal amount of floor stock on the 23 hour unit
since over the counter, controlled meds, and injectables are not stocked in the night
cabinet. This will be kept to a minimum if possible. If a consumer is discharged after
operating pharmacy hours and is on a controlled substance or over the counter product
which has not yet been dispensed by the pharmacy, the physician will have to obtain any
discharge meds from the floor stock supply and must sign out the floor stock “pink card”
for controlled meds. Again, empty bags and blank labels will be supplied for such

The two most important points for the successful operation of this procedure:

        1)      Meds removed from the night cabinet must be returned to the pharmacy on
                the 8:45AM delivery and
        2)      If the consumer will be discharged before the 11:45AM delivery, the night
                cabinet meds must be held on the unit and will serve as the discharge

NOTE:           We do not normally supply medical drugs for discharge, but if bulk meds
                (Not unit dose) have been dispensed, they should be given to the consumer
                since they cannot be returned to stock.

    REV 01-2010                                                                        103
                         SECTION VI:
                   MEDICATION FORMULARY

   Ointment: 60 gm tube                       AFRIN NASAL SPRAY
                                                See oxymetazoline
    See Aripiprazole
                                              ALBUTEROL (Proventil, Ventolin)
ACETAMINOPHEN (Tempra, Tylenol)                 Tablet: 4 mg
  Susp: 160 mg/5 cc                             Inhaler: 17gm
  Supp: 650 mg                                  Solution for Nebulization: 3 cc
  Tablets: 325 mg                               Syrup: 2 mg/5 ml

(Tylenol #3) C III                              70% Rubbing (Isopropyl)
    Tablets: 325 mg with 30 mg codeine
ACETAZOLAMIDE (Diamox)                          See spironolactone
  Tablets: 250 mg
                                              ALENDRONATE SODIUM (Fosamax)
ACETIC ACID                                     Tablets: 70 mg
  2% aluminum acetate/acetic acid (Domeboro
  Otic)                                       ALLEGRA
                                                See Fexofenadine
  Cream: 30 gm Tube                           ALLOPURINOL (Zyloprim)
                                                Tablets: 100mg
  See triprolidine with pseudoephedrine       ALPHAGAN (See brimonidine tartrate)
                                                Ophth. Sol. 0.15%
  See pioglitazone hcl                        ALPRAZOLAM (Xanax)
                                                Tablets: 0.5mg, & 1 mg
  Capsule: 200 mg                             ALUMINUM ACETATE (Domeboro)
  Ointment: 5%                                  Tablets: One tablet in 16 oz of water to
                                                make solution.
ADDERALL          CII                           (Burrow's Solution)
  See amphetamine esters
                                              ALUMINUM HYDROXIDE (Amphogel)
ADRENALIN                                       Gel: 325 mg/5ml
  See epinephrine
                                              ALUMINUM, MAGNESIUM HYDROXIDE
ADVAIR                                        WITH SIMETHICONE
  See fluticasone prop/salmetrol                (Mylanta DS, Maalox Plus Tabs)

     REV 01-2010                                                                           104
   Susp: 5 oz bottle
   Tablets: Chewable
ALUPENT                                See phytonadione
  See metaproterenol
                                     ARIPIPRAZOLE (Abilify)
AMANTADINE (Symmetrel)                  Tablets: 2mg, 5mg, 10mg, 15mg, 20mg,
  Capsules: 100 mg                   30mg

AMBIEN                               ARISTOCORT
  See Zolpidem tartrate                See triamcinolone

AMINOPHYLLINE                        ARTANE
  Injection: 250 mg/10 ml ampule       See trihexyphenidyl tablets

  Tablets: 10 mg, 25 mg, & 50 mg       Solution: polyvinyl alcohol 1.4%

AMLODIPINE (Norvasc)                 ASCORBIC ACID (Vitamin C)
  Tablets: 5 mg                        Tablets: 250 mg, 500 mg

AMMONIA INHALANT                     ASPIRIN
  See Vaporole                         Tablets: 1 1/4 gr (81mg)
                                       Tablets: 5 gr (325mg)
AMMONIUM LACTATE (Lac Hydrin)          Tablets: 5 gr (325mg) enteric coated
  Lotion: 12%
AMOBARBITAL (Amytal)        C II       See hydroxyzine
  Injection: 0.5 gm vial             ATENOLOL (Tenormin)
                                       Tablet: 50mg
  Capsules: 250 mg, 500 mg           ATIVAN       C IV
  Susp: 250 mg/5cc in 200cc bottle     See Lorazepam

  Tablets: 10 mg                       Inj: 1 mg/10 ml syringe
                                       Ophth Soln: 1% 5cc bottle
  Capsule: 30mg                      ATROVENT
                                       See ipratropium bromide
  See aluminum hydroxide gel         ATORVASTATIN CALCIUM (Lipitor)
                                       Tablets: 10 mg & 40 mg
  See clomipramine                   AUGMENTIN (amoxicillin & clavulanate)
                                       Tablets: 250 mg:125 mg; 500 mg:125 mg;
ANCEF (Kefzol)                                                 875 mg:125 mg
  See cefazolin                        Susp: 250 mg:62.5 mg, 150 ml bottle
                                       Susp: 400mg:57mg, 100ml bottle
Drops)                               AURALGAN DROPS
   Drops: 6 cc bt                      (See antipyrine/benzocaine)

AQUA CARE                            AVEENO
  See urea 10%                         (See colloidal oatmeal)

     REV 01-2010                                                               105
AZITHROMYCIN                                  See pencillin-G benzacaine
  Capsules: 250 mg
                                           BIOTENE TOOTHPASTE
  See triamcinolone                        BISACODYL (Dulcolax)
                                              Tablets: 5 mg
BACLOFEN (Lioresal)                           Supp: 10 mg
  Tablets: 10 mg                              Enema

BACITRACIN                                 BISMUTH SUBSALICYLATE
  Ointment                                    1.7% (Pepto-Bismol)

BACTRIM                                    BODY LOTION (Lobana)
  See sulfamethoxazole with trimethoprim     8 oz bottle

  See mupirocin 2%                           Solution: 4% in 95% alcohol

BASIS SOAP (Oilatum)                       BRETHINE
  See superfated soap                        See terbutaline

BATH OIL                                   BRIMONIDINE TARTRATE (Alphagan)
  with lanolin                               Ophth. Sol. 0.15%

  Nasal Spray: 0.042% 25 g                   Tablets: 2.5 mg

BENADRYL                                   BUDESONIDE/FORMOTEROL
  See diphenhydramine                        160MCG / 4.5MCG

BENTYL                                     BUPROPION
  See dicyclomine                            Tablets: 75 mg & 100mg

BENZOIN                                    BUSPIRONE HCL (BuSpar)
  Compound Tincture                          Tablets: 5 mg, & 10 mg

BENZOYL PEROXIDE                           CALAMINE LOTION
  Gel: 5% , 10%                              Plain: 4 oz bottle
  Tablets: 0.5mg, 1 mg, & 2mg              CALCIUM CARBONATE
                                             Tablet: 500 mg calcium/125 i.u. vitamin D
BETADINE                                     (Oyst Cal-D 500)
  See povidone-iodine complex                750 mg calcium (Tums E-X)

  Cream: 0.1%                                1.5 oz bottle
  Lotion: 0.1%
                                           CAPTOPRIL (Capoten)
BETAXOLOL (Betoptic-S)                       Tablet: 12.5mg, 25 mg
  Ophthalmic Susp. 0.25%
BIAXIN                                       See sucralfate
   See Clarithromycin

     REV 01-2010                                                                    106
   Tablets: 25-100mg                         CEPHALEXIN (Keflex)
                                               Capsules: 250 mg, 500 mg
CARBAMAZINE (Tegretol)                         Susp: 250 mg/5cc
  Tablets: 200 mg, 100 mg chewable tablets
  Capsule: 100mg ER, 200mg ER, 300mg ER      CEREBYX
  Susp: 100 mg/5 ml                            See fosphenytoin sodium injection

  Otic: 6.5% (Debrox)                          (See triethanolamine)
  Oral: 10% (Glyoxide)
                                             CETAPHIL SKIN CLEANSER
  See doxazosin mesylate                     CETIRIZINE (Zyrtec)
                                               Tablet: 5mg, 10mg
  See Diltiazem                              CHARCOAL, ACTIVATED
                                               Suspension: 25 gms/120 ml
  (See Levocarnitine)                        CHLORAL HYDRATE (Noctec)              C IV
                                               Syrup: 500 mg/5cc
  Tablet: 3.125mg, 12.5mg                    CHLORDIAZEPOXIDE
                                               Capsules: 10mg, & 25mg
  See clonidine HCL                          CHLOROPHYLL DERIVATIVES (Derifil)
                                               Tablets: 100mg (water soluble deodorizing)
  Capsule: 250mg                             CHLORASEPTIC
                                               Liquid: mouthwash, gargle, throat spray
CEFAZOLIN (Ancef, Kefzol)                    CHLORHEXIDINE GLUCONATE
  Inj: 1 gm vial                               Liquid: Oral Rinse (Peridex)
                                               Surgical scrub: (Hibiclens, Betasept)
  (See cefuroxime)
                                             CHLORPROMAZINE (Thorazine)
CEFTRIAXONE SODIUM (Rocephin)                  Conc: 100 mg/cc
  Inj: 1 gm vial                               Inj: 25 mg/cc, 2 cc ampule
                                               Tablets: 10 mg, 25 mg, 50 mg, 100 mg, and
CEFUROXIME                                     200 mg
  Tab: 250mg, 500mg
                                             CHLORPROPAMIDE (Diabinese)
CELEBREX                                       Tablets: 250mg
   See Celecoxib
                                             CHOLESTYRAMINE POWDER
CELECOXIB                                      Questran for Oral Suspension
  Capsule: 100mg, 200mg
                                             CICLOPIROX OLAMINE (Loprox)
CELEXA                                         Cream - 1 oz tube
   See citalopram
                                             CIMETIDINE (Tagamet)
CELLULOSE (Unifiber)                           Tablets: 200 mg
  Powder: 255 g can                            Liquid: 300 mg/5 ml

CEPACOL LOZENGES                             CIPROFLOXACIN (Cipro)
  See menthol/phenol                            Tablets: 250 mg, 500mg, & 750mg

     REV 01-2010                                                                         107
   Tablets: 20mg                         COLCHICINE
                                           Tablets: 0.6mg
   See methylcellulose laxative          COLLOIDAL OATMEAL (Aveeno)
                                           Bath Packets
  Tablets: 500 mg                        COREG
                                           See carvedilol

CLARITIN                                 CORN PADS
  See loratadine
CLEOCIN                                    See hydrocortisone
  See clindamycin
CLINDAMYCIN (Cleocin)                      See warfarin
  Capsules: 150 mg
  Pediatric Granules 75mg/5ml            COZAAR
  Topical Soln: 60 ml bottle               See losartan

CLOMIPRAMINE (Anafranil)                 CYANOCOBALAMIN (Vitamin B-12)
  Capsules: 25 mg, 50 mg                   Injection: 1mg

CLONAZEPAM (Klonopin)             C IV   CYCLOBENZAPRINE (Flexeril)
  Tablets: 0.5 mg, 1 mg, 2 mg              Tablet: 10mg

CLONIDINE HCL (Catapres)                 CYMBALTA
  Tablets: 0.1 mg, 0.2mg, 0.3mg            See duloxetine hcl
  TTS: 1, 2, 3
                                         CYPROHEPTADINE (Periactin)
CLOPIDROGREL                               Tablets: 4 mg
  Tablets: 75mg
                                         DANDRUFF SHAMPOO
CLORAZEPATE (Tranxene)            C IV     Polytar, Selsun
  Tablets: 7.5 mg                          Selsun Blue

CLOTRIMAZOLE 1% (Lotrimin)               DANTROLENE (Dantrium)
  Cream                                    Capsules: 25 mg
  Vaginal tablets                        DARVOCET N 100
                                           See propoxyphene napsylate
CLOZAPINE                                  w/acetaminophen
  Tablets: 25 mg & 100mg
CLOZARIL                                   See propoxyphene napsylate
  (See clozapine)
COAL TAR (Psorigel)                        See carbamide peroxide 6.5% otic soln.
  Solution: 10%
COGENTIN                                   See dexamethasone
  See benztropine mesylate
                                         DEMEROL C II
COLACE                                     See meperidine
  See dioctyl sodium sulfosuccinate

     REV 01-2010                                                                    108
  See sodium valproate               DIFLUCAN
                                        See Fluconazole
  See sodium divalproex              DIGOXIN (Lanoxin)
                                       Inj: 0.5 mg/2 ml
DEPO-PROVERA                           Tablets: 0.125mg, & 0.25mg
  See Medroxyprogesterone
                                        See phenytoin
  Tablet: 100mg                      DILTIAZEM (Cardizem)
                                       Tablet: 30mg,
DESENEX                                ER Capsule: 120mg, 180mg, & 240mg
  See undecylenic acid
                                     DIMENHYDRINATE (Dramamine)
DESYREL                                Tablet: 50 mg
  See Trazadone
                                     DIOCTYL SODIUM SULFOSUCCINATE
DEXAMETHASONE (Decadron)             (Colace, DSS)
  Inj: 4 mg/ml, 1 ml vial               Capsules: 100mg and 250 mg
                                        Syrup: 20 mg/5 cc and 50mg/5ml
  (See Dextroamphetamine)            DIPHENHYDRAMINE (Benadryl)
                                        Capsules: 25 mg, 50 mg
DEXTROAMPHETAMINE (Adderall) C-II       Elixir: 12.5 mg/5 ml
  Tablet: 10 mg                         Inj: 50 mg/ml, 1 ml ampule

DEXTROSE 50%                         DIPHENOXYLATE (Lomotil)        CV
   Inj: 50 ml syringe                   Tablet: 2.5 mg
   See glyburide                     DIPHTHERIA AND TETANUS TOXOIDS
                                        Pediatric Strength
DIABETIC DIAGNOSTIC AGENTS              Adult Strength
  One Touch Test Strips (50/pk)
  One Touch Control Soln. Hi & Low   DIPYRIDAMOLE (Persantine)
                                        Tablet: 25 mg
   (See chlorpropamide)              DOMEBORO OTIC SOLUTION
                                       See acetic acid
   See acetazolamide                 DONNATAL
                                       See Belladonna
  Oint: 2 oz tube                    DORZOLAMIDE HCL (Trusopt)
                                       Ophthalmic Solution
  Inj: 10 mg/2 ml ampule             DOXAZOSIN MESYLATE (Cardura)
  Tablets: 2 mg, 5 mg, 10 mg           Tablets: 2 mg & 4 mg

DIBUCAINE                            DOXEPIN (Sinequan)
  Oint: 1%                             Capsules: 25mg & 50mg

                                     DOXYCYCLINE (Vibramycin)
DICLOXACILLIN (Dynapen)                Tablets: 100 mg
  Capsules: 250 mg & 500mg

     REV 01-2010                                                           109
DRAMAMINE                                           See lithium carbonate
  See dimenhydrinate
                                                 ESOMEPRAZOLE MAG TRIHYD (Nexium)
DRY SKIN PREPARATIONS                              Capsule: 20mg & 40 mg
  Cream: Eucerin, Nivea
  Lotion: Lubriderm equivalent                   ESTROGENS, CONJUGATED (Premarin)
  Oil: Nivea/Alpha Keri/equivalent oil with        Tablets: 0.3 mg, 0.625 mg, 1.25 mg
  lanolin                                          Vaginal Cream: 45 gm tube

DSS                                              ETHYL CHLORIDE
  See dioctyl sodium sulfosuccinate                Topical Spray: 120 ml/bottle

DULOXETINE HCL (Cymbalta)                        EUCERIN CREAM
  Tablets: 30 & 60 mg                              Dry Skin Cream

DYAZIDE                                          FAMOTIDINE (Pepcid)
  See triamterene and hctz                         Tablets: 20mg

DYNAPEN                                          FER-IN-SOL DROPS
  See dicloxacillin                                See Ferrous Sulfate

ECOTRIN                                          FERROUS GLUCONATE
  See aspirin                                      Tablets: 300 mg

EFFEXOR XR                                       FERROUS SULFATE
   See venlafaxine                                 Syrup: 220 mg/5cc (Mol-Iron)
                                                   Tablets: 325 mg
ELAVIL                                             Drops: 75 mg/0.6ml
  See amitriptylline
                                                 FEXOFENADINE (Allegra)
ELIMITE CREAM 5%                                   Tablets: 60mg and 180mg
  See permethrin
ENALAPRIL MALEATE (Vasotec)                        See metronidazole
  Tablets: 5 mg & 10mg
EPIPEN                                             See sodium biphosphate
  See Epinephrine
                                                   (See cyclobenzaprine)
  Inj: 1:1000 (1 mg/ml) ampule 1 cc amp          FLONASE
  Syringe: 1:10,000 solution, 10 cc                 (See fluticasone propionate)
  EpiPen Auto Injection, 0.3mg
ERYTHROMYCIN ETHYLSUCCINATE                        (See fluticasone propionate)
  Susp: 400 mg/5 ml
ERYTHROMYCIN BASE                                  Tablets: 100mg & 200mg
  Ophth Oint: 5 mg/gm - 1/8 oz tube (Ilotycin)
  EC tablets: 250mg                              FLUMAZENIL
                                                   0.5 MG/ 5 ML
  Solution 2% : 60 ml/bottle                     FLUOXETINE HYDROCHLORIDE (Prozac)
ESKALITH CR                                        Pulvules: 10 mg & 20 mg

     REV 01-2010                                                                        110
   Liquid: 20mg/5ml
FLUPHENAZINE (Prolixin)                     Tablet: 5 mg
  Tablet: 2.5mg, 5mg, & 10mg
  Conc: 5mg/ml                            GLUCAGON
  Inj: 2.5mg/ml, 10 ml vl                   Inj: 1 mg/vial
  Decanoate: 25 mg/ml, 5 ml vl
                                            See metformin

  Oral Inhalation: 44 mcg & 110 mcg         See glipizide
  Nasal Spray: 50 mcg
FLUTICASONE PROP/SALMETROL                  Liquid Glucose Dextrose 40%
   Inhalation: 100/50, 250/50, & 500/50   GLYBURIDE
                                            Tablet: 2.5mg, 3mg, & 5mg
  Tablets: 50 mg & 100mg                  GLYCERIN
                                            Supp: Adult
FOLIC ACID                                  Supp: Infant
  Tablets: 1 mg
                                          GLYNASE PRESTAB
FOSAMAX                                     See glyburide
  See alendronate sodium
FOSPHENYTOIN SODIUM INJ (Cerebyx)           carbamide peroxide 10% oral solution
  Vial: 50 mg PE/ml
                                          GUAIFENESIN (Robitussin, Mucinex)
FOSTEX SOAP                                 Syrup: 10 mg/5 ml
  See salicylic acid                        Tablet: 600mg LA

FUROSEMIDE (Lasix)                        GUAIFENESIN WITH
  Inj: 20 mg/2 ml vial                    DEXTROMETHORPHAN (Robitussin DM)
  Tablets: 20 mg & 40 mg                    Syrup: 100 mg & 15 mg/5 ml respectively
  Liquid: 10mg/ml                           alcohol 1.4%

GABAPENTIN (Neurontin)                    GUAIFENESIN WITH
  Capsules: 100 mg & 300 mg               PSEUDOEPHEDRINE (Robitussin PE)
                                            Syrup: 100 mg & 30 mg/5 ml respectively
GABITRIL                                    alcohol 1.4%
  See tiagabine
GAS RELIEF DROPS                            See clotrimazole
  See simethicone
                                          HALOPERIDOL (Haldol)
GEMFIBROZIL (Lopid)                         Concentrate: 2 mg/ml - 4 oz/bottle
  Tablets: 600mg                            Inj: 5 mg/ml ampule
                                            Tablets: 0.5 mg, 1 mg, 2 mg, 5 mg, & 10
GENTAMICIN (Garamycin)                      mg,
  Ophth Oint: 1/8 oz tube                   Decanoate: 100mg vial
  Ophth Soln: 5 ml bottle

GEODON                                    HEMORRHOIDAL PREPARATIONS
  See ziprasidone                         (Anusert, Anucort)

     REV 01-2010                                                                   111
   Oint: 1 oz tube with applicator
   Supp: Plain & HC (hydrocortisone) with     IMODIUM
   applicator                                   See loperamide

  Bay-Hep                                       Tablets: 2.5mg

HEPATITIS B VACCINE (Recombivax)              INDERAL
  Recombivax HB 1 ml/10 mcg antigen vial         See propranolol
  Recombivax HB 0.5ml/ 5mcg antigen vial
HIBICLENS (Betasept) (Chlorhexidine)            Capsule: 25mg
  Soln: 32 oz
                                              INFLUENZA VIRUS VACCINE
HOMATROPINE                                      Injection: Annual variant
  Ophth Soln: 2%

HUMIBID LA                                    INSULIN
  See guaifenesin                                NPH: 100 units/cc - 10 ml vial (Human)
                                                 Regular: 100 units/cc - 10 ml vial (Human)
HYDROCHLOROTHIAZIDE                              Humalog-10 ml vial
  Tablets: 25 mg, 50 mg                          Humalog 75/25 – 10 ml vial
                                                 Lantus 100U/ml – 10 ml vial
                                                 Novolin 70/30 100 units/cc - 10 ml vial
  Cream: 1%, 1 oz tube                        INVEGA
  Lotion: Topical 1%                             See Paliperidone
  Oint: 1%, 1 oz tube

(Cortisporin)                                   Cream: 3% with 1% hydrocortisone
   Oint: 3.5 gm tube (Ophth)                    (Vioform HC) 20 gm tube
   Susp: 7.5 cc bottle (Ophth)
   Susp: 10 cc bottle (Otic)                  IPECAC SYRUP
   Soln: 10 cc bottle (Otic)                     30 cc bottle

  Tabs: 7.5mg/500mg & 10mg/650mg                 Inhaler: 18 mcg
                                                 Solution: 0.02%
  Inj: 100 mg/2 ml, 2ml vial (Vistaril)       ISONIAZID
  Syrup: 10 mg/5 ml (Atarax)                     Tablets: 300 mg

  Capsules: 25 & 50 mg                           See pilocarpine

IBUPROFEN ( Motrin)                           ISORDIL
   Tablets: 200 mg, 400 mg, 600 mg & 800 mg      See isosorbide

ILOTYCIN                                      ISOSORBIDE
   See erythromycin                              Tablets: 10 mg

  Tablets: 25mg, & 50mg                       KAY-CIEL (KCL 10%)

     REV 01-2010                                                                        112
   See potassium chloride               Tablets: 25 mg, 100mg, & 150 mg

KAYEXLATE                            LANOLIN
  See sodium polystyrene sulfonate     Topical lubricant: 60 gm tube

KEFLEX                               LANOXIN
  See cephalexin                       See digoxin

KEFZOL                               LANSOPRAZOLE
  See cefazolin                        Solutab: 30mg

INJECTION                              See furosemide
   30mg/ml inj
                                     LATANOPROST (Xalatan)
KENALOG                                Ophth . Sol 0.005%
  See triamcinolone
KEPPRA                                 See levofloxacin
  See levetiracetam
                                     LEVETIRACETAM (Keppra)
KETOCONAZOLE                           Tablets: 250 mg & 500 mg
  Cream: 2%
  Shampoo: 2%                        LEVOFLOXACIN
                                       Tablets: 250 mg , 500mg, 750mg
   See potassium chloride            LEVOTHYROXINE (Synthroid)
                                       Tablets: 0.025 mg, 0.05 mg, .075 mg, & 0.1
LABETALOL (Normadyne)                  mg
  Tablets: 100mg & 200mg
LAC HYDRIN                              (See chlordiazepoxide)
  See ammonium lactate lotion
                                     LIDEX (flucinonide)
LACRI-LUBE (Ophth Oint)                 Ointment: 30gm tube 0.05%
  See petrolatum
LACTAID                                 See xylocaine
LACTASE ENSYME                         Tablet: 600mg
  See Lactaid
LACTINEX                                See baclofen
  See Lactobacillus Acidophilus
LACTOBACILLUS ACIDOPHILUS                See atorvastatin calcium
  Tablets: Lactinex
                                     LISINOPRIL (Prinivil, Zestril)
LACTULOSE (Chronulac)                   Tablets: 10 mg & 20 mg
  Syrup 10gm/15ml
                                     LITHIUM CARBONATE
LAMICTAL                                Capsules: 150 mg & 600mg
  See lamotrigine                       Tablets: 300 mg & 450 mg CR

LAMOTRIGINE                          LITHIUM CITRATE

     REV 01-2010                                                             113
   Syrup: 300 mg/5 ml                     MAGNESIUM CITRATE
                                            Soln: 300 ml bottle
   Tablets: 500mg                         MAGNESIUM OXIDE (Mag-Ox)
                                            Tablet: 400 mg
  See diphenoxylate                       MAGNESIUM SULFATE
                                            Inj: 50%, 1 gm/2 ml vial
  Tablets: 2mg
LOPID                                       See triamterene/hydrochlorothiazide
  See gemfibrozil
                                          MEBARAL     C IV
LOPRESSOR                                   See mephobarbital
  See metoprolol
                                          MEBENDAZOLE (Vermox)
LOPROX                                      Tablets: 100 mg
  See ciclopirox olamine
                                          MEDROXYPROGESTERONE (Provera)
LORATADINE (Claritin)                       Tablets: 2.5 mg, 10 mg
  Tablets: 10mg                             Depo Injection: 150 mg/ml, 1 ml vial

LORAZEPAM (Ativan) C IV                   MEGACE
  Tablets: 0.5 mg, 1 mg, 2 mg               See Megestrol Acetate
  Tubex: 2 mg/ml
                                          MEGESTROL ACETATE
LORTAB                                      Tablets: 20mg
  See hydrocodone/acetaminophen
LOSARTAN (Cozaar)                           Tablet: 3mg
  Tablets: 25mg                           MELLARIL
                                            See thioridazine
  See clotrimazole                        MENTHOL/PHENOL (Cepacol)
  Capsules: 5 mg, 10 mg, 25 mg, & 50 mg   MEPERIDINE (Demerol) C II
                                            Inj: 50 mg/ml ampule
LOZOL                                       Tablets: 50 mg
  See indapamide
                                          MEPHOBARBITAL (Mebaral) C IV
L-TYROSINE                                  Tablets: 32 mg, 50 mg, 100 mg
   Caps: 500mg
                                          METAMUCIL (psyllium hydrophilic
LUVOX                                     mucilloid)
  See fluvoxamine maleate                   Concentrate Sugar Free
                                            Smooth Texture (regular)
PLUS                                        Inhalation Aerosol: 0.65 mg
  See aluminum magnesium hydroxide
  w/simethicone                           METFORMIN HCL (Glucophage)
                                            Tablets: 500mg & 850mg
  See nitrofurantoin                      METHERGINE
                                            See methylergonovine

     REV 01-2010                                                                   114
METHOCARBAMOL (Robaxin)                         MOLINDONE HCL (Moban)
  Tablet: 750mg                                   Tablets: 10 mg & 25 mg

METHYLCELLULOSE (Citrucel)                      MOL-IRON
  851 gm/30 oz can                                See ferrous sulfate

METHYLERGONOVINE (Methergine)                   MONISTAT
  Tablets: 2 mg                                   See miconazole nitrate

METHYLPREDNISOLONE                              MONTELUKAST SOD (Singulair)
  Inj: Na succinate (125 mg/vial Solu-Medrol)     Tablet: 10mg

METHYLPHENIDATE (Ritalin) C II                  MORPHINE       C II
  Tablets: 5 mg, 10 mg, & 20 mg ER                Inj: 10 mg/ml - 1 ml ampule

METOCLOPRAMIDE (Reglan)                         MOTRIN
  Tablets: 10 mg                                  See ibuprofen
  Syrup: 5 mg/5 ml
  Inj: 10 mg/2 ml                               MULTIVITAMINS
                                                  See vitamins
METOPROLOL (Lopressor & Toprol XL)
  Tablets: 25 mg, 50 mg                         MUPIROCIN (Bactroban)
  Tablets XL: 25mg                                Ointment: 2%

METRONIDAZOLE (Flagyl)                          MURO 128 5%
  Tablets: 250 mg                                 See sodium chloride

MICONAZOLE NITRATE 2% (Monistat)                MYCITRACIN
  Suppository/ Cream 3-Day Combo Pack             See neomycin
  Cream: 7 day therapy

MIDAZOLAM HCL (Versed) C-IV                     MYCOLOG II
  Inj: 5 mg/ml vial                               See nystatin-triamcinolone

MILK OF MAGNESIA (MOM)                          MYCOSTATIN
  Suspension                                      See nystatin

MINERAL OIL                                     MYLICON
  Liquid: Heavy                                   See simethicone
  Enema, oil retention
MINIPRES                                        MYSOLINE
  See prazosin                                    See primidone

MIRALAX                                         NALOXONE (Narcan)
  See polyethylene glycol                         Inj: 0.4 mg/ml ampule
                                                  Inj: 2mg/2ml
  Tablets: 15 mg & 30 mg                        NAPHAZOLINE .05% with ANTAZOLINE
                                                .5% (Vasocon-A)
MOBAN                                              Ophth Soln: 15ml bottle
  See molindone HCL
                                                NAPROXEN (Naprosyn)
MODICON (Necon) 28-day                            Tablets: 250 mg
  See (norethindrone 0.5 mg/ethinyl estradiol
  0.035 mg)                                     NARCAN

     REV 01-2010                                                                115
  See naloxone
                                       NIX CREME RINSE
NEFAZODONE (Serzone)                      See permethrin
  Tablets: 100mg, 150 mg, & 200mg
NEO-CALGLUCON                             See ketoconazole
  See calcium glubionate
                                       NOCTEC C IV
                                         See chloral hydrate
(Neosporin)                            NOLVADEX
   Oint: 0.9 gm packet                   See tamoxifen
   Ophth Oint: 4 gm tube
                                       NORETHINDRONE ACETATE (Norlutate,
(Neosporin)                              Tablets: 5 mg
   Ophth Soln: 10ml
                                       NORETHINDRONE WITH ETHYINYL
NEO-SYNEPHRINE                         ESTRADIOL
  See phenylephrine                      Tablets: 1 mg with 35 mcg (Ortho-Novum
NEURONTIN                                 ( Ortho-Novum 7/7/7)
  See gabapentin

NEUTROGENA SOAP                        NORMADYNE
  Bar                                    See labetalol

NEXIUM                                 NORTRIPTYLLINE
  See esomeprazole                       Capsule: 25 mg

                                         See amlodipine
NICOTINE                               NUPERCAINAL
  Gum: 2 mg                              (See dibucaine)
  Patches: 7mg, 14mg, 21mg
                                       NYSTATIN (Mycostatin) (Nilstat)
NICOTINIC ACID (Niacin)                  Susp: 100,000 u/ml; 60 cc bottle
  Capsules: 250 mg (Nicobid)             Cream: 30 gm tube
  Capsules: 125 mg (Nicobid)             Oint: 30 gm tube

NIFEDIPINE (Procardia)                 NYSTATIN-TRIAMCINOLONE (Mycolog
   Capsules: 10 mg                     II)
   XL Tablets: 30 mg, 60 mg, & 90 mg       Cream: 30 gm tube
                                           Oint: 30 gm tube
   Capsules: 50 mg                     OCUFLOX
                                         See ofloxacin
   Tablets: 0.4 mg (1/150 gr)          OFLOXACIN
   Patches: 0.2mg/hr, 8cm                Ophth. Sol 0.3%
            0.4mg/hr, 16cm
            0.1mg/hr, 5cm              OIL RETENTION ENEMA
  Dry Skin: Cream 6oz                  OLANZAPINE (Zyprexa)
            Oil 12oz                     Tablets: 2.5 mg, 5 mg, 10 mg, 15 mg

     REV 01-2010                                                               116
                                                Inj: 1.2 MU/ml
  Inj: 10mg
  Tablets: 5mg, 10mg                         PENICILLIN V POTASSIUM (Pen-V-K)
                                               Tablets: 250 mg, 500 mg
  Capsules: 20 mg, 40mg                      PEPCID
                                               See Famotidine

ORAP                                         PEPTO-BISMOL
  See pimozide                                 See bismuth subsalicylate

ORTHO-NOVUM                                  PERCOCET CII
  See norethindrone with ethinyl estradiol     See oxycodone/acetaminophen
OXYBENZONE                                     See cyproheptadine
  Lotion: Sunscreen 50
OXYBUTYLIN CHLORIDE (Ditropan)                 See chlorhexidine gluconate 0.12%
  Tablets: 5mg
OXCARBAZEPINE (Trileptal)                      Nix Creme Rinse 1% 2 oz bottle
  Tablets 150mg, 300mg, 600mg                  Elimite Cream 5%

(Percocet) CII                                 Tablets: 2 mg, & 8 mg
   Tablets: 5 mg/325 mg
OXYMETAZOLINE (Afrin)                          See dipyridamole
  Nasal Spray

                                             PETROLEUM JELLY
OYST-CAL-D-500                                 Oint: 1 oz tube
  See calcium carbonate                        Ophth Oint: Lacrilube, Puralube

PALIPERIDONE (Invega)                        PHENAZOPYRIDINE (Pyridium)
  Tablet: 3mg, 6mg, 9mg                        Tablets: 100 mg

PANTOPRAZOLE (Protonix)                      PHENERGAN
  Tablet: 40mg                                 See promethazine HCL

PARLODEL                                     PHENOBARBITAL C IV
  See bromocriptine mesylate                   Elixir: 4 mg/ml
                                               Inj: 130 mg/ml vials
PAROXETINE (Paxil)                             Tablets: 15 mg, 30 mg, 60 mg, 100 mg
  Tablets: 10 mg & 20mg
PAXIL                                          Inj: 1%, 10 mg/ml, 2 ml vial
  See Paroxetine
                                             PHENYTOIN (Dilantin)
PEDIAZOLE (Erythromycin E.S. 200mg &           Capsules: 30 & 100 mg
sulfasoxazole 600mg/5cc)                       Inj: 100 mg/2 cc syringe
    Susp: 200 ml/bottle                        Tablets: 50 mg
                                               Suspension: 125/5ml

     REV 01-2010                                                                      117
PHYTONADIONE (Aquamephyton)
  Inj: 10 mg/ml                                PREDNISONE
                                                 Tablets: 5 mg & 20mg
   Ophth. Sol: 1, 2, & 4%                      PREMARIN
                                                 See estrogens conjugated
  Tablets: 2mg                                 PREVACID
                                                 See lansoprazole
   Tablets: 15mg & 30mg                        PRILOSEC
                                                  See omeprazole
   See clopidrogrel                            PRIMIDONE (Mysoline)
                                                 Tablets: 50 mg, 250 mg
POLYVALENT (Pneumovax)                         PRINIVIL
  Inj: 1 ml vial                                  See lisinopril

  Powder                                         Inj: 100 mg/ml, 10 ml vial

   Powder: 10 gm Vial                            See nifedipine
   Ointment: 30 gm
POLYMYXIN                                      PROLIXIN
B-NEOMYCIN-HYDROCORTISONE                        See fluphenazine
   Otic Soln: 10 cc bottle                     PROMETHAZINE (Phenergan)
   Otic Susp: 10 cc bottle                       Inj: 25 mg/ml ampule
   Ophth Susp: 7.5 cc bottle                     Suppositories: 25mg, 50mg
   Ophth Oint: 3.5 gm tube                       Tablet: 25 mg
POLYVINYL ALCOHOL                                Syrup: 6.25 mg/5 ml
   Solution: Artificial Tears
                                               PROPOXYPHENE NAPSYLATE
POTASSIUM ACETATE                                Tablet: 100mg (Darvon-N)
  Inj: 2 mEq/ml, 20 ml vials
                                               PROPOXYPHENE NAPSYLATE WITH
POTASSIUM CHLORIDE                             ACETAMINOPHEN (Darvocet N 100) C-IV
  Inj: 2 mEq/ml; 10 ml vial                      Tablets: 100mg propoxyphene/650mg
  Oral Solution 10%, 20 mEq/15 cc (Kay-ciel)     acetaminophen
  Oral Solution: 20 mEq/pk (K-Lor)
  Tablet: 750mg (10 mEq)                       PROPRANOLOL (Inderal)
                                                 Tablets: 10 mg, 20 mg, 40 mg
  Scrub: 4 oz & 32 oz bottle                   PROTONIX
  Soln: 0.5 oz & 32 oz bottle                    See: pantoprazole
  Douche Soln: 8 oz bottle
  Oint: 15 gm                                  PROVENTIL FOR INHALATION
  Perineal Wash Conc.: Kit                       See albuterol

PRAZOSIN (Minipres)
  Capsules: 1 mg, 2 mg                         PROVERA
                                                 See medroxyprogesterone
PRED FORTE (Prednisolone Acetate)
  Ophth Soln: 1% 5ml                           PROZAC

     REV 01-2010                                                                118
   See fluoxetine hydrochloride           RIFAMPIN
                                             Capsules: 300 mg
  Syrup: 30 mg/5 cc                       RISPERIDONE
  Tablets: 30 mg, 60 mg                      Inj. LA 25 mg, 37.5 mg, & 50 mg
                                             Tablets: 0.5 mg, 1mg, 2 mg, 3 mg, & 4 mg
PSORIGEL                                     M Tabs: 0.5mg, 1 mg, & 2 mg
  (See coal tar)

  Metamucil                                  See Risperidone

PYRIDIUM                                  RITALIN & RITALIN ER
  See phenazopyridine                        See methylphenidate

PYRIDOXINE (Vitamin B-6)                  ROBAXIN
  Tablets: 25 mg & 50 mg                    See methocarbamol

QUESTRAN                                  ROBITUSSIN (Plain, DM, & PE)
  See cholestyramine                        See guaifenesin

  Tablets: 25 mg, 100mg, 200mg, & 300mg     See ceftriaxone

RANITIDINE                                ROMAZICON INJ
  Tablet: 150 mg                            See flumazenil
  Inj: 25 mg/ml, 2 ml
  Syrup: 15 mg/ml                         SALICYCLIC ACID
                                            Soap: With sulfur (Fostex)
  See metoclopramide                      SALINE NASAL SPRAY
                                            Sea Mist Nasal Spray
  See temazepam                           SALIVA SUBSTITUTE

RECOMBIVAX HB                             SEBUTONE (POLYTAR)
  See hepatitis B vaccine                   Shampoo: 4 oz bottle

REGLAN                                    SECOBARBITAL (Seconal)         C II
  See metoclopramide                        Capsules: 100 mg

REMERON                                   SELENIUM SULFIDE
  See mirtazapine                           Suspension: 2.5% topical (Selsun Brown)
                                            Suspension: 1% topical (Selsun Blue)
  See temazepam                           SENNA EXTRACT
                                            Syrup: 8 oz bottle (Senna)
RETIN-A                                     Tablets: Senokot S (w/DSS)
  See tretinoin
RETROVIR                                    Toothpaste/Gel
  See zidovudine
                                          SEPTRA AND SEPTRA D.S.
RIFADIN                                     See sulfamethoxazole with trimethoprim
   See rifampin

     REV 01-2010                                                                     119
   See salmetrol                         See methyl prednisolone

SEROQUEL                              SPIRONOLACTONE (Aldactone)
  See quetiapine fumarate                Tablet: 25 mg

SERTRALINE (Zoloft)                   STELAZINE
  Tablets: 25 mg, 50 mg, & 100mg        See trifluoperazine

SERZONE                               STERILE WATER FOR INJECTION
  See nefazodone                        Vial: 20 ml/sdv

SHAMPOO, BABY                         SUCRALFATE (Carafate)
                                        Tablet: 1 gm
SILVADENE                               Susp: 1 gm/10 ml
   Cream: Silver Sulfadiazine
SIMETHICONE (Mylicon Drops, Mylanta     See pseudoephedrine
Gas, Gas Relief )
   Tablets: 80 mg                     SULFACETAMIDE
   Drops: 40 mg/0.6 ml                  Ophth Oint: 4 gm tube
                                        Ophth Solution: 10%, 15 cc bottle
  Tablets: 10mg, 20mg, 40mg           SULFAMETHOXAZOLE WITH
                                      TRIMETHOPRIM (Bactrim, Septra)
SINEMET                                 Suspension: 200 mg, sulfa with 40 mg/5 cc
   See carbidopa & levodopa             Tablet: 400 mg, sulfa with 80 mg
                                        Double Strength (DS) tablets: 800 mg sulfa
SINEQUAN                                with 160 mg trim.
   See doxepin
                                      SULFASALAZINE (Azulfadine)
SINGULAIR                               Tablets 500 mg
   See montelukast sodium
                                      SULFUR AND SALICYLIC ACID
SODIUM BIPHOSPHATE (Fleets)             Soap: Fostex
  Enema Adult: 4 1/2 oz bottle
  Enema Pediatric: 2 1/2 oz bottle    SUNSCREEN
                                        Lotion: SPF 30 & SPF 46
  Inj: 10 ml vial; 2 mEq/ml           SUPERFATTED SOAP (Oilatum)
  Tablet: 1 gm                          Bar: 3.3 oz
  Soln: Ophth. 5% (Muro)
  Oint: Ophth 5% (Muro)               SYMBICORT
                                        See: Budesonide / Formoterol
  Tablets: 250 mg & 500 mg            SYMMETREL
  Sprinkles: 125 mg                     See amantadine

(Kayexalate)                            See levothyroxine
   Suspension: 15 g/60 ml
SODIUM VALPROATE (Depakene)             Tablets: 10 mg
  Syrup: 250 mg/5 cc
SOLU-MEDROL                             See carbamazepine

     REV 01-2010                                                               120
                                           TOBRAMYCIN (Nebcin)
TEMAZEPAM (Restoril) CIV                     Inj: 80 mg/2 ml
  Capsules: 15 mg, 30 mg
                                           TOBRAMYCIN WITH DEXAMETHASONE
TENORMIN                                     Ophthalmic Susp 0.3%/0.1%
  See Atenolol
TERBUTALINE SULFATE                          See imipramine
  Inj. 1 mg/ml
                                           TOLNAFTATE (Tinactin)
TETANUS AND DIPHTHERIA TOXOIDS               Cream: 15 gm tube
  Inj: Pediatric & Adult                     Powder: 45 gm can
                                             Solution: 10 cc bottle
  Inj: Single Dose Syringe                 TOPAMAX
                                             See topiramate
  Syringe: 0.5ml                           TOPIRAMATE
                                             Tablets: 25 mg, 100 mg & 200 mg
  Capsule: 250 mg                          TOPROL XL
                                             See metoprolol
plus)                                      TORADOL INJECTION
   Solution: 15 cc bottle                    See ketoralac

                                           TRAMADOL HCL
THEOPHYLLINE (Slo-bid)                       Tablets: 50mg
  Capsules: 50mg, 100 mg , 200mg & 300mg
  (Sustained Action)                       TRANSDERMAL-NITRO
                                             See nitroglycerin
  Inj: 100mg                               TRANXENE        C IV
  Tablet: 100mg                              See clorazepate

THIOTHIXENE (Navane)                       TRAZADONE (Desyrel)
  Capsules: 2 mg, 5 mg, 10 mg                Tablets: 50 mg & 100 mg

THORAZINE                                  TRETINON (Retin-A)
  See chlorpromazine                         Cream: .05% 20 gm tube

THYROID                                    TRIAMCINOLONE
  Tablets: 30mg, 60mg                        Cream: 0.1%, 80 gm tube
                                             Oint: 0.1%, 80 gm tube
TIAGABINE (Gabitril)                         Gel: In Orabase; 5 gm tube
   Tablets: 4 mg                             Inhaler: 100mcg

TIGAN                                      TRIAMTERENE &
   See trimethobenzamide                   HYDROCHLOROTHIAZIDE (Dyazide,
TIMOPTIC (Timolol)                           Capsule: 25 mg/37.5 mg
  Ophth Soln: 0.25% & 0.5%, 5ml bt
                                           TRIFLUOPERAZINE (Stelazine)
TOBRADEX                                     Tablets: 2 mg & 5 mg
  See Tobramycin/Dexamethasone
                                           TRIHEXYPHENIDYL (Artane)

     REV 01-2010                                                               121
   Tablets: 2 mg, 5 mg                   VENTOLIN
                                           See albuterol
  See perphenazine                       VERAPAMIL
                                           Inj: 5 mg/2ml
TRILEPTAL                                  Tablets: 80 mg, 120 mg SR, 180 mg SR &
  See oxcarbazepine                        240 mg SR

TRIPROLIDINE WITH                        VERMOX
PSEUDOEPHEDRINE HCl (Actifed)              See mebendazole
  Tablets 2.5mg & 60mg
  Syrup 1.25mg & 30mg/5cc                VERSED
                                           See midazolam HCl
  See dorzolamide                        VIBRAMYCIN
                                            See doxycycline
TUBERCULIN PPD (5 test unit/cc)
  Solution: 10 test vials                VIOKASE
  See acetaminophen                      VIOFORM HC
                                            See iodochlorhydroxyquin
  See acetaminophen with codeine         VISINE
                                            See tetrahydrozoline
  See tramadol                           VISTARIL
                                            See hydroxyzine

UNDECYLENIC ACID (Desenex)               VITAMIN B-1
  Powder: 45 gm can                         See thiamine

UNIFIBER                                 VITAMIN B-6
  See cellulose                             See pyridoxine

UREA CREAM 10%                           VITAMIN B-12
  Tube: Aqua Care (10%) 2.5 oz              (See cyanocobalamin)

VALIUM C IV                              VITAMIN C
  See diazepam                              See ascorbic acid

VANCENASE AQ                             VITAMIN E
  See beclomethasone                        Softgels 400 I.U.

VAPOROLE                                 VITAMINS, MULTI
  See ammonia inhalant                      Tablets, chewable
                                            Drops, liquid
VASOCON A (Naphazoline and Antazoline)      Each tablet or 1 cc of drops contain:
  Ophth Soln: 15ml                          100% of the RDA (adults/infants) of
VASOTEC                                     A,D,C,E,B1,B2,B6,B12,Niacin
  See enalapril maleate
                                         VITAMINS, MULTI WITH IRON
VENLAFAXINE (Effexor) XR                    Tablets: 27 mg Iron
  Capsule: .75mg, 37.5mg, & 150mg           Drops: 50ml

     REV 01-2010                                                                    122
   Tablets                                         Tab: 2.5mg

VITAMINS WITH ZINC (Z-Bec)                       ZOLPIDEM (Ambien)
   Tablets                                         Tablets: 5 mg

WARFARIN (Coumadin)                              ZOMIG
  Tablet: 1mg, 2mg, 2.5 mg,3mg & 5 mg              See zolmitriptan/phenylalanine
  (See bupropion)                                ZOVIRAX
                                                   See acyclovir
  See latanoprost                                ZYLOPRIM
                                                   See allopurinol
  See alprazolam                                 ZYPREXA
                                                   See olanzapine
XYLOCAINE (Lidocaine)
  Inj: 1.0% - 20 ml vial                         ZYRTEC
       2.0% - 20 ml vial                           See Cetirizine
       1.0% - MPF 10 ml amp
       2.0% - 5 ml syringe (cardiac)             Zyvox
  Oral Solution: 2% - 100 cc bottle (Xylocaine     See Linezolid
                                                 IV SOLUTIONS
  See ranitidine                                 DEXTROSE 5 %
                                                   1000 ML
                                                 DEXTROSE 5%, 0.9% SODIUM
Z-BEC (Z-GEN)                                    CHLORIDE
   See vitamins w/zinc                             1000 ML
                                                 SODIUM CHLORIDE 0.9%
ZESTRIL                                            1000 ML
  See lisinopril

   Capsule: 100mg


   Capsule: 220 mg

   Capsule: 20 mg, 40 mg, 60 mg, & 80 mg

   See azithromycin

  See simvastatin

  See sertraline

     REV 01-2010                                                                    123

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