1. Introduction to Prescription Drug Orders
Colleen Dula, PharmD, BCACP
Director, Professional Practice Laboratory
Clinical Assistant Professor
The Ohio State University College of Pharmacy

2. Objectives Review medication classifications
Discuss legal requirements of outpatient prescription orders
Identify tips to avoid medication errors

3. Legal Controls Over the Counter (OTC) Drugs
Drugs deemed safe enough for self-treatment of simple conditions
Behind the Counter (BTC) Drugs
Restricted over the counter drugs based on potential for misuse or harm
Maintains reasonable access for patients to self-treat
Patients must request from and consult with the pharmacist
Prescription or Legend Drugs
Drugs useful after expert diagnosis of licensed practitioner
Federal Law Prohibits Dispensing without a Prescription
Controlled Substances
Have potential for abuse or psychological or physical dependence
Comprehensive Drug Abuse Prevention & Control Act of 1970 established 5 schedules based on potential for abuse & medical use

4. Medication Schedules Schedule I (May not be prescribed) Schedule II
Heroin, Methamphetamine, LSD
Schedule II
Methadone, Oxycodone, Oxycodone combinations (e.g. Percocet®), Morphine, Fentanyl, Hydrocodone combinations (e.g. Vicodin®)
Methylphenidate, Dextroamphetamine
Schedule III
Codeine combinations (e.g. Tylenol #3®)
Testosterone
Schedule IV
Benzodiazepines
Zolpidem (Ambien®), Eszopiclone (Lunesta®)
Tramadol (Ultram®)
Schedule V
Codeine containing cough syrup (available BTC)
Diphenoxylate products (e.g. Lomotil®)

5. What is the Prescription?

6. Ohio Administrative Code 4729-5-21
The Prescription
An order, by a licensed practitioner, for a medication.
“A prescription, to be valid, must be issued for a legitimate medical purpose by an individual prescriber acting in the usual course of his/her professional practice.”
Methods of transmitting or receiving prescription drug orders include:
Signed hard copy prescription
Oral prescription given by prescriber or the prescriber’s agent
Facsimile of a signed prescription
Prescription sent using a board approved electronic prescription transmission system
Ohio Administrative Code

7. Who can prescribe in Ohio?

8. Ohio Administrative Code 4729-5-15
Prescriber
Doctor of medicine (MD)
Doctor of osteopathic medicine (DO)
Doctor of podiatry (DPM)
Doctor of veterinary medicine (DVM)
Dentist (DDS)
Optometrist (OD)
“Therapeutic pharmaceutical agents certificate”
Advanced practice nurse (restrictions)
CNS (Clinical nurse specialist)
CNM (Certified nurse midwife)
CNP (Certified nurse practitioner)
Physician Assistant (restrictions)
Ohio Administrative Code

9. Ohio Administrative Code 4729-5-15
Prescriber
“Those persons pursuing an approved internship, residency, or fellowship program in this state are authorized to write prescriptions only when acting within their scope of employment in the hospital(s) or institution(s)
Ohio Administrative Code

10. Outpatient Prescription Orders
Prescriptions are the primary method of physician-to-pharmacist communication
Can be useless if incomplete, confusing, or not filled by the patient
Results of miscommunication:
Delay of care
Undesired outcome (preventable ADEs)
Insurance reimbursement problems

11. By law, what must each prescription contain?
Ohio Administrative Code

12. Outpatient Prescription Order
The Ohio State University
Physicians Group
123 Main St. Columbus, OH 43210
Patient’s Name: Joe Smith__________
Address: 456 Buckeye Lane Date: 9/29/2014
Rx: Percocet 5/325mg
# 30 (thirty)
Sig: i po q 6 hr prn pain
Refills: Mary Jones M.D.
Mary Jones M.D AJ
  For Instructional Purposes Only
Patient’s full name
Address & phone # of prescriber
Patient’s address
Date issued
Drug name & strength
Quantity to dispense*
Directions for use
Address often added by pharmacist (check records/profile, ask patient, or prescriber) – If contained on backtag label that is sufficient
Must contain date issued, if prescriber does not want patient to fill until certain date they can write that in the directions, they cannot post date a prescription. For example prescriber should write the date issued plus do not fill until…
For controlled substances quantity must be numerical and alphabetical
For hand written order prescriber must manually sign Rx
DEA required for controlled substances (often preprinted)
Refill PRN not valid
Other useful information that should be provided or included but not required by law age/date of birth and weight (especially for pediatric patients)
Prescriber signature
Preprinted full name & professional title of prescriber
Refills authorized
If nothing specified, 0 refills allowed for that prescription unless you call the physician
"Refill P.R.N." is NOT valid
Ohio Administrative Code
Prescriber DEA #
Required for controlled substances

13. What else should be included?

14. Prescription Orders
Additional items that should be included on prescription orders but NOT required by law
Patient date of birth
Patient weight (especially in pediatrics)
Route of administration
Dosage form
Purpose of medication (i.e. indication)

15. Prescription Orders – Other Requirements
DAW (dispense as written) must be handwritten (in Ohio)
Section (A)(1) ORC
Only 3 orders per prescription
Can not include controlled substances
Each controlled substance must be written on its own prescription

16. Tamper-Resistant Prescriptions in Ohio
Claim to be eligible for reimbursement through ODJFS, a written format must be on a tamper resistant form
Ohio Department of Job and Family Services
Consumers enrolled in the Ohio Medicaid or Disability Medical Assistance programs
Must contain all three features
Feature to prevent unauthorized copying
Feature to prevent erasure or modification of information
Feature to prevent the use of counterfeit prescription forms
Ohio Administrative Code 5101:3-9-06

18. Controlled Substances Requirements
Only 1 order per prescription
Prescriber DEA number must be on each controlled substance prescription
Quantity must be written numerically and alphabetically
Refill regulations
CII – no refills, multiple scripts for up to 90 day supply, “do not fill until”
CIII-IV – max 5 refills, must be within 6 months from date written
CV – max refills 1 year
CII’s must be handwritten or electronically printed and manually signed (No telephone orders*)
Controlled Substances Act (CSA), ORC

19. D.E.A. Number
Assigned to individual prescriber for controlled substances
Unique letter and number combination
2 letters followed by 7 numbers
Can be checked for legitimacy
Interns, residents, and fellows are assigned individual number to use as a hypenated suffix with the hospital D.E.A. number
DEA number must be written on each prescription for a controlled substance.
DEA can be determined if it is real or not by a mathematical formula.

20. Tips for Electronic Prescribing
All fields must be completed to have legal prescription
Carefully select drug, dose, frequency, etc.
Proofread, proofread, proofread
E-prescribing will send script to selected pharmacy
Always ask patient what pharmacy they go to
Any changes after prescription is sent require a new prescription and/or a call to the pharmacy
Printed electronic prescriptions must be manually signed
Ask questions!
While there are advantages to e-prescribing including decision support features there are also pitfalls and areas prone to error so don’t be afraid to ask questions.

21. Electronic Prescribing

22. Pharmacist’s Role Pharmacists can do on his/her own:
Generic substitution
Reduce quantity dispensed
Add patient address
Compound

23. Pharmacist’s Role Pharmacists cannot do without calling:
Add or subtract refills
Add quantity
Change drug
Including formulary substitutions
Change strength
Change formulation
Add physician’s D.E.A. number

24. Medication Errors
Definition - "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."
National Coordinating Council for Medication Error Reporting and Prevention

25. Medication Errors - IOM
Estimated 1.5 million preventable ADEs/year
Cost in ambulatory care setting in Medicare patient estimated at almost $900 million in 2000
Preventing Medication Errors: Quality Chasm Series - IOM 2006

26. Tips to Avoid Errors Write legibly
Include all required elements on orders/prescriptions
Avoid Abbreviations
Drug Names
Sig codes
Medical Terminology
Avoid trailing zeros 1.0mg, use leading zeros 0.1mg
Use metric system (e.g. mL vs. tsp)
Specify strength rather than unit
250mg vs. 1 tablet
Specify dosage form
Be aware of sound alike/look alike medications

27. Error Prone Abbreviations

28. Summary Support interdisciplinary practice
Educate patients on medications
Encourage use of one pharmacy
Encourage patients to talk to pharmacists
Promote medication lists for patients

29. Acknowledgements Stu Beatty, Pharm.D., BCPS Anna Haas-Gehres, Pharm.D.
Cari Brackett, Pharm.D., BCPS

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