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Slang Terms and Jargon Can Cause Medication Errors

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Slang Terms and Jargon Can Cause Medication Errors Volume 19, Number 10 November/December 2005 Drugs & Therapy B � U � L � L � E � T � I � N MEDICATION SAFETY FORMULARY UPDATE The Pharmacy and Therapeutics Slang terms and jargon can Committee met October 18, 2005. 4 products were added in the Formulary cause medication errors and 2 were deleted. 1 dosage form was evaluated and designated nonformu- his month “Magic Mouthwash” ents. An allergy screen would not be lary and not available, and 2 drugs T was deleted from the Formulary done, unless the individual ingredients were evaluated, but not added. Criteria (see Formulary Update). The P&T are appreciated. for use were modifi ed for 3 drugs. Committee took this action for medica- Magic Mouthwash will no longer be tion safety reasons. This continues the dispensed at Shands UF because there ◆ ADDED policy of not allowing the use of non- is no evidence that it works better than specifi c terms for mixtures that have a plain saline rinse. Clozapine Tablets traditionally been used. This action follows the banning of (generic by IVAX) Terms like “Magic Mouthwash” are the term “Butt Paste” several years Glutaraldehyde 0.6% Solution slang, jargon, or coined phrases for ago. Like Magic Mouthwash, Butt Paste (compounded) mixtures that have a specifi c purpose. is a nonspecifi c mixture of ingredients. Levofl oxacin In this instance, the “magic” is pain The “Butt Paste” mixture contained (Levaquin® by Ortho McNeil)* reduction in patients who have muco- Questran Light® (cholestyramine) in sitis of the mouth. Mucositis is a very Aquaphor®. The theory is that the cho- Ondansetron Tablets ® painful condition in patients receiving lestyramine binds bile acids that may (Zofran by GlaxoSmithKline) aggressive cytotoxic chemotherapy. contribute to perineal dermatitis. There *Restricted to ID approval The logic behind Magic Mouthwash are only case reports supporting the was to combine ingredients with use of this mixture. ◆ DELETED different potential mechanisms of ac- Some mixtures for “Butt Paste” Estradiol Valerate (generic) tion. The Magic Mouthwash mixture contain antifungals (eg, clotrimazole) or Magic Mouthwash that has been used at Shands at UF different protectants (eg, karaya gum). (compounded)** contained lidocaine viscous as a local There is even a commercially available anesthetic, diphenhydramine (Benad- product call Boudreaux’s Butt Paste® **Nonformulary and not available, ® effective December 1, 2005 ryl ) elixir as another local anesthetic, that contains boric acid, castor oil, min- and nystatin suspension as an antifun- eral oil, zinc oxide, and peru balsam. ◆ NONFORMULARY AND NOT gal. The most commonly used Magic Orders written for “Butt Paste” are not AVAILABLE Mouthwash contains equal parts of valid and will not be dispensed. Zinc Clozapine Orally-Disintegrating lidocaine viscous, diphenhydramine oxide ointment is recommended as an Tablets elixir, and aluminum-magnesium alternative. ® (FazaClo by Alamo hydroxide (Maalox®). The antacid was Other coined terms should also be Pharmaceuticals) included as a protectant. This “lido- avoided. A “Banana Bag” is any varia- ◆ EVALUATED, BUT NOT ADDED benalox” or BMX (Benadryl-Maalox- tion of intravenous dextrose and/or Xylocaine) mouthrinse is “swished and sodium chloride with multiple vitamins, Duloxetine swallowed” or “swished and spit.” thiamine, folic acid, plus-minus magne- (Cymbalta® by Eli Lilly) Unfortunately, there is no standard sium, and/or potassium. This mixture is Mycophenolate Extended- for Magic Mouthwash. Some versions also sometimes referred to as a “Rally Release (Myfortic® by Novartis) contain nystatin to treat fungal infec- Bag” or “Rally Pack.” An order for a tions or hydrocortisone or dexametha- “Banana Bag” is not a valid order. ◆ CRITERIA FOR USE CHANGED sone as anti-infl ammatories. Some “GI Cocktail” is another coined term Cefepime (Maxipime® by Elan)*** versions contain sucralfate instead that can lead to confusion. The typical Ciprofl oxacin of aluminum-magnesium hydroxide. (continued on page 3) (Cipro® and generics)*** There are even listed formulas that contain antibiotics like tetracycline ◆ Gatifl oxacin (Tequin® by Bristol or sulfamethoxazole-trimethoprim Myers Squibb)*** (Septra®). INSIDE THIS ISSUE ***Streamlining by the Anti-Infective Problems can arise when patients re- ◆ Restricted antibiotics in clinics Stewardship Program approved ceive a product different than what the prescriber intended. The patient could ◆ Annual index (continued on next page) have an allergy to one of the ingredi- Formulary update, from page 1 dehyde for atrial and ventricular septal estrogens), it was removed from the Clozapine is an atypical antipsy- defect (ASD & VSD) repairs. These data Formulary. chotic that was requested for addi- suggest that glutaraldehyde improves Magic Mouthwash is a mixture tion because of nonformulary use the durability of these repairs. of medications that has been used at Shands Vista. Clozapine has not However, there are signifi cant safety to treat mucositis, particularly in been listed in the Formulary becausebecause concerns with this product. Policies will patients receiving chemotherapy it previously was available only via be established for safe preparation, stor- for cancer. Magic Mouthwash has a limited-distribution program that age, labeling, handling in the operating been listed in the Formulary, and the prohibited it from being stocked in the room (OR), and disposal. The solution annual formulary review identifi ed hospital setting. Now it can be stocked. will be colored with fl uoroscein to avoid this listing as a potential safety risk. Published studies, systematic re- confusion with other clear solutions. Prescribers may not be aware of its views, and evidence-based guidelines Glutaraldehyde 0.6% will only be deliv- constituents. justify the addition of clozapine based ered from the OR Pharmacy directly to The magic mouthwash formulation on its proven effectiveness. Because the staff performing the surgery. that has been used at Shands at UF of the potential to cause agranulocyto- Levofl oxacin is a third-generation consisted of 4 parts nystatin sus- sis in 1% of patients (or less), weekly fl uoroquinolone. It has been considered pension 100,000 units/mL, 3.5 parts white blood cell counts are required a restricted nonformulary drug. This diphenhydramine (Benadryl®) elixir, during the fi rst 6 months of treatment. category of drugs is being phased out and 1 part lidocaine (Xylocaine®) Bi-weekly monitoring is required for of the Formulary because it implies viscous 2%. There are other formula- the next 6 months, and monitoring is that a drug is reasonable and available tions of “Magic Mouthwash” used required monthly for patients treated for specifi c uses but is “nonformulary.” at other institutions (ie, containing longer than a year. If a patient’s white This is better described as a formulary aluminum-magnesium hydroxide blood cell count decreases below pre- agent that is restricted. Thus, the Anti- [Maalox®] and/or corticosteroids). established guidelines, they must stop Infective Subcommittee recommended This can be confusing. Patients may clozapine and not be rechallenged or that this designation be changed. This be allergic to 1 of the ingredients, risk death. does not alter the limited manner that which may not be appreciated based In addition to the risk of agranu- levofl oxacin will be used at Shands at on the labeling of the product. locytosis, clozapine has other poten- UF. A Cochrane evidence-based review tially serious adverse effects includ- Ondansetron is a selective sero- on the interventions for treating oral ing seizures, cardiomyopathy, and tonin antiemetic commonly used for mucositis in patients with cancer other cardiac and respiratory effects. chemotherapy-induced and post-opera- concluded that there was no evi- Clozapine’s other common adverse ef- tive nausea and vomiting. In January dence that Magic Mouthwash is ef- fects include weight gain, hyperglyce- 2000, ondansetron orally disintegrat- fective. The American Cancer Society mia (diabetes), sedation, hypotension, ing tablets (ODT) were added in the (ACS) guidelines for the prevention tachycardia, nausea, hyperlipidemia, Formulary. Ondansetron oral solid and treatment of oral mucositis state hypersalivation (especially at night), tablets were deleted and the policy of that there is no signifi cant evidence and sweating. dispensing the ODT for all oral orders of the effectiveness or tolerability of Hospital policy will assure appro- was adopted. This decision was made any mixture used for mucositis. priate monitoring of clozapine before because the ODT dosage form was Therefore, Magic Mouthwash was dispensing. In the hospital setting, more versatile and there was no dif- removed from the Formulary. Saline policies usually require weekly moni- ference in cost. The net effect was a rinse is recommended as an alter- toring so that the patient’s duration of decrease in inventory with a perceived native because there is published therapy does not need to be determined. increase in dosing fl exibility. The ODT evidence that saline mouthwash Current evidence-based guidelines could be used instead of an oral liquid promotes healing and is equivalent to recommend clozapine for treatment- or, in some cases, in place of injectable other products used for mucositis. resistant schizophrenia, patients with ondansetron. Duloxetine is a selective serotonin/ schizophrenia and suicidal ideation Since that decision, there have been norepinephrine reuptake inhibitor or behavior, and possibly
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