Stability of Solutions: Decanting off the Truth

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 Manufacture’s Date? • Need to consider: • Stability of product(s) • Stability data of the compounds outside of manufacturer’s 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

13. Response • Varied from 6 months, 1 year, manufacturer’s expiry date on bottle to don’t do it at all • Not very clear on what the approach should be or who to trust!

14. Potential Changes to Current Practice?

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 Isn’t 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) • Patient’s 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

27. Limitations of the project • Only obtained data from ER scanners • Only looked at a 2 week interval • August 1st-15th • 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?!