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Ambulatory Care Pharmacy Update, Vol. 2 Spring 2015

Ambulatory Care Pharmacy Update, Vol. 2 Spring 2015

If you have an item you would like included in an upcoming newsletter, please email Jeanette Cavano at Jeanette.cavano@sfdph.org.

Vaccine Safety

According to the World Health Organization, adverse events due to vaccine errors are more common that adverse events due to the vaccines themselves. In 2012, the Institute for Safe Medication Practices (ISMP) partnered with the California Department of Public Health to develop the ISMP National Vaccine Errors Reporting Program (VERP), the only vaccine error-reporting program in the U.S. Below is a summary of contributing factors in vaccine errors identified through the VERP over a two year period, and some recommendations for ways to reduce the risk of such errors.

Type of Error Suggestions to Prevent
Error with age-specific formulation
  • Ask for patient’s birth date, verify age and review medical record
  • Affix warning labels to draw attention to vaccines with different age-specific formulations
Wrong patient errors due to confusion with siblings
  • Structure appts to vaccinate one patient at a time
  • Only bring one patient’s vaccines into the treatment area at a time
  • Verify patient’s identity using name and date of birth
Invalid doses (given too soon) or missed opportunities to vaccinate
  • Review medical record for current immunization status
  • Locate missing vaccination records from previous providers
  • Post up-to-date, easy-to-read immunization schedules for staff and patients
  • Establish standard order sets
Wrong route errors
  • Post a quick reference for clinicians to verify route
  • Highlight or affix auxiliary labels to identify vaccines prone to wrong route errors: influenza, rotavirus, MMR, varicella
Errors with combination vaccines or those with diluents
  • Only use diluents supplied by the manufacturer
  • Clearly label or distinguish vaccines with diluents
  • Keep two-component vaccines together if storage requirements do not differ
Wrong vaccine errors related to nomenclature
  • Circle or highlight brand names on packages for those vaccines with long generic names
  • Prescribe vaccines with look-alike generic names by using brand names
  • If abbreviations are permitted, only use CDC-approved abbreviations
  • Prohibit coined or informal names
Wrong vaccine and dose errors related to labeling and packaging
  • Store vaccines with similar packaging on different refrigerator or freezer shelves
  • Unless vaccine is prepared in front of the patient and administered immediately, vaccines prepared in syringes must be labeled
Errors related to unsafe vaccine storage
  • Never store different vaccines in the same containers
  • Do not store vaccines with similar labels, names, abbreviations or overlapping components (e.g., dTap, TDap, DT, Td) immediately next to each other on the same shelf
  • Separate storage areas for pediatric and adult vaccines
Administration of an expired drug
  • Check expiration dates weekly
  • Remove/sequester expired vaccines from areas where viable vaccines are storedIf an expired vaccine is administered in error, revaccination with a valid dose is advised
Involve the patient in the verification process
  • Provide patients, parents, or legal guardians with a VIS in their native language
  • The VIS should not substitute for direct communication about risks and benefits of vaccination
  • Ask the patient or caregiver to participate in the process of verification to ensure the patient is within the specific ages intended for the vaccine and by comparing the vaccine name to that on the VIS
Based on Acute Care ISMP Medication Safety Alert! March 26, 2015 Vol. 20 Issue 6

Adult Pneumococcal Vaccination Recommendations

You may have heard that the Advisory Committee on Immunization Practices updated recommendations for pneumococcal vaccination last August. They now recommend routine use of 13-valent pneumococcal conjugate vaccine (Prevnar 13) among adults aged 65 and older. Additionally, ACIP has recommended administration of Prevnar 13 for adults age 19 and older with immunocompromising conditions, CSF leaks, cochlear implants or functional or anatomic asplenia.

Simple, right?

Here’s a table to help you remember who should receive the Prevnar 13 and on the next page is a diagram of the order for vaccine administration.

Note: if Pneumococcal vaccine naïve, PCV13 should be administered first.

Risk group Underlying medical condition Recommended Recommended Administer second dose after 5 years
Immunocompetent Chronic heart disease
Chronic lung disease§
Diabetes mellitus
Cerebrospinal fluid leak
Cochlear implant
Chronic liver disease, cirrhosis
Cigarette smoking
Functional or anatomic asplenia Sickle cell disease other hemaglobinopathyCongenital or acquired asplenia
Immunocompromised Congenital or acquired immunodeficiency
Chronic renal failure
Nephrotic syndrome
Hodgkin disease
Generalized malignancy
Iatrogenic immunosuppression*
Solid organ transplant
Multiple myeloma
Risk group Underlying medical condition Recommended Recommended
Age ≥ 65 years N/A
Includes congestive heart failure and cardiomyopathies, excludes hypertension
§Includes chronic obstructive pulmonary disease, emphysema, and asthma.
Includes B- (humoral) or T-lymphocyte deficiency, complement deficiencies, and phagocytic disorders (except chronic granulomatous disease).
*Diseases requiring treatment with immunosuppressive drugs, including long-term systemic corticosteroids and radiation therapy.

Dose Timing

  • PCV13: administer before PPSV23 in vaccine-naïve patients; give at least one year after previous PPSV23 doses.
  • PPSV23: give at least 8 weeks after PCV13 (optimally 6 to 12 months apart in age ≥65 group). One dose of PPSV23 is recommended for those >65. If vaccinated before age 65, wait at least 5 years from last dose to revaccinate.

Co-administration with Other Vaccines

  • PCV13 & PPSV23 should NOT be co-administered. Co-administration of PCV13 & inactivated influenza are considered immunogenic & safe; however, the MMWR cites a randomized study that found slightly lower immunogenicity with both PCV13 & inactivated influenza vaccines when administered concomitantly in adults ≥65 years old compared to either vaccine given alone. No data are currently available on co-administration of PCV13 with any other adult vaccines.
Adapted from MMWR/ October 12, 2012/ Vol. 61/ No. 40 & MMWR/ September 19, 2014/ Vol. 63/ No. 37. With input from Camille Beauduy, PharmD, SFGH Infectious Disease Clinical Pharmacist

Pneumococcal Vaccine Timing

Pharmacy Graphic Newsletter Spring 2015

For more information, please visit EZIZ.

Measles Vaccine Reminders

AccoVaccine picturerding to the CDC, between January 1 and April 3 of this year, 159 people from 17 states and the district of Columbia were reported to have the measles. Most of these cases are part of a large, ongoing outbreak linked to an amusement park in California. At least 40 people who visited or worked at Disneyland theme park in Orange County in mid-December contracted measles.

Measles is highly contagious and highly preventable through vaccination. Two doses of measles vaccine is more than 97% effective in preventing measles. The California Department of Public Health recommends that anyone not already immunized against measles get immunized.
Who should be vaccinated against measles?

  1. Children should get 2 doses of MMR vaccine:
    • 1st dose at 12 through 15 months of age
    • 2nd dose at 4 years through 6 years of age
    • Children can get the 2nd dose earlier, as long as it is at least 28 days after the first dose].
  2. Students at post-high school educational institutions without evidence of immunity* against measles need two doses of MMR vaccine, with the second dose administered no earlier than 28 days after the first dose.
  3. People born during or after 1957 who do not have evidence of immunity* against measles should get at least one dose of MMR vaccine.

* Evidence of Immunity
You are considered protected from measles if you have at least one of the following:

  • written documentation of adequate vaccination:
    • at least 1 dose of measles-containing vaccine on or after the 1st birthday for preschool-age children and adults not at high risk
    • 2 doses of measles-containing vaccine for school-age children and adults at high risk, including college students, healthcare personnel, and international travelers
    • laboratory evidence of immunity
    • laboratory confirmation of measles
    • birth in the United States before 1957

Procedure for administering MMR in SFHN Primary Care Clinics during 2015 Outbreak

We have been asked by our Communicable Disease Division (and AITC and Erin Bachus) to offer the MMR to a limited number of adult patients who don’t have a usual source of care. The publicized place for the MMR vaccination is the Adult Immunization and Travel Clinic (for adults) at 101 Grove and the Family Health Center (for children 17 and under). But for people who cannot pay the fee, we will offer the MMR at OPHC (Tuesday 9:45-11:45am and Thursdays 1-4pm), MHHC (Monday – Friday 9-10am, M, T, Th, F 1:30-3:30 pm) and SAFHC (Wed 3:30-4:30 beginning 3/11/15) on a Drop-In basis. You will give MMR to your own patients at your site as needed.

For SFHN patients:

  • Register the patient
  • If a woman, screen for pregnancy risk
  • Offer a pregnancy test at time of the visit if the woman is at risk. If positive don’t vaccinate and refer for pre-natal care. If negative explain the risk of getting vaccinated today vs. waiting for a month while abstaining from sex and repeating the UPT. If the UPT is negative and the patient wants to accept the risk today, proceed
  • Have patient review and sign the usual consent MMR form
  • Give the vaccine from 317 Outbreak Vaccine supply
  • Chart IZ and/or UPT visit in eCW (on paper for those clinics not yet on eCW)- RN or designee
  • If a man, same as above but no pregnancy screen

Non-SFHN patients:

Confirm with the person s/he does not have a usual source of care or is not insured or their insurance doesn’t pay for the MMR

  • DO NOT REGISTER the patient or charge them for this visit
  • If a woman, screen for pregnancy risk
  • Offer a pregnancy test at time of the visit if the woman is at risk. If positive don’t vaccinate and refer for enrollment in SFHN or elsewhere and for pre-natal care. If negative explain the risk of getting vaccinated today vs. waiting for a month while abstaining from sex and repeating the PT If the UPT is negative and the patient wants to accept the risk today, proceed.
  • Log patient’s name on 317 Outbreak Response Vaccine Usage Log attached
  • Have patient review and sign MMR consent form
  • Give the vaccine from VFC 317 supply
  • Hold consent forms and log in a retrievable place


SFHN patients:
There is not a recommendation to check measles titers widely. Because most adults living in the U.S. are immune and a positive measles titer is highly correlated with protection, checking a measles IgG before vaccination is reasonable unless administration is very time sensitive (which may be the case in a contact investigation).

Non-SFHN patients:
We will NOT DRAW TITERS on patients who are NOT established SFHN patients. They can receive the vaccine as above.

Additional Information:

There is not a recommendation for booster (MMR) doses. People born before 1957 are considered immune for most purposes. For patients born in or after 1957, it would be reasonable to target the following in order of priority:

  1. People who may have been exposed to a case.
  2. People planning to travel outside the U.S. Import of measles is a key part of recent outbreaks. Travel to Western Europe is also a risk factor.
  3. People who know they were not vaccinated as children or think they may not have received all vaccines. This may apply to those born outside the U.S.

Is that Warfarin still necessary?

Warfarin is a decades old drug that has been proven effective for multiple indications including VTE treatment and prophylaxis, atrial fibrillation, APLS, valve replacements and clotting disorders. However, warfarin’s treatment duration should always be evaluated at every provider visit as warfarin is a high risk medication given its inherent ability to cause bleeding. There are clinical cases where risks may outweigh treatment benefits, and warfarin treatment should be discontinued. The CHEST 2012 guidelines from the American College of Chest Physicians specify the latest recommendations for treatment duration based on indications. We encourage all providers to review the following as a reminder of when to discontinue warfarin therapy:

Indication INR goal Duration
Atrial fibrillation/flutter 2-3 Potentially lifelong
Bioprosthetic aortic valve replacement or repair 2-3 1st 3 months
Bioprosthetic mitral valve replacement or repair 2-3 1st 3 months
Cardioembolic stroke prophylaxis 2-3 Lifelong
Mechanical aortic valve replacement (AVR) 2-3 Lifelong
Mechanical aortic valve replacement (AVR) and risk factors for thromboembolism (AFib, previous thromboembolism, LV dysfunction, or hypercoaguable condition) 2.5-3.5 Lifelong
Mechanical mitral valve replacement (MVR) 2.5-3.5 Lifelong
Mechanical mitral valve replacement (MVR) and risk factors for thromboembolism (AFib, previous thromboembolism, LV dysfunction, or hypercoaguable condition) 2.5-3.5 Lifelong
Venous thromboembolism (1st event): DVT, PE 2-3 Typically 3 months
Venous thromboembolism (>1 event): DVT, PE 2-3 Potentially lifelong
By Shin-Yu Lee, PharmD and Christina S. Wang, PharmD

Understanding Prescription Instructions: Use of UMS and Global Favorites

What does “Take 1 tab daily with meals” mean to you? How about “Take 1 pill twice daily?” What do these directions mean to your patients? Is twice a day morning and evening? Morning and lunchtime? Any two times you happen to remember? In one study at the VA,(1) only 42% of patients described taking a medication correctly according to the directions of the prescriber. Another study found that patients with lower literacy were more likely to overcomplicate their regimens and not consolidate things that could be taken together. Some patients on a 7-drug regimen that could have been consolidated to a four times a day schedule took their medications as many as 14 different times a day!(2)

The Universal Medication Schedule is a methodology that simplifies medication administration instructions for patients and/or their caregivers. The goal of using UMS is to improve patient understanding of and adherence to their medication instructions. UMS instructions provide explicit timing with standard intervals (morning, noon, evening and bedtime). So Take 1 pill daily becomes Take 1 pill in the morning or Take 1 pill at bedtime.

The idea of making prescription instructions clear, simple and explicit is supported by many large organizations, including the National Council for Prescription Drug Programs, the Institute of Medicine, the VA National Center for Patient Safety, the US Pharmacopeia and the FDA. In 2011, the California State Board of Pharmacy adopted regulations promoting the use of UMS language on prescription labels when appropriate. UMS has also been promoted by our own internal experts, including Dean Schillinger, Urmimala Sarkar, and Neda Ratanawongsa. Furthermore, UMS just makes good common sense.

However, wide adoption of this language on prescription labels has been slow to catch on. Pharmacists may be leery about deviating from the exact language on a prescription, technical barriers prevent easy communication of this language across systems (for example from an e-prescribing system into a pharmacy system used to create the label). Electronic health records do not support the use of UMS language well, often requiring prescribers to enter directions as “free text” instead of coded entries, which then prevents the system from being smart enough to calculate needed days’ supply (meaning more “clicks” for the person entering the order—we know how you love extra “clicks!”).

In an attempt to encourage the use of UMS language, the “Take” field in ECW was populated with a series of entries using this language; however, we soon discovered that the field was so small that it was difficult to see the entire entry. This meant prescribers might choose the wrong option, increasing the risk for medication errors. These options have now been removed from ECW.

With tremendous help from Lenny Chan, our ECW Pharmacy Champion, and David Smith, in patient clinical pharmacist, we have created a new solution. A list of “Global Medication Favorites” has been built and will be available for use soon. These are medications commonly prescribed in our system pre-built with standard directions using UMS language. Instructions for how to access and use the “Global Medication Favorites” can be found on the next two pages. Go-live date to be announced very soon.

By choosing to use these options, you can simplify your ordering, no longer having to choose from a long drop-down list of 30 different options to find that one enteric-coated 81 mg aspirin, and these orders are pre-populated with standard directions for use.

We hope you find this a helpful improvement to simplify your prescribing. We also hope it helps your patients understand better how to take their medications. If you are prescribing a medication that is not an option in the global favorites, please do consider writing that prescription with UMS-language directions.


  • Take 1 pill in the morning
  • Take 2 pills at bedtime
  • Take 1 pill in the morning and 2 pills at bedtime
  • Take 1 pill in the morning, 1 pill at noon and 1 pill at bedtime
1. Implementation of a VA patient-centered prescription label. Keith W. Trettin, Erin Narus VA National Center for Patient Safety
2. Wolf MS, et al. Arch Intern Med 2011;171(4):300-305.

Global Medication Favorites

Function: Based on the top 200 drugs dispensed at the SFGH Outpatient Pharmacy, a list of frequently prescribed drugs in primary care has been created, pre-populated with common directions, quantities, and number of refills to improve provider convenience, and quality of prescriptions.

General principle:

  • For chronic meds – 90 day supply and 3 refills
  • For antibiotics (except for prophylaxis) – no refills
  • For CII controlled substances – excluded
  • For CIII-V controlled substances – short duration, no refills
  • Other short-term medications – 30-90 days with 1 refill

Universal Medication Schedule: Multiple studies have demonstrated that patients are more likely to interpret accurately, and demonstrate comprehension of prescription direction in UMS instructions versus the current standard, particularly in lower literate and limited English-speaking patients. It can reduce the risk of adverse drug events, which lead to approximately 4.5 million ambulatory visits each year. The Global Medication Favorites have incorporated UMS language where it is applicable.

How: To prescribe, go to the Treatment window, and select Add.

eCW screenshot adding medicatin favorites

Select the database you want to search by selecting Standard, My Favorites, or Both.

  • Standard: search only the Standard Medispan database in CareLinkSF (1)
  • My Favorites: search only the Global Medication Favorites, and any personal medication favorites you have created (2)
  • Both: search both database (3)
  • Using the Find box, search for the drug by name

eCW screenshot adding medicatin favorites 2

The Take field often is not long enough to display the complete direction. When it is the case, hover your mouse pointer on the Take field to see the full direction (below).

eCW screenshot adding medicatin favorites 5

You can click on the line directly if you see a prescription that looks exactly the way you want to prescribe, but you can also click the pen button to edit the prescription (below). Please make sure the direction, days of supply and quantity match with each other. Use the prescription displayed on the bottom to review the prescription one last time before clicking

[Apply] to finish the prescribing process.

eCW screenshot adding medicatin favorites 6

2017-11-16T12:16:42-07:00 April 15th, 2015|