Medication Prescribing Error Reporting and Prevention Program: A 14-Year Experience

Table 1.  Examples of Processes Implemented at Albany Medical Center To Reduce Risk of Adverse Events Due To Prescribing and Other Medication Errors

Process/Program	Medication-Use Issue "Targeted" by Process	Program Description
Medication-Use Quality Improvement Team	Leadership and oversight responsibility for all aspects of medication use within medical center.	Multidisciplinary team reviews all Formulary decisions for issues related to safety/optimal medication use. Reviews all policies, procedures, protocols, pathways for patient safety issues. Reviews all medication errors, adverse drug reaction reports. Initiates/implements appropriate medication system changes.
AMC Formulary Process	Safety issues related to all medications considered in evaluation of medications within medical center.	Formulary decision may include, restrictions on uses, restrictions on site of use, monitoring requirements, required use of protocols, pathways and order sheets, special labeling, standardized preparation and administration, etc.
AMC Printed/Electronic Formulary Information	Availability of information on appropriate medication use Standardization of medication use Reference to all relevant AMC policies, procedures, protocols, pathways.	Formulary written as an "action-oriented" drug information source and medication use guide, with specific recommendations for care giver actions (see renal drug dosing, food-drug and drug-drug interaction, programs below as examples). Includes special warnings and recommendations related to reducing risk to patients. Provides process to standardize and limit variability in care (eg, prescribing restrictions, available drug formulations, drug preparation, drug administration, monitoring, patient education, etc.) Each drug monograph includes cross reference to all relevant order sheets, protocols, policies, and procedures. Formulary available in print and electronic form (intranet) to all prescribers and nursing staff. See Appendix 2 for sample monographs
Centralized pharmacist deployment	Consistency of order review, improved use of RPh expertise, improved communication between pharmacist and other caregivers.	Centralized pharmacists are assigned to review all orders, provide drug information, problem resolution, communication, etc. with a consistent "set" of patient care units. Unit telephones programmed to dial directly to assigned pharmacist.
Standardized order sheets	Improved prescribing, improved pharmacist order review, improved relevant information exchange, standardization.	Order sheets available for antimicrobials (1981), adult, pediatric, and neonate TPN (1987-1989), chemotherapy (1987), CAPD (1994).
Multidisciplinary pre-printed protocols	Consistent, accurate, and complete medication ordering, dispensing/preparation administration and monitoring. Reduces need for reliance on individual performance. Reduces variability.	Protocols developed by multidisciplinary groups. Developed based on consensus evidence-based best practices. Defines and standardizes ordering, administration, dispensing and administration. Protocols are used for specific medications (IVIG, ibutilide), specific therapies (TPN, high dose methylprednisolone in spinal cord injury), nursing procedures, common medical conditions/surgical procedures. Over 150 protocols in effect. (See Appendix 3 for example).
Adult critical care drug standards	Reduce risk for error by standardization of critical care drug ordering, administration, and preparation.	Critical care drug dosing, preparation, administration and monitoring requirements are defined and standardized. IV Pump rate guides provided. (See Appendix 4 for sample guidelines.)
Pediatric critical care drug standards	Reduce risk for error by standardization of critical care drug ordering, administration, and preparation. Eliminate need for dose and preparation calculations.	Similar to above-described adult program. Utilizes color-coded weight-based standard concentrations. Physicians order only "mg per kilogram" dose, pharmacy computer order entry, drug preparation and pump setting guideline pre-determined based on patient weight. (See Appendix 5 for sample guidelines.)
Pediatric "mg/kg" dosing requirements	Reduce dosing errors in pediatrics	All orders for pediatric patients must be accompanied by a weight-based equation used to determine the dose. Standard dosing recommendations provided in AMC Formulary. All doses and dose equations checked by pharmacist.
Renal dosing recommendations	Reduce dosing errors related failure to adjust for renal impairment.	Standardized dose renal dose adjustment recommendations provided in AMC Formulary. Pharmacist checks doses of all primarily renally excreted drugs based on calculated creatinine clearance.
Surgical prophylaxis process	Ordering, administration, and documentation of antibiotic surgical prophylaxis.	Antibiotic surgical prophylaxis included on protocol (see above) for surgical procedures. Pre-admission screening orders prophylaxis based on established standards. Process and responsibility for administration and documentation in OR holding area or suite clearly defined.
Food-drug interaction	Reduce patient risk of important food-drug interaction or dose timing	Important food-drug interactions identified. Colored sticker (identical to/similar to those used on prescription vials sent with drug) to be placed in med administration record as alert to RN when administering and as prompt to counsel patient.
Drug-drug interaction program	Reduce patient risk of important drug-drug interaction.	Pharmacy computer alerts prompt pharmacist to review list of drug-drug interaction for recommended action: Contraindicated interaction -- do not dispense, call prescriber Usually contraindicated/immediate onset -- dispense only in specific conditions after confirmation with prescriber. Provide written information sheet. Relative contraindication/delayed onset -- send written information for inclusion in medical record.
HIV drug order reviews	Reduce risk for errors with HIV drug regimens.	Clinical pharmacist provides secondary review of all orders for antiretrovirals and HIV-related therapies.
Pharmacy operating procedures	Reduce risk to patients by reducing allowable variability of drug ordering and administration.	Pharmacy limits and standardizes drug availability and preparation procedures. These limitations are listed in the Formulary, in protocols or controlled internally by the pharmacy. This, in turn, reduces options for prescribers when ordering, standardizes pharmacy computer entry and preparation, and standardizes administration by nursing staff. Pharmacy processes continually reviewed for improvement opportunities based on analysis of errors documented by error reporting processes.
"STAT" line	Facilitate order review by pharmacist in medically urgent situations and reduce need for floor stock	Dedicated phone line to assigned pharmacist; facilitates rapid but controlled and standardized order review and drug preparation for urgently needed drugs at any site and at any time.
Pharmacy "auto-correction" of common prescribing errors	Standardize and improve efficiency of pharmacist activities in error prevention.	Pre-approved list of common prescribing errors and problems (dosage form errors, dosing errors, etc.) allow pharmacist to write standardized order to correct problem without needing to contact prescriber.
Pharmacist education program	Error detection awareness and skills of pharmacists.	Ongoing feedback and discussion of errors documented by program provided to staff. System changes and individual actions to reduce future risk developed and implemented based on staff input and expertise.

Authors and Disclosures

Timothy S. Lesar, PharmD, is Director of Pharmacy, Albany Medical Center, Albany, New York.

 

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Appendix 1

Prescribing Error Data Collection Form

Timothy Lesar, PharmD

Albany Medical Center

Albany, New York

Goals:

1. Improved understanding of the frequency/nature of medication prescribing errors.

2. Development of improved error prevention processes.

Objectives:

Standardize the collection and evaluation of medication prescribing errors through the use of a standard data collection form and data set.

Definitions:

1. A "clinically significant" medication prescribing error is defined as any error in the prescribing of a medication which:

   1. Has a reasonable chance of being "carried out" within the institution.

   2. Has a reasonable chance of producing an adverse patient outcome (reduced efficacy or adverse effect no matter how minor) if the order is carried out.

2. "Error type" is defined as the end result if the error is carried out (eg, overdose, allergy, drug interaction).

3. "Contributing factor" is defined as the apparent cause or factor that contributes to the occurrence of the error (eg, use of abbreviations, use of dose calculations, failure to account for patient characteristics such as renal impairment).

Identification of contributing factors is necessary to design appropriate error- prevention strategies. Further levels of inquiry (such as "why/how does the contributing factor increase the risk for error?") may be necessary to better understand specific errors and design error prevention strategies.

Process:

1. Each institution develops a method for collecting corrected prescribing errors

2. Each institution trains RPh on data collection

3. Each institution assigns an individual to be responsible for data abstraction

4. Each confirmed (i.e., prescriber agrees order is in error and corrects) prescribing error is abstracted using the standard data collection form by the responsible individual.

5. Summary/analysis of data completed and reported to appropriate staff and committees.

Completing the Data Collection Form

1. Complete one form for each error. If more than one error is present in a order, complete a form for each error

2. Use appropriate data formats and codes

3. In text sections, use concise statements and abbreviations. Usually best to start with name of drug so that data field is more "sortable" -- (example- "ampicillin ordered in pcn allergic pt")

4. Drug class: when more than one drug class is involved, put code of class most likely to produce an adverse event as "Drug #1".

5. "Contributing factors" often require judgement. More than one contributing factor may be present. Code the most likely contributor as "Factor #1".

6. The second page of the contributing causes helps to specify contributing factors which will help identify potential targets for prevention initiatives.

References:

Lesar TS, Lomaestro BM, Pohl H. Medication prescribing errors in a teaching hospital. A nine-year experience. Arch Intern Med. 1997;157:1569-1576.

Lesar TS, Briceland L, Stein D. Factors related to medication prescribing errors. JAMA. 1997;277:312-317.

Lesar TS. Errors in the use of medication dosage equations. Arch Pediatr Adolesc Med. 1998;152:340-344.

Prescribing Error Data Collection Form

Hospital_____________________________________________________________

Data Element	Data	Standard Codes/Description
Date (day-month-year)
Time (military time)
Error file # (numeric)
Prescriber (coded numeric)
Service (standard codes)		Med, Surg, Peds, ED
Pharmacist (coded numeric
Problem (short text)		Short summary of problem such as "gentamicin q8 in renal imp., 70 yo pt"
Resolution (short text)		Short summary of resolution such as "change to q24h"
Drug Class (standard codes)	Drug #1__________ Drug #2__________ Drug #3__________	A = antimicrobials AC = anticoagulants AD = antidepressants AP= antipsychotics AH = antihistamine B = benzodiazepines/sedative/hypnotics BD = blood derivative/biological C = cardiovascular CC = cough and cold CH = chemotherapy CS = corticosteroids D = anti-diabetic agents DM = dermatologic DU = diuretics E = antiemetics EL = electrolytes G = gastrointestinal H = hormonal HM = hematologic MV = minerals /vitamins N = narcotics NN = non-narcotic analgesics/antinflamm O = ophthalmic OT = other P = parkinsonian PS = various psychiatric RI = respiratory inhaled RS = respiratory systemic S = anti-seizure agents V = vaccine
Error Type (standard codes)	Type___________	OD = overdose / over-duration UD = underdose All = allergy to drug Dup = duplicated drug therapy WD = wrong drug WR = wrong route DF = wrong dose form WP = wrong patient Misc = other errors
Contributing Factor (standard code) (see references)	Factor#1__________ Factor #2_________ Factlor#3_________	PC = pt characteristic related DT = drug therapy related DF = dose form related NOM = nomenclature related CALC = calculation / dose unit /decimal SYS = care system related
Potential severity (standard code)	Severity_________	A = fatal or severe toxicity, failure B = serious toxicity, failure C = any potential for adverse effect
Comments (short text)

Contributing Cause	Check all that apply to error	Example
Patient Characteristic Related
Renal impairment		Gentamicin q8h in patient with Cr = 1.9
Hepatic Impairment		Triazolam 0.25mg in patient with cirrhosis
Age		Tobramycin 100 q8h in 95 year old
Weight		Tobramycin 80mg in 130kg patient
Drug interaction		Erythro started on patient on carbamazepine
Allergy same class		Amp ordered on penicillin allergic patient
Allergy related class		Cefazolin ordered on patient with pcn anaphylaxis
No indication		Misoprostil for patient not on NSAIDs
Contraindication		Enalapril for potentially pregnant patient
Wrong patient		Drug ordered on wrong patient
History taking		Cisapride 50mg qid ordered per patient hx
Other
Drug Therapy related
Therapeutic treatment duration		Azithro for 10 days
Toxicity treatment duration		Colchicine 1mg IV q6 h without stop
Therapeutic dose frequency		Levofloxacin 250mg bid instead of 500 qd
Toxicity dose frequency		Methotrexate qd instead of qweek for RA
Wrong drug, same class		Clarithro ordered instead of azith for patient on cisapride
Wrong route		Betamethasone IV
Failure to adjust for route		Labetolol 300mg IV
Unusual route		Tobra ordered 300IV q12h instead of nebs
Unusual therapy		Erythro 500mg qid for GI motility instead of 250 tid to start
Failure to appreciate combination components		Percodan ordered for patient with ulcer
Drug interaction		Cisapride ordered for patient on nefazodone
Other
Dosage Form
Wrong form for intended use		Aqueous PCN for strep throat
Wrong frequency for form		Morphine liquid q12h
Wrong form for route		MS Contin PT
Other
Nomenclature related
Brand name lacking suffix		Procardia 60 qd
Generic- no dose form specified		Nifedipine 60 qd
Sound-alikes		Albuterol instead if Atrovent
Abbreviations for frequency		Procardia XL 90mg qid instead of qd
Abbreviations for route		Bisacodyl PT instead of PR
Abbreviations for drug		HCTZ for hydrocortisone
Failure to appreciate components of combinations		Unasyn ordered for patient with penicillin allergy
Other
Calculation/ unit/dose expression
Calculation		Errant mathematical solution
Decimal point		Levothyroxine 0.25mg instead of 0.025mg
Unit of measure		Tablespoonfuls instead of teaspoonfuls
Dose rate expression		Vasopressin 0.4units/h instead of per min
Other
Administrative processes		Errors when renewing orders
Other

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Appendix 2. Sample Formulary Monographs

COLCHICINE

Forms available:

Tablet: 0.5mg, 0.6mg; Injection: 1mg.

Uses: An anti-gout agent used in the treatment of acute gouty arthritis and in the prophylaxis of gouty arthritis.

Contraindications: Severe renal, hepatic or cardiac disorders. Hypersensitivity to colchicine.

Precautions: Systemic toxicity is dose dependent. Do not exceed a max total dose of 6mg PO or 2mg (4mg previously recommended as max) IV for any one attack. Fatalities have been reported after total cumulative doses of 5-7mg (IV). Use with caution in elderly, debilitated, wasted patients, and in patients with mild-moderate liver, renal or hematologic disease. INTRAVENOUS COLCHICINE IS POTENTIALLY HIGHLY TOXIC AND MUST BE USED WITH CAUTION.

Usual dose: ORAL, ACUTE GOUTY ATTACK:
Adults: 0.5-0.6mg PO q1h (orders for less frequent dosing will not be honored) until one of the following happens: 1. pain is relieved; 2. a max PO dose of 2-3mg is administered in the first 24h; 3. a max cumulative PO dose of 6mg is reached over 1-2days for one treatment course; or 4. nausea, vomiting or diarrhea occur. For elderly, debilitated patients with reduced muscle mass, or patients with renal, liver or hematologic disorders, total PO dose should not exceed 3mg per treatment course.

ORAL, PROPHYLAXIS:
Adults: 0.5-0.6mg q12-24h or every other day depending upon frequency of attacks. For elderly, debilitated patients or patients with renal, liver or hematologic disorders, 0.5mg once daily or every other day is the max recommended dose for IV doses max of 1-2mg max per treatment course.

INTRAVENOUS, ACUTE GOUTY ATTACK:
Adults: 1-2mg IV once (max dose of 2mg total for any one treatment course). One to two weeks should elapse before repeating max dosing recommendations. 1-2mg total (see above).

Common adverse effects: Nausea, vomiting, abdominal pain and diarrhea occur commonly with PO colchicine, but are uncommon with IV doses. Other reactions include rash, neuropathy, myopathy, tissue injury from extravasation, alopecia, renal toxicity. Significant and potentially fatal bone toxicity may occur at higher doses and in patients with stated precautions.

Nursing implications: Administer IV colchicine over 20-30min. Give PO tablets with food or milk.

INSULINS (see individual monographs below)

Table. Insulin Preparations: Kinetics and Compatibilities

Insulin Preparations1		Onset (h)	Peak (h)	Duration (h)	Compatible mixed with
Ultra Rapid-Acting	Insulin Lispro Injection	5 min	0.25-0.5	1	All2
Rapid-Acting	Insulin Injection (Regular) Prompt Insulin Zinc Suspension (Semilente)	0.5-1 1-1.5	1-2 5-10	6-8 12-16	All2 Lente
Intermediate Acting	Isophane Insulin Suspension Insulin Zinc Suspension (Lente)	1-1.5 1-2.5	4-12 7-15	24 24	Regular Regular2, semilente
Long-Acting	Protamine Zinc Insulin Suspension (PZI) Extended Insulin Zinc Suspension (Ultralente)	4-8 4-8	14-24 10-30	36 >30	Regular Regular, semilente

1. AMC carries only recombinant human insulins (Novolin^®, Humulin^®, Humalog^®).

2. Combinations of Lente and Regular Insulins should be used immediately.

INSULIN, HUMAN - Regular, NPH, Lente, mixtures (Humulin^® , Novolin^® )

Forms available: U-100: Regular, NPH, Lente, 70NPH/30 regular. AMCH pharmacy provides Regular insulin as 1 unit/ml to neonates.

Uses: Treatment of diabetes mellitus. Treatment of severe hyperkalemia.

Precautions: Use only regular insulin for IV administration. Monitor dose changes carefully. Neonates are extremely sensitive to insulin, start low and titrate.

Usual Dose: When ordering: NEVER USE "u" TO ABBREVIATE UNITS

ALWAYS PRECEDE A DECIMAL POINT WITH A ZERO (i.e.:0.5 units, not .5u)

NEVER FOLLOW A DECIMAL POINT WITH A ZERO (i.e.: 5 units, not 5.0u)

DIABETES MELLITUS: Dose will vary depending on response. Neonates: See Neonatal/Pediatric Critical Care Drug Guidelines in orange section of formulary. Children/Adults: 5-10units of regular insulin SC initially, then 1-4 units SC of regular insulin before meals and at hs. For NPH or lente insulin, initial dose is usually 7-25 units SC before breakfast with adjustments of 2-10 units SC made on a daily-weekly basis. Combinations of rapid and intermediate acting insulins and multiple daily injections may be required to adequately control blood glucose. Sliding scale insulin dosing may be used in acute transitional periods or during hospitalization.

DIABETIC KETOACIDOSIS: See Neonatal/Pediatric or Adult Critical Care Dosing Guidelines in the orange section of the formulary for continuous infusion. 

HYPERKALEMIA: Children: 0.1units/kg IV with 2ml/kg D25W over 30min (repeat in 30-60min) or infusion of D25W 1-2ml/kg/h with 0.1 units insulin /kg/h. Adults: Symptomatic Hyperkalemia (arrhythmias on EKG): Calcium Gluconate 1g rapid IV over 1-3 minutes (contraindicated in patients with digoxin toxicity or severe coronary artery disease).

Sodium bicarbonate (reserved for patients with severe metabolic acidosis, pH <7.2) 50mEq over 5 minutes.

Insulin 5-10 Units IV with 50ml dextrose 50% rapid IV push (dextrose is not necessary if it is known that the patient is already hyperglycemic). Start a dextrose 10% infusion after initial insulin dose to prevent late hypoglycemia.

Asymptomatic Hyperkalemia: Sodium polystyrene/kayexalate 30-60g PO for 1-2 doses (followed by repeat potassium levels at 4-6 hour intervals), calcium gluconate, sodium bicarbonate, and insulin are not necessary.

Common adverse effects: Hypoglycemia: symptoms include hunger, pallor, sweating, confusion, nausea, palpitations, paresthesias, tremors, weakness, loss of consciousness. Local reactions include itching, redness, swelling, hypertrophy or atrophy of fat.

Critical drug interactions: Beta blockers may mask hypoglycemia symptoms. Thiazide diuretics and furosemide may antagonize the effects of insulin. Alcohol, anabolic steroids, salicylates and MAOI may increase the hypoglycemic effects of insulin.

Monitoring: Glucose (hourly if continuous infusion used to treat hyperkalemia) otherwise per protocol. Level I, II, or III monitoring required. Monitor carefully for signs of hypoglycemia.

Nursing implications: Do not shake insulins. Do not inject cold insulin. Refer to Adult Capillary Glucose/Hypoglycemic Order, Hypoglycemia Orders for Non-Pregnant Adults, Emergent DKA Management Protocol.

INSULIN, LISPRO (Humalog^® )

Forms available: U-100: ultra-rapid acting regular insulin (See insulin monograph for kinetic and compatibility information regarding insulins).

Uses: Treatment of diabetes mellitus. Rapidly absorbed insulin - time administration just prior to meals. DO NOT USE AS PART OF A SLIDING SCALE REGIMEN OR FOR THE MANAGEMENT OF DKA (see Insulin, Human).

Precautions: Monitor dose changes carefully. Use with caution in settings of inconsistent or delayed glucose or food absorption, such as patients with gastroparesis or currently taking acarbose. If patient has insulin "allergy", conversion to insulin, lispro will not be useful unless insulin desensitization is also done.

Usual Dose: When ordering: NEVER use "u" TO ABBREVIATE UNITS ALWAYS PRECEDE A DECIMAL POINT WITH A ZERO (i.e. 0.5 units, not .5u). NEVER FOLLOW A DECIMAL POINT WITH A ZERO (i.e., 5 units, not 5.0 units).

DIABETES MELLITUS: Dose will vary depending on response. Neonates: not recommended. Children/Adults: Insulin, lispro and insulin, human regular are equipotent on a molar basis. Individualize dose to patient.

Common adverse effects: See under "Insulin, Human" monograph.

Critical drug interactions: See under "Insulin, Human" monograph. Acarbose may potentiate hypoglycemia of insulin, lispro.

Nursing implications: Do not shake insulins. Do not inject cold insulin. Patients must eat within 15 min after administration of insulin, lispro to avoid hypoglycemia. If mixed with a long-acting insulin, insulin, lispro should be drawn into the syringe first. Observe closely for signs of hypoglycemia.

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Appendix 3. Sample Protocol

Albany Medical Center
Physicians Order Sheet
Dependent Protocol

Instructions:

 

1. Imprint patient name plate prior to placing in chart

2. Order must be dated. Timed and signed by the ordering credentialed prescriber

3. Check appropriate boxes

4. Provide weight and height

5. Fax to pharmacy

 

Acute Spinal Cord Injury

Supportive data: High dose IV methylprednisolone improves 6-month outcomes of patients with acute spinal cord injury treated within 8 hours of injury. Patients treated within 3 hours of injury should be maintained on therapy for a total of 24 hours, those initiating treatment between 3 and 8 hours should be maintained on therapy for 48 hours. Significant increased risk for sepsis and pneumonia exists with treatment, this risk increases with increasing duration of therapy. ( NACSIS trials - JAMA 997;277:1597-1604)

 

1. Admit to______________________________________________________

2. Diagnosis:_____________________________________________________

3. Service:     Orthopedics     Neurosurgery     Other:__________________

4. IV Fluids- D5/LR at 100ml/h

5. NPO

6. Labs: ED: CBC, PT, PTT, Profile II, type and screen
   Additional labs:______________________________________________

7. Vital signs with oxygen saturation q2h for 24h and then q4h

8. Neuromuscular assessment q2h (Spinal Cord Neurological Assessment Sheet)

9. Oxygen 2 liters NC, if saturation less than 92% on room air.

10. Compression stockings and sequential compression device.

11. Mobility: Bedrest -- remove back board ASAP.

    ____ Log roll q2h

    ____ Maintain flat for _________ h

    ____ Soft cervical collar

    ____ Hard Philadelphia Collar

    ____ Cervical traction _______________________ lbs. Pin Care- _ strength hydrogen peroxide (diluted with normal saline) TID

    ____ Roto Rest therapy- initiate 15 degrees each site and advance to 45 degrees as tolerated.

    ____ Other:__________________________________________________

12. Medications:

    ____ Spinal cord bowel regimen (docusate 100mg tid, senna 2 tabs daily, docusate/benzocaine minienema (Therevac^®) 1pr daily, lidocaine jelly 2% as needed)

    ____ Thromboembolism prevention:

    ____ Heparin 5000 units SQ q12h

    ____ Other:__________________________________________________

    ____ Cimetidine 300mg IV q8h until taking po, then nizatidine 150mg PO bid

    ____ Methylprednisolone (see below for dosing table and pharmacy preparation)

    1. Patient weight: _________kg

    2. Administer methylprednisolone as follows:

       ____ Methylprednisolone IV loading dose: 30mg/kg IV = _________________mg (rounded per table below)
       Provided by pharmacy as a minibag to be administered over 15 minutes

       ____ 45 minutes after completion of loading dose, initiate continuous IV Infusion:
       5.4mg/kg/hour = __________mg/hr (rounded per reference table below).

       Continue infusion for:

       ____ 23 hours (24 hour total therapy)

       ____ 47 hours (48 hours total therapy)

    3. Flush tubing with 20ml NS when continuous infusion complete

 

____ Morphine sulfate _____________ mg IV q2h as needed for severe pain

____ Oxycodone 5mg and acetaminophen 325mg, (Percocet^®) 1-2 tablets q4h PO as needed for moderate pain when taking

____ Diazepam 5mg po/IV q6h as needed for spasm

____ Other:____________________________________________

____ _________________________________________________

____ _________________________________________________

____ _________________________________________________

Pharmacy to supply methylprednisolone as follows:

 

• Methylprednisolone IV continuous infusion bag: a 24 hour supply of drug in total volume of 480ml..

• The first maintenance bag is to be infused at 20ml per hour for a total of 23 hours (SOME OVERFILL WILL BE LEFT IN BAG).

• If 47-hour infusion ordered, a second identical 480ml bag will be provided to be infused at 20ml per hour for an additional 24 hours.

 

Patient Weight Kg	Loading Dose: 30mg/kg infused over 15 minutes	Infusion Dose: 5.4mg/kg hour starting 45minutes after completion of loading dose.	Total drug in infusion bag 24h
38-42	1.25.g	219mg/h	5.25g
43-47	1.25g	240mg/h	5.75g
48-52	1.5g	271mg/h	6.5g
53-57	1.75g	302mg/h	7.25g
58-62	1.75g	323mg/h	7.75g
63-67	2.g	354mg/h	8.5g
68-72	2g	375mg/h	9g
73-77	2.25g	406mg/h	9.75g
78-82	2.5g	427mg/h	10.25g
83-87	2.5g	458mg/h	11g
89-92	2.75g	490mg/h	11.75g
93-97	2.75g	510mg/h	12.25g
98-102	3g	542mg/h	13g
103-107	3.25g	573mg/h	13.75g
108-112	3.25g	594mg/h	14.25g
113-117	3.5g	625mg/h	15g
118-122	3.5g	646mg/h	15.5g
123-127	3.75g	677mg/h	16.25g
128-132	4g	698mg/h	16.75g
133-137	4g	729mg/h	17.5g
138-142	4.25g	760mg/h	18.25g
143-147	4.5g	781mg/h	18.75g
148-152	4.5g	813mg/h	19.5g

TL/W IV methylprednisolone20

Date Time Prescriber    

Printed name/stamp _______________

Signature _________________

pager __________________

Sidebar

Appendix 4

Albany Medical Center Department of Pharmacy

High Dose Methylprednisolone for Spinal Cord Injury

Drug Preparation Guide:

 

• Bolus dose provided as a minibag to be infused over 15 minutes.

• Infusion dose provided as total 24 hour dose in a total of 480ml to be infused at a rate of 20ml/hour in all patients.

 

Bolus Dose			Infusion Dose in Total of 480 ml
Patient Weight Kg	Loading Dose: 30mg/kg infused over 15 minutes	Volume of MP solution for load	Infusion Dose: 5.4mg/kg hour starting 45minutes after completion of loading dose.	Total drug in infusion bag 24h	Volume of MP solution (1g/15ml)	Volume of D5W to QS to 480ml
38-42	1.25.g	18.8ml	219mg/h	5.25g	79	401
43-47	1.25g	18.8ml	240mg/h	5.75g	86	394
48-52	1.5g	22.5ml	271mg/h	6.5g	98	382
53-57	1.75g	26.3ml	302mg/h	7.25g	109	371
58-62	1.75g	26.3ml	323mg/h	7.75g	116	364
63-67	2.g	30ml	354mg/h	8.5g	128	352
68-72	2g	30ml	375mg/h	9g	135	345
73-77	2.25g	33.8	406mg/h	9.75g	146	334
78-82	2.5g	37.5	427mg/h	10.25	154	326
83-87	2.5g	37.5	458mg/h	11g	165	315
89-92	2.75g	41.3	490mg/h	11.75g	176	304
93-97	2.75g	41.3	510mg/h	12.25g	184	296
98-102	3g	45	542mg/h	13g	195	285
103-107	3g	45	573mg/h	13.75g	206	274
108-112	3.25g	48.8	594mg/h	14.25g	214	266
113-117	3.5g	52.5	625mg/h	15g	225	255
118-122	3.5g	52.5	646mg/h	15.5g	233	247
123-127	3.75g	56.3	677mg/h	16.25g	244	236
128-132	4.g	60	698mg/h	16.75	251	229
133-137	4g	60	729mg/h	17.5g	263	217
138-142	4.25g	63.8	760mg/h	18.25	274	206
143-147	4.25g	63.8	781mg/h	18.75g	281	199
148-152	4.5	67.5	813mg/h	19.5g	293	187