1. Stability of Solutions: Decanting off the Truth Manish Khullar, BSc Pharm Interior Health Pharmacy Resident October 3, 2013

2. Learning Objectives To understand some of the current issues in the dispensary To recommend a method to dating products in the dispensary To describe the various issues that occur with best possible medication histories

3. Outline Issue behind the dating of decanted products Drug information question Drug distribution project Best possible medication histories

4. Decanting of Solutions

5. What is Currently Done in the Dispensary Products that are currently decanted into stock bottles are given an expiration date After the expiration date is up, the product is discarded and new product is dispensed Sometimes from the same stock bottle! ex. Chlorhexidine and its 30 day expiration date

6. Drug Information Question… Is the current method used for expiration dating of solutions in the dispensary the most appropriate, efficient and cost effective way to dispense these medications?

7. Why Do We Care? Wasting product Wasting money Takes time away from the nursing staff Takes more time away from the pharmacy department Staff is confused on what to do!

8. Why Not Just Use Manufactures Date? Need to consider: Stability of product(s) Stability data of the compounds outside of manufacturers bottle Possible contamination of stock bottles? Types of ingredients in compounds

9. Currently in the Dispensary… No guideline is currently being employed or followed in the dispensary to come up with a proper expiration date for decanted solutions No standard for Interior Health currently exists

10. My Approach United States Pharmacopoeia (USP) 795 (non-sterile products) 797 (sterile products): – For non-aqueous formulations The beyond use date is not later than the time remaining until the earliest expiration date of any ingredients or 6 months, whichever is earlier. – For Water-Containing Oral Formulations (ie reconstituted products) The beyond use date is not later than 14 days when stored at controlled room temperatures. – For Water-Containing Topical/Dermal and Mucosal Liquid and Semisolid Formulations The beyond use date is not later than 30 days. *The beyond use date shall not be later than the expiration date on the container of any component.

11. Search Literature search (pubmed, medline) no relevant articles References United states pharmacopoeia (USP), Trissel's Stability of Compounded Formulations, Remington BC College of Pharmacists referred me to USP 795 and 797 Health Canada referred me to USP 795 and 797 Manufacturer…

12. Commonly Decanted Solutions/Suspensions at KGH Response receivedResponse not received Benzydamine Ferrous Sulfate Furosemide Morphine Sulfate Chlorhexidine Gluconate Sucralfate Suspension Ranitidine Digoxin Diphenhydramine Sodium Hypochlorite 6% Acyclovir Suspension Codeine Syrup

13. Response Varied from 6 months, 1 year, manufacturers expiry date on bottle to dont do it at all Not very clear on what the approach should be or who to trust!

14. Potential Changes to Current Practice? DrugUSP 795/797Manufacturers Recommendations Currently Benzydamine6 monthsProduct date or 1 year whichever is shorter Decanted as single doses PRN Ferrous Sulfate6 monthsProduct date or 1 year whichever is shorter Decanted as single doses PRN Furosemide6 monthsNot recommendedDecanted as single doses PRN Morphine6 monthsProduct date or 1 year whichever is shorter Manufacturers date Chlorhexidine6 monthsManufacturers date30 days Sucralfate6 monthsNot recommendedManufacturers date Ranitidine6 monthsNot recommendedDecanted as single doses PRN Creams/Ointments30 days max-30 days

15. Conclusion Recommendations for expiration dates on decanted solutions should be a judgment call and recommendations from both the USP and manufacturer should be considered

16. BPMH: When Best Isnt Good Enough Manish Khullar, BSc Pharm Interior Health Pharmacy Resident October 3, 2013

17. Background Best possible medication histories (BPMH) are conducted upon admission to the hospital Majority received are from ER They are used as a physician order form for the first time and physician order forms or pre- printed orders (PPOs) are used thereafter In order to process BPMHs as physician orders, all areas must be filled out appropriately and accompanied by a physician signature

18. Importance of Proper BPMHs There are a high number of discrepancies (84.3%) between gold standard BPMHs and medication profiles found in Pharmanet Canadian studies have shown that 40-50% of patients have experienced unintentional medication discrepancies upon admission to an acute care facility 46% of medication errors occur on admission or discharge http://www.bcpsqc.ca/ccm-public/documents/fernandes.pdf J Crit Care 2003; 18(4): 201-5 BMC 2012; 12(42): 17

19. Importance of Proper BPMHs Allows pharmacy staff to know proper medication history was taken from the patient Proper BPMHs frees up more time for pharmacy staff and provides more efficient workflow Prevents having to contact the physician, nursing staff and unit clerks does not take time away from them If properly done, the chances of mistakes and harm to the patient could be prevented or minimized

21. Project Randomly selected 100 BPMHs from the emergency department ER scanners A randomization table was used and gathered 200 BPMHs from August 1/2013, onwards From the 200, 100 were selected using the odd numbers from the randomization table For each BPMH: All pages received? Home Medication Report included? Was it the initial scan? Verification column filled out? Physician order column filled out? Was there a physician signature? Total number of issues

22. Results 63/100 did not meet all or some of the criteria 51/63 did not have the bare minimum requirements: Verification column Physician order column Physician signature 12/63 incomplete BPMHs could still be used and processed based on the current dispensary practice

23. Breakdown of Errors

24. Results 37 total BPMHs were considered complete based on this criteria These 37 completed BPMHs were then looked at in detail…

25. Errors Identified Therapeutic Interchange* Order to continue completed antibiotic therapy Order to continue completed therapy Missed drug order Incomplete order (ie no dose and/or route and/or frequency) Patients own medication (POM)* Duplicate drug order Continue medication without verifying dose Continue medication when patient not taking therapy Did not use PPO (fentanyl and insulin) New physician order came before BPMH *workload measure (ie. not true errors)

26. Results Legend A Therapeutic interchange B Order to complete continued therapy (Abx) C Order to complete continued therapy (Rx) D Missed order E No Dose, No Route, No Frequency F POM G Duplicate Drug Order H Patient takes checked, continued verified dose checked I Patient not taking, continue verified dose J Did not use PPO K New Physician order came before BPMH

27. Limitations of the project Only obtained data from ER scanners Only looked at a 2 week interval August 1 st -15 th Strict criteria for BPMHs Did not look at BPMHs from patients from direct admit or pre-surgical screening

28. How Can we use this data? Allows us to know what issues are most common in the dispensary Helps us as an education tool for physicians and nurses Able to improve in this area and increase workflow efficiency With more free time, pharmacists in the dispensary could be available to do BPMHs in the future

29. QUESTIONS?!