National Patient Safety Goal (NPSG) 3E-Anticoagulation

The pharmacy department's anticoagulation dosing policy was recently updated to incorporate changes from the May 2008 Chest Guidelines. The updates were discussed and approved at the P&T meeting. Pharmacists have the authority to order labs for patients who are not being managed by the pharmacy service to ensure compliance with the policy. If lab results are outside the expected or desired range, the pharmacist

Insulin Pen Conversion

Insulin is considered a "high-risk" medication with numerous opportunities for errors in the administration process. In an effort to increase safety and to potentially decrease nursing time, TCMC plans to convert to insulin pen use. Patients will have their own insulin pen(s), which will be bar-coded and will not require refrigeration. There will be auto-substitutions for products that are not on the TCMC formulary. NPH insulin will continue to be supplied as a vial, as there is no pen available. A comprehensive nursing education program is being developed to ensure proper administration technique.

Droperidol Formulary Status

In order to avoid compliance issues with back box warnings for droperidol, the emergency room physicians have decided to remove it from all ED areas and to use alternate agents. Droperidol use will be restricted to the Cardiology service and cardiac monitored areas.

FDA News Antipsychotic Alert

A black box warning has been added to conventional antipsychotics, matching the 2005 warning for atypical antipsychotics, to warn prescribers of an increased risk of death when used to treat elderly patients with dementia-related psychosis. Neither conventional nor atypical antipsychotics are approved for the treatment of patients with dementia-

Black Box Warnings

A comprehensive policy for ensuring safe use of drubs with black box warnings has been developed and was discussed at the P&T meeting. The policy encompasses both actions to be taken when new black box drug warnings are issued by the FDA and also on actions to be taken when the drugs are ordered in the hospital. A list of 20 current formulary agents with black box warnings (out of a potential 240) was selected and specific guidelines outlined to optimize their safety are described briefly below. Pharmacists will write for specific lab tests that have not been ordered by the physician if necessary.

Aminoglycosides Neuro/Nephrotoxicity

Dosing will continue per pharmacy when requested and serum creatinine and drug levels will be monitored by pharmacy for all other patients.

Amphotericin B (non-liposomal) Nephrotoxicity

Serum creatinine will be monitored and all doses checked for appropriateness. Use of the hospital pre-printed order is encouraged.

Amiodarone oral Pulmonary/ hepatotoxicity

LFTs will be monitored for all patients receiving > 600mg/day.

John Gama, Clinical Pharmacy Manager

There are now two other thrombin's commercially available. One of which is derived from human plasma (Evithrom®). Recothrom® has greater purity than the current formulary bovine thrombin, is nearly identical to plasma-derived human thrombin, and is essentially free of nonthrombin proteins.

The FDA approved indications for all three thrombin products are identical. The current formulary thrombin (of bovine origin) has a Black Box Warning for occasionally being associated with abnormalities in hemostasis that are rarely fatal. These hemostatic effects appear to be related to the formation of antibodies against the bovine thrombin, which can be more common with repeated clinical applications of the bovine thrombin. Recothrom® does not carry this Black Box Warning.

For this safety reason, the Pharmacy and Therapeutics Committee would like to recommend the conversion from our current formulary bovine thrombin to the recombinant technology derived thrombin.

Before we make this decision, we would like your opinion. Do you see any problem in making this conversion? If you object to the conversion, then please contact John Gama at gamaja@tcmc.com or (760) 940-3020 to voice your concerns