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Formulary Additions:
1) Micardis ®) is an angiotensin II receptor blocker indicated for hypertension.
2) Lexiscan ® is a diagnostic agent indicated for radionuclide myocardial perfusion imaging.
3) Pulmicort Inhaler ® is an anti-inflammatory synthetic corticosteroid indicated for Asthma
4) Flector patch ® ® is a non-steroidal anti-inflammatory topical patch used for acute pain due to minor strains, sprains,
and contusions.
5) Pentacel vaccine ® is indicated for active immunization against diphtheria, tetanus, pertussis, poliomyelitis, and
invasive disease due to Haemophilus influenzae type b.
Safety alerts (The following information is from ISMP Medication Safety Alerts):
1. Investigate and clarify requests for missing doses
A physician ordered vitamin K1 (phytonadione) 2 mg IV for a patient with an elevated INR of 3.8. When the drug did
not become available for removal from the automated dispensing cabinet (ADC) within a usual timeframe, the nurse
faxed the pharmacy a “missing medication” request, in case pharmacy had overlooked the order. The nurse
misinterpreted the order, however, as vitamin K1 20 mg IV due to a poorly handwritten order by the physician, and
wrote the “missing medication” request as such. The pharmacist recognized the order for vitamin K1 20 mg IV as
being too high and clarified the order to the physician-ordered dose of 2 mg prior to dispensing.
2. Safety Brief: Provera, Prozac, or Proscar?
An order was written for Provera (medroxyPROGESTERone) 10 mg PO daily; however, the handwritten order was
misinterpreted as Prozac (FLUoxetine) 10 mg PO daily. Check out the newsletter to find out how several other nurses,
pharmacists, and physicians interpreted the order.
3. Safety Brief: The lot number is where?
It was discovered that documentation errors had been occurring at a particular hospital, by more than one nurse, with
the lot number and expiration date of PNEUMOVAX 23 (pneumococcal polysaccharide vaccine [polyvalent]). Read
more about what caused the confusion and steps you can take to help reduce similar errors from occurring at your
hospital in this issue of the newsletter.
4. Safety Brief: Fatal sound-alike.
A patient’s physician had called in an order for an ample of naloxone in order to treat the patient for respiratory
depression secondary to a dose of parenteral morphine that the patient had received. The nurse who took the phone
order, however, heard LANOXIN (digoxin) which the nurse administered.
Warning on Testosterone Gel Products
FDA will require that two topical testosterone gel products carry a boxed warning stating that
children could be inadvertently exposed to testosterone if they contact the gel on the skin of another
person, and listing specific recommendations to prevent this. The gels, available only by prescription,
are used to treat men who don't produce sufficient testosterone. The products are Testim 1%, which
is applied to the shoulders and upper arms, and AndroGel 1%, which can also be applied to the
abdomen.
The current labeling does have precautions about exposing children, but FDA continues to receive
reports where children have come in contact with the gel on another person's body, with serious
effects. Some children have experienced inappropriate enlargement of the genitalia, premature
development of pubic hair, advanced bone age, and behavioral changes. In a few cases, some signs
did not regress when the exposure to testosterone stopped.
FDA is requiring the gel manufacturers to develop a Medication Guide that will describe these
risks. It will be given to patients each time their prescriptions are dispensed.

Guidance on Using Pentacel
(Combination DTaP – IPV – Hib Product)
Indications for Use and Schedule
Approved for: Minimum Age and Minimum Intervals:
• Children ages 6 weeks through 4 years • Minimum age for dose 1 is 6 weeks
• Not approved for persons 5 years of age and older • Minimum age for dose 2 is 10 weeks
Routine schedule: • Minimum age for dose 3 is 14 weeks
• Primary series: 2 months, 4months, & 6 months • Minimum age for dose 4 is 12 months
• Booster dose: 15-18 months of age • Minimum intervals:
Hib shortage: Defer the routine booster dose until the Hib o 4 weeks between dose 1 & 2
supply improves.
o 4 weeks between dose 2 & 3
o 6 months between dose 3 & 4
(remember minimum age for dose 4 is 12 months)
Reconstitution Storage and Handling
• Use the DTaP-IPV liquid to reconstitute the Hib powder. • Store the DTaP-IPV vial and the Hib vial in the
original box in the refrigerator at 35º-46º F
• Use only the DTaP-IPV in the Pentacel package as the (2º-8ºC).
diluent.
• Protect from light.
• Shake well before using.
• Do not freeze!
Vaccine Administration
• Intramuscular (IM) injection in the anterolateral thigh or • Can be given with other vaccines, at the same
deltoid of the arm visit (use separate sites; space at least 1 inch
apart)
• 1 inch needle; 22-25 gauge
• The combined DTaP-IPV-Hib vaccine may be
• Professional judgment is appropriate when selecting needle used when any component of the vaccine is
length and site indicated, and if the other components are not
contraindicated

Pharmacy Clinical Interventions at SPUH [Saint Peter’s University Hospital]
For July through August 2009
Interventions - P & T Summary
Date Prepared: 2009-08-12
Period Reported: 2009-07-01 - 2009-08-31
Intervention Category # Accepted # Rejected %Acc Saving
Total Interventions 1181 2 99.83% $65767

New Safety Information on Tarceva
New information has been added to the labeling of the chemotherapy drug Tarceva (erlotinib). The revised labeling now
warns about three kinds of serious adverse events:
• Gastrointestinal perforation, which may be fatal. This risk is increased in patients receiving concomitant anti-angiogenic
agents, corticosteroids, NSAIDs, or taxane-based chemotherapy, and it is also greater in those with a history of peptic
ulceration or diverticular disease. Tarceva should be permanently discontinued if the patient develops gastrointestinal
perforation.
• Bullous, blistering and exfoliative skin conditions, possibly including Stevens-Johnson syndrome and toxic epidermal
necrolysis, which can be fatal. Tarceva treatment should be interrupted or discontinued if the patient develops one of these
conditions.
• Ocular disorders, including corneal perforation or ulceration. Tarceva should be interrupted or discontinued if the patient
experiences symptoms of an acute or worsening eye disorder, such as eye pain.
Preventing Methadone Overdose
Due to the serious and sometimes fatal overdoses that have occurred when methadone is used to
treat chronic pain, the Institute for Safe Medication Practices (ISMP) has issued a report warning
of the possible risks.
Methadone is a tricky medication that differs from other opioids in a number of ways:
• Methadone remains in the body long after its analgesic effect has worn off. Although the pain
relief only lasts 4–8 hours, some of the drug may remain in the body for anywhere from 2 days to
2 weeks.
• You may not experience the full analgesic effects of methadone until you've been using it for
3-5 days, so dosages need to be started small and increased much more slowly than other opioids.
• Just because you may have a high tolerance to other opioids doesn't mean you have a high
tolerance to methadone. Methadone needs to be started at much lower dosages.
• If you stop taking methadone for three consecutive days, you may lose your tolerance and be at
risk for an overdose if you go back to taking your previous dosage.
• Because patients have different absorption rates and metabolism, methadone dosages have to be
given with a very individualized approach.
Signs of methadone overdose include trouble breathing or shallow breathing; extreme
tiredness or sleepiness; blurred vision; inability to think, talk or walk normally; and feeling
lightheaded, dizzy or confused. If you experience any of these symptoms, get medical
attention right away.

Improving The Overall Outcomes of HIT [heparin induced thrombocytopenia] Therapy at SPUH:
• A standard protocol was developed to ensure that critical laboratory values are communicated to the
“most responsible physician”, so that the appropriate actions can be taken
• Adequately flagged & segregated critical lab values in the electronic patient records (EPR)
• Successfully communicate to patients, families, and community caregivers critical
lab values & new drug allergies that are identified during hospital admission
• Implemented a universal process for identifying and following-up on discharged patients who have
abnormal or critical lab results
• Implemented a reliable drug allergy documentation process in the EPR
Misread Orders Due to Drug Names ending in the lowercase letter “l”
A.) Figure 1
B.) Figure 2
C.) Figure 3

Continuation…..
Suggested Safe Practices when dealing with drugs that end with a lowercase “l”:
• Allow adequate spacing between the drug name and the dose on handwritten prescriptions, printed
prescriptions and order sets, and electronic formats such as pharmacy computer selection screens,
computer-generated medication labels and records, printed forms and communications, and shelf labels.
Even a clearly typed prescription for 25 mcg of LEVOXYL (levothyroxine) could be misread as 125 mcg
if it appears without proper spacing as Levoxyl25 mcg, especially since both dosage strengths are
available for this medication.
• Encourage prescribers to use block printing with uppercase characters to reduce the risk of
handwritten drug name recognition errors. Some prescription forms incorporate shaded blocks to promote
this practice.
• Use symbolic differentiation to reduce the risk of character misidentification. For example, in Europe,
it’s common to see a zero written with a slash through it to differentiate it from the letter “O.” The
number 7 can be written with a bar through it to prevent confusion with the number 1. The letter “Z” with
a bar through it also can prevent confusion with the number 2.
• Make sure the drug and dose make sense. Is this the usual recommended dose? Is the medication
available in that strength? Otherwise, follow-up with the prescriber may be necessary to clarify the order.
Keep in mind that the context in which the order is read may not be helpful in all cases to properly
identify alphanumeric characters. For example, it would be
unlikely to read ZETAR as “2TAR,” but it would be easy to interpret
an order for “HCTZ50mg” as either hydrocortisone 250 mg or hydrochlorothiazide 50 mg.

Our Rutgers’s Pharmacy Students Topic of Discussion
Presented by: Nadia Awad, Pharm.D. Candidate 2011
Ernest Mario School of Pharmacy, Rutgers University
A Brief Overview of Clostridium difficile Infection
Clostridium difficile (C. diff.) is a gram-positive, spore-producing
Etiology bacterium that produces three types of toxins: toxin A, toxin B, and
binary toxin. These toxins cause injury and inflammation to the
gastrointestinal tract, leading to fluid loss and diarrhea, and may
potentially be lethal.
Transmission Spores produced by C.diff. can withstand heat and acidity. As a
result, they can live on body surfaces of workers in healthcare
facilities and remain on the surfaces of medical equipment for long
period of time
-MAJOR: Recent antimicrobial therapy (≤8 weeks); antimicrobials
commonly implicated include:
--ß-lactam antibiotics (esp. ampicillin, amoxicillin, and 2nd to 3rd
Risk Factors generation cephalosporins)
--fluoroquinolones
--clindamycin
-Age ≥65 -Recent surgery
-Immunosuppression -Concurrent illness
-Prolonged hospital stay
-Enzyme immunoassay positive for toxins A or B
Diagnosis and -Fever, fatigue, malaise
Presentation -Increased white blood cell count that occurs within a short period of
time
-Reduced levels of albumin
-Nausea/vomiting/abdominal pain
-Diarrhea that ranges from mild to life-threatening
-Replacement of electrolytes and fluids using electrolyte solutions,
normal saline, or lactated Ringer’s solution
Treatment -AVOID anti-peristaltic agents such as loperamide and diphenoxylate
in order to allow the patient to naturally expel the toxins from the
body
-Antibiotics indicated for treatment include metronidazole or oral
vancomycin, depending on disease severity
-Probiotics to help restore normal gut flora
-Diarrhea lessens by day five of therapy (resolution usually occurs
within two weeks)
Monitoring Response to Therapy -Fever resolves by day two of therapy
-Obtain stool samples and test for the presence or absence of toxins
NOTE: Toxins may still be present in stool samples even if the patient
is asymptomatic; resolution of symptoms is generally a sign of cure
-Wash hands frequently with soap and water to prevent contact
transmission
Prevention of Infection -Use bleach solutions to decontaminate surfaces
-Isolate patients with C.diff infection to prevent transmission
-Wear appropriate gloves/gowns when visiting patients with C.diff
infection
-Use antimicrobial therapy appropriately