...an educational memo from your Pharmacy and Therapeutics Committee

January, 2003

It is generally recognized that adults ingesting 4000 mg of acetaminophen per day can lead to hepatotoxicity. However it may not be obvious if a combination product contains acetaminophen and in what amount. An FDA panel has recommended adding stronger warnings to acetaminophen-containing products about the risks of overdosing and potential toxicities. Nurses at St. Francis Medical Center will be charting daily acetaminophen doses taken on the MAR and will alert physicians when the 24-hour total exceeds 4000 mg. Some points to consider regarding analgesics containing acetaminophen:

No published data to support more than 650mg acetaminophen for treating everyday causes of pain.

APAP is an abbreviation for N-Acetyl-para-aminophenol, which is also known as acetaminophen.

Avoid multiple combination analgesic products containing acetaminophen.

Consider using single entity analgesics or non-steroidal anti-inflammatory drugs (ex. ibuprofen).

Many OTC cough and cold remedies contain acetaminophen.

The acetaminophen content of combination analgesic products currently on the Formulary are below:

Tylenol w/ Codeine elixir and suspension 120mg/5ml Lortab elixir 500mg/15ml

Tylenol w/ Codeine tablets (any strength) 300mg/tablet Darvocet N-100 650mg/tablet

Vicodin 500mg/tablet Fioricet 325mg/tablet

Vicodin ES 750mg/tablet Percocet 325mg/tablet

The following Hepatitis A and Hepatitis B vaccine brand changes will be made to help reduce drug costs. Please consult product literature for more dosing information.

Hepatitis A (Vaqta) (Havrix)

Child (2-18) 25 units (0.5ml) 720 ELU (0.5ml)

Adult (19 & older) 50 units (1ml) 1440 ELU (1ml)

Hepatitis B (Recombivax) (Engerix-B)

Child (up to 19) 5 mcg (0.5ml) 10 mcg (0.5ml)

Adult (20 & older) 10 mcg (1ml) 20 mcg (1ml)

The following flaws in written drug orders can lead to medication errors and potential patient harm. Audits are currently being performed to assure compliance with these standards.

Lack of leading zero before a decimal point (ex. .5)

Use of trailing zero after a decimal point (ex. 5.0)

Using ‘U’ for abbreviating the word units ( ex. 500 U)

Using the symbols ‘>’ or ‘<’ instead of writing out ‘greater than’ or ‘less than.’

Illegible orders that require verification

Streptokinase has been removed from the Formulary due to lack of use. Similarly, prednisolone tablets were removed and any new orders will be auto-substituted with prednisone tablets. Based on CDC guidelines, the single antigen tetanus toxoid product has been deleted and age-appropriate diphtheria-tetanus toxoid vaccine was approved for auto-substitution.