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Medication Use in Outpatient Care Areas (15.2)

Medication Use in Outpatient Care Areas (15.2) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Clinics

15.2





Effective Date:
September 2002
; Policy and Procedure Manual
Chapter: Clinics
□ Operations Manual

Policy #: 15.2
Original
; Revision:
August 2013
Page 1 of 11 Title: Medication Use in Outpatient Care Areas


I. PURPOSE: To provide a mechanism for obtaining and processing orders for clinic administered
medications.

II. POLICY: This policy will outline workflow required for the selection and procurement of clinic
administered medications and serve as a guideline that will aid the provider and pharmacy in
determining the appropriate steps necessary to efficiently and safely provide medications to patients
in clinics

III. FORMS
a. Outpatient Medication Order Form (SR #300137)
b. Appendix A: Non-Stocked Medication Workflow for UWHC Clinics
c. Appendix B: Medications Requiring Internal Pharmacy PA per Policy 8.30
d. Appendix C: University Station Retail Pharmacy Stock list
e. Appendix D: East Retail Pharmacy Stock list
f. Appendix E: West Retail Pharmacy Stock list
g. Appendix F: Expectations to workflow

IV. DEFINITIONS
a. Clinic stock: a medication that has been approved by the Drug Product Selection and Supply
(DPSS) Committee to be stored within the clinic for administration under the general supervision
of the physician
b. Clinic non-stock: a medication that providers wish to administer in clinic but are not approved to
be stocked within that clinic
c. Retail Pharmacy
i. East, West, and University Station clinics – pharmacy within the clinic
ii. CSC clinics – central pharmacy

V. PROCEDURE
a. Any medications administered in a UWHC clinic must be obtained from a UWHC pharmacy
i. Administration of a medication that is supplied by the patient is prohibited
ii. Details and exceptions to this rule can be found in Policy 8.30: Management of Clinic
Administered Medications with Internal Pharmacy Prior Authorization
b. Medications for UWHC clinics will be obtained from three locations based on the following
criteria
i. Clinic Floorstock
1. Approved medications routinely used in clinics
2. Medication stock is maintained and charged by a pharmacy technician
3. If the clinic has depleted their stock of a medication and it is needed for a
patient in clinic, the retail pharmacy will replenish the stock
a. The clinic staff will contact the retail pharmacy and obtain the
medication
b. The pharmacist at the retail pharmacy will dispense the medication to
the clinic staff and leave a note of the dispense for the clinic technician
so appropriate charges are done the next business day
4. In general controlled substances will not be stocked in clinic areas due to the
rigorous documentation required
a. Exceptions must follow Policy 7.6: Documentation of Controlled
Substance Use in UWHC Clinics
5. Additions/deletions to a clinic floorstock must be approved by the DPSS
committee, see Policy 13.13: Medication Floor/Area Stock





Effective Date:
September 2002
; Policy and Procedure Manual
Chapter: Clinics
□ Operations Manual

Policy #: 15.2
Original
; Revision:
August 2013
Page 2 of 11 Title: Medication Use in Outpatient Care Areas


6. Storage and audit requirements must follow the following policies
a. Policy 1.43: Storage, Handling, Security, and Disposition of
Medications
b. Policy 1.32: Medication Refrigerator Audit Policy
c. Policy 1.19: Regulatory Compliance Inspections
7. Medication samples obtained from manufacturers are excluded from this
procedure and should follow Policy 8.36: Control of Trial Supplies of
Prescription Medication: Samples, Drug Vouchers, & Starter Supplies
ii. Central Pharmacy at CSC
1. Medications that require preparation in a sterile environment must be prepared
in the sterile products area (SPA) in the central pharmacy of the hospital and/or
medications requiring a prior approval (prior authorization) according to Policy
8.30: Management of Clinic Administered Medications with Internal Pharmacy
Prior Authorization will be dispensed from the central pharmacy to ensure that
medications are utilized appropriately and in the most cost-effective manner
a. This prior authorization process includes both a clinical and fiscal
review (patient eligibility and coverage determination)
b. List of these medications can be found in Appendix B
2. In general, orders for these medications will be placed 3-5 business days in
advance of administration to the patient
a. The provider must complete a “ Outpatient Medication Order Form” in
its entirety
b. The clinic faxes the order to the infusion center for review and entry
into Health Link
3. A pharmacist will review the order for appropriateness of the drug, dose,
frequency and route of administration, allergies, drug interactions,
contraindications and determine whether or not internal or third party prior
authorization is required
4. If prior authorization is required, designated pharmacy personnel will
investigate the claim and communicate any action necessary to the clinic,
providers, third party payers or the Drug Policy Program
5. The medication order is entered into Health Link by the reviewing pharmacist
6. Labels for medication preparation/distribution print in the central pharmacy
7. Central pharmacy prepares the medication and arranges for delivery to the
clinic
a. Delivery will be during the next business day by the clinic technician for
pre-planned orders
b. Emergency orders will be delivered via taxi
8. Pharmacy personnel shall arrange for proper storage of prepared medications if
not designated for immediate use
9. See Appendix A for workflow diagram
iii. Retail Pharmacy at the clinic
1. A list of medications infrequently administered in clinic but are needed acutely
will be stocked in the retail pharmacy for day-of dispensing
a. This list will be specific to each retail pharmacy in the clinics
b. The list will be maintained by the pharmacy department and stored in a
database
c. Additions/deletions to this list must be approved by the DPSS
committee





Effective Date:
September 2002
; Policy and Procedure Manual
Chapter: Clinics
□ Operations Manual

Policy #: 15.2
Original
; Revision:
August 2013
Page 3 of 11 Title: Medication Use in Outpatient Care Areas


2. Other medications that will be stocked in the retail pharmacy are controlled
substances, medications with unique dispensing or preparation requirements,
and medications stocked in the clinic (back-up if the clinic is stocked-out – see
section b.i.3 above for details)
3. The provider must complete a “Outpatient Medication Order Form” in its entirety
a. The staff member filling out the form should include a pager number or
phone number for the pharmacy to call when the medication is ready
for pick up in the retail pharmacy
a. The clinic faxes the order to the infusion center (or central pharmacy
during afterhours) for review and entry into Health LinkTo ensure the
pharmacist received the order and is aware the medication is needed
immediately, the clinic must call or page the pharmacist to notify them
of the order
4. A pharmacist will review the order for appropriateness of the drug, dose,
frequency and route of administration, allergies, drug interactions,
contraindications and determine whether or not internal or third party prior
authorization is required
a. The pharmacist will include the pager or phone number for the retail
pharmacy to call when medication is ready for pick up (the number
should be included on the label comments)
5. If prior authorization is required, designated pharmacy personnel will
investigate the claim and communicate any action necessary to the clinic,
providers, third party payers or the Drug Policy Program
6. Labels for medication preparation/distribution print in the retail pharmacy
a. The pharmacist will process the order and change the dispense
location to the retail pharmacy to ensure the label prints there
7. The pharmacist at the retail pharmacy will call or page the clinic (number on
label) when the medication is ready for pick up
8. Clinic staff will pick up the medication from the retail pharmacy
9. See Appendix A for workflow diagram
c. Documentation of medication administration must be completed in the electronic medical record for
all drugs administered
d. Credits for patient cancellations, medication administration omitted, etc.
i. Clinics should return any un-administered product to pharmacy technician with a note
stating the circumstances for a patient credit
ii. Patient charges will be credited by the pharmacy staff
iii. If a patient specific drug cannot be used on another patient, the clinic that requested the
drug will be charged
1. This charging will be done by the pharmacy manager that oversees the clinic
medication distribution
2. The patient’s name and MR number, medication name and dose, and the date of
the visit should be emailed to this manager for charging
e. Patient Schedule Changes
i. All schedule changes must be communicated on an order form and faxed to the infusion
center
ii. Complete all sections of the form and then record request for schedule change in the
ordering section of form.
iii. Schedule changes must be communicated to pharmacy so that drug charge will match
clinic visit so that appropriate billing can be completed





Effective Date:
September 2002
; Policy and Procedure Manual
Chapter: Clinics
□ Operations Manual

Policy #: 15.2
Original
; Revision:
August 2013
Page 4 of 11 Title: Medication Use in Outpatient Care Areas


f. Medications for take home use shall be ordered by the physician via Health Link or on a
prescription
i. The prescriptions will be filled and dispensed by the pharmacy of the patients choice
ii. This assures all labeling and legal requirements are met for medications dispensed to
patients
g. Medications supplied by UWHC Pharmacy to non-UWHC clinics
i. Floorstock items will be charged to the clinic when replenished by the clinic technician (not
charged to patients)
1. Medications out of stock may be obtained from the UWHC retail pharmacy if the
pharmacy has the medication on hand
2. The pharmacist at the retail pharmacy will supply the medication to the clinic
staff and leave a note of the dispense for the clinic technician so appropriate
charges are done the next business day
ii. Orders received for non-stock patient specific medications in non-UWHC clinics
1. If the pharmacist cannot find an encounter in Health Link for the clinic specified
on the order, the pharmacist should call the clinic to determine if it is a UWHC
clinic
2. If the clinic is not a UWHC clinic, the order must NOT be entered into Health
Link
3. The pharmacist should notify the clinic that patient specific orders cannot be
placed for patients in non-UWHC clinics
a. For UWMF Clinics they should be directed to contact the Central
Pharmacy at 1 S Park at (608) 287-2400.

VI. REFERENCES AND RELATED POLICIES, PROCEDURES
a. Contact information
i. Infusion Center
1. Fax: 263-6350
2. Pharmacist phone number: 890-7509
3. Pharmacist pager: 3645
4. Prior authorization coordinator phone number: 890-7510
5. Tube station: 432
ii. Central Pharmacy
1. Fax: 262-2584
2. Pharmacist phone number: 263-0666
3. Tube station: 210
b. Policies
i. Policy 8.30: Management of Clinic Administered Medications with Internal Pharmacy
Prior Authorization
ii. Policy 7.6: Documentation of Controlled Substance Use in UWHC Clinics
iii. Policy 13.13: Medication Floor/Area Stock
iv. Policy 1.43: Storage, Handling, Security, and Disposition of Medications
v. Policy 1.32: Medication Refrigerator Audit Policy
vi. Policy 1.19: Regulatory Compliance Inspections
vii. Policy 8.36: Control of Trial Supplies of Prescription Medication: Samples, Drug
Vouchers, & Starter Supplies









Effective Date:
September 2002
; Policy and Procedure Manual
Chapter: Clinics
□ Operations Manual

Policy #: 15.2
Original
; Revision:
August 2013
Page 5 of 11 Title: Medication Use in Outpatient Care Areas


VII. COORDINATION:
a. AUTHORED BY: Kimberly Sherman, PharmD
b. REVIEWED BY: Clinic non-stocked medication workflow steering committee, DPSS Committee,
Ambulatory Nursing Council
c. COMMITTEE APPROVAL BY: Ambulatory Policy & Procedures


Approved By: ____________________________


Date: ____________






Effective Date:
September 2002
; Policy and Procedure Manual
Chapter: Clinics
□ Operations Manual

Policy #: 15.2
Original
; Revision:
August 2013
Page 6 of 11 Title: Medication Use in Outpatient Care Areas


Appendix A: Non-Stocked Medication Workflow






Effective Date:
September 2002
; Policy and Procedure Manual
Chapter: Clinics
□ Operations Manual

Policy #: 15.2
Original
; Revision:
August 2013
Page 7 of 11 Title: Medication Use in Outpatient Care Areas


Appendix B: Medications Requiring Internal Pharmacy PA per Policy 8.30

Medications Requiring Internal Pharmacy PA per policy 8.30 
Abatacept (Orencia)  natalizumab (Tysabri) 
belimumab (BENLYSTA)  octreotide (SANDOSTATIN LAR DEPOT) 
bevacizumab (AVASTIN)  omalizumab (Xolair) 
Botulinum Toxin (Botox)  pegaptanib(MACUGEN) 
canakinumab (Ilaris)  pegloticase (KRYSTEXXA) 
capsaicin 8% Patch (Qutenza)  pentamidine (PENTAM) 
darbepoetin alfa (ARANESP)  plerixafor (Mozobil) 
denosumab (Prolia)  ranibizumab (LUCENTIS) 
etonogestrel (IMPLANON)  risperidone microspheres (RISPERDAL CONSTA) 
golimumab (SIMPONI)  rituximab (RITUXAN) 
hydroxyprogesterone caproate  romiplostim (Nplate) 
hylan (SYNVISC)  sodium hyaluronate (HEALON 5) 
hylan GF‐20 (SYNVISC ONE)  sodium hyaluronate (HEALON) 
ibandronate (BONIVA)  sodium hyaluronate(HEALON GV) 
infliximab (Remicade)  tocilizumab (Actemra) 
immune globulin (IVIG)  ustekinumab (STELARA) 
leuprolide (LUPRON DEPOT)  verteporfin (VISUDYNE) 
leuprolide (LUPRON DEPOT‐PED)  zoledronic acid (RECLAST)  
leuprolide (LUPRON)  zoster vaccine (ZOSTAVAX) 
levonorgestrel (MIRENA)  


Updated July 2012





Effective Date:
September 2002
; Policy and Procedure Manual
Chapter: Clinics
□ Operations Manual

Policy #: 15.2
Original
; Revision:
August 2013
Page 8 of 11 Title: Medication Use in Outpatient Care Areas


Appendix C: University Station Retail Pharmacy Stock List





University Station Retail Pharmacy Stock for Clinic
Administration
Updated 06/2012
Aflibercept (EYLEA) 2mg/0.05ml inj
bevacizumab (AVASTIN) 2.5mg/0.1mL intraocular inj
Bupivacaine/Epi Inj 0.5%/1:200,000 1.8ML
ceftriaxone (ROCEPHIN) 1g and 250mg vial
Hyaluronate inj (HEALON 5) 13.8mg/0.6mL syr
Hyaluronate inj (HEALON GV) 7.7mg/0.55mL syr
Hyaluronate inj (HEALON) 10mg/mL 0.55mL syr
hydromorphone (DILAUDID) 1mg/mL 1mL injection
Hydromorphone (DILAUDID) 2mg/mL 1mL injection
hydroxyzine (VISTARIL) 50mg/mL 2mL vial
Japanese encephalitis vaccine 1 dose/vial
ketorolac (TORADOL) 30mg/mL 2mL vial
morphine 10mg injection
Ondansetron ODT 4mg tab
penicillin G benzathine (BICILLIN LA) 1.2 million unit inj
Phenylephrine ophth solution 10% 5mL bottle
rabies vaccine 2.5 unit/mL syringe
Ranibizumab inj (Lucentis) 0.5mg/0.05mL
triamcinolone acetonide (TRIESENCE) 40mg intraocular
susp
varicella virus vaccine (VARIVAX) 0.5mL
Verteporfin inj (Visudyne) 15mg
yellow fever vaccine1 dose vial
Zoster vaccine 0.65mL





Effective Date:
September 2002
; Policy and Procedure Manual
Chapter: Clinics
□ Operations Manual

Policy #: 15.2
Original
; Revision:
August 2013
Page 9 of 11 Title: Medication Use in Outpatient Care Areas


Appendix D: East Retail Pharmacy Stock List


East Clinic Pharmacy Stock for Clinic Administration
Updated 06/2012
ceftriaxone (ROCEPHIN) 1g and 250mg vial
dexamethasone (DECADRON) 10mg/mL 10mL vial
FluMist intranasal live influenza vaccine (seasonal)
hydromorphone (DILAUDID) 1mg injection
immune glob RHO (D) 1500 unit/1.3mL vial
ketorolac (TORADOL) 30mg/mL 2mL vial
Leuprolide Acetate (3 month) 22.5 MG IM kit
Leuprolide Acetate (4 month) 30 MG IM kit
meperidine (DEMEROL) 50mg injection
morphine 2mg injection
Morphine sulfate 15mg IR tab
omalizumab (XOLAIR) 150mg vial
Oxycodone/APAP 5/325mg tab
penicillin G benzathine (BICILLIN LA) 1.2 million unit inj
rabies immune globulin 150 unit/mL 2mL vial
rabies vaccine 2.5 unit/mL syringe
varicella virus vaccine (VARIVAX) 0.5mL
Zoster vaccine 0.65mL





Effective Date:
September 2002
; Policy and Procedure Manual
Chapter: Clinics
□ Operations Manual

Policy #: 15.2
Original
; Revision:
August 2013
Page 10 of
11
Title: Medication Use in Outpatient Care Areas


Appendix E: West Retail Pharmacy Stock List

West Clinic Pharmacy Stock for Clinic Administration
Updated 06/2012
acetic acid 10% 5mL UD
ceftriaxone (ROCEPHIN) 1g and 250mg vial
haloperidol decanoate (HALDOL) 100 mg/mL 5mL vial
hydromorphone (DILAUDID) 1mg injection
immune glob RHO (D) 1500 unit/1.3mL vial
immune globulin-IM 2 mL vial
ketorolac (TORADOL) 30mg/mL 2mL vial
Leuprolide depot inj 3.75mg kit
meperidine (DEMEROL) 50mg injection
morphine 2mg injection
Octreotide acetate inj 10mg kit
Octreotide acetate inj 20mg kit
omalizumab (XOLAIR) 150mg vial
penicillin G benzathine (BICILLIN LA) 1.2 million unit inj
phenol 80% 15mL
prochlorperazine (COMPAZINE) 5mg/mL 2mL vial
rabies immune globulin 150 unit/mL 2mL vial
rabies vaccine 2.5 unit/mL syringe
sodium hydroxide solution 10% 5mL UD
sodium tetradecyl 10mg/mL 2mL vial
thyrotropin alfa (THYROGEN) vial + diluent NF
varicella virus vaccine (VARIVAX) 0.5mL
Zoster vaccine 0.65mL





Effective Date:
September 2002
; Policy and Procedure Manual
Chapter: Clinics
□ Operations Manual

Policy #: 15.2
Original
; Revision:
August 2013
Page 11 of
11
Title: Medication Use in Outpatient Care Areas


Appendix F: Expectations to workflow

Exceptions to Policy 15.2
for Medications Administered Clinic
06/2012

1. Bevacizumab at U-Station
a. Unit doses are drawn up weekly by central pharmacy and delivered to U-Station outpatient
pharmacy
b. For scheduled/routine injections
i. Paper orders will be sent to infusion center 3-5 days prior to appointment
ii. Orders are entered by infusion center pharmacist after insurance review
iii. Labels print at U-Station pharmacy
iv. Unit doses are dispensed from U-Station retail pharmacy
v. Staff from Ophthalmology clinic will pick up every morning
vi. This staff will reconcile injections received with schedule for day and call the infusion
center pharmacist with any missing doses
c. If the injection is not given
i. The clinic staff will fax a list to the infusion center indicating which injections were not
given
ii. The infusion center pharmacist to credit the doses not given
iii. The clinic staff will leave the list of injections not given in the refrigerator for the clinic
technician
iv. The clinic technician will return unused syringes to the pharmacy
d. For emergent/non-planned injections
i. Day-off dispensing workflow will be followed (same as all other clinics)
2. Omalizumab at East and West Allergy clinics
a. Paper orders are faxed to infusion center pharmacist prior to patient’s appointment
b. Orders are entered by infusion center pharmacist after insurance review
c. Labels print in a batch each day at outpatient pharmacies
d. Vials and closed system devices are dispensed from the outpatient clinic pharmacies
i. This is usually done by the clinic technician the day before they are needed in clinic
e. Clinic staff pick up all the orders for the day in the morning
f. Nurses reconstitute vials in clinic using closed system device when patient arrives
3. Thyrogen at West
a. Paper orders are faxed to infusion center pharmacist prior to patient’s appointment
b. Orders are entered by infusion center pharmacist after insurance review
c. Labels will print at West retail pharmacy
d. Unit doses are dispensed from West retail pharmacy
e. Either staff from the clinic will pick up from the pharmacy or the clinic technician will deliver to
the clinics the day before the dose is due
4. Leuprolide Kits
a. Due to the unique reconstitution apparatus in the kit, despite this medication being on the
hazardous list, the kits will be dispensed to the clinics and nurses will mix kits in clinic