Stability of Solutions: Decanting off the Truth Manish Khullar, BSc Pharm Interior Health Pharmacy...
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![Page 1: Stability of Solutions: Decanting off the Truth Manish Khullar, BSc Pharm Interior Health Pharmacy Resident October 3, 2013.](https://reader035.fdocuments.in/reader035/viewer/2022062307/5518b82e550346991f8b5214/html5/thumbnails/1.jpg)
Stability of Solutions: Decanting off the Truth
Manish Khullar, BSc PharmInterior Health Pharmacy Resident
October 3, 2013
![Page 2: Stability of Solutions: Decanting off the Truth Manish Khullar, BSc Pharm Interior Health Pharmacy Resident October 3, 2013.](https://reader035.fdocuments.in/reader035/viewer/2022062307/5518b82e550346991f8b5214/html5/thumbnails/2.jpg)
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
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Outline
• Issue behind the dating of decanted products • Drug information question• Drug distribution project
• Best possible medication histories
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Decanting of Solutions
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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
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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?
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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!
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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
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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
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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.
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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…
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Commonly Decanted Solutions/Suspensions at KGH
Response received Response not received
BenzydamineFerrous SulfateFurosemide Morphine SulfateChlorhexidine GluconateSucralfate SuspensionRanitidine
DigoxinDiphenhydramineSodium Hypochlorite 6%Acyclovir SuspensionCodeine Syrup
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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!
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Potential Changes to Current Practice? Drug USP 795/797 Manufacturer’s
Recommendations Currently
Benzydamine 6 months Product date or 1 year whichever is shorter
Decanted as single doses PRN
Ferrous Sulfate 6 months Product date or 1 year whichever is shorter
Decanted as single doses PRN
Furosemide 6 months Not recommended Decanted as single doses PRN
Morphine 6 months Product date or 1 year whichever is shorter
Manufacturer’s date
Chlorhexidine 6 months Manufacturer’s date 30 days
Sucralfate 6 months Not recommended Manufacturer’s date
Ranitidine 6 months Not recommended Decanted as single doses PRN
Creams/Ointments 30 days max - 30 days
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Conclusion
• Recommendations for expiration dates on decanted solutions should be a judgment call and recommendations from both the USP and manufacturer should be considered
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BPMH: When Best Isn’t Good Enough
Manish Khullar, BSc PharmInterior Health Pharmacy Resident
October 3, 2013
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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
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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): 201-5BMC 2012; 12(42): 17
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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
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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
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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
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Breakdown of Errors
514
23
30
37
26Missing HMR
Not First Scan of BPMH
Missing at least one page
No Verification
No Physician Order
No Signature
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Results
• 37 total BPMHs were considered complete based on this criteria
• These 37 completed BPMHs were then looked at in detail…
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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)
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ResultsLegend
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
A11.32%
B1.89%
C1.89%
D1.89%
E11.32%
F37.74%
G7.55%
H16.98%
I3.77%
J3.77%
K1.89%
Distribution of Common Errors on 'Complete' BPMHs
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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
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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
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QUESTIONS?!