Approved Hospital Formulary
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Approved Hospital Formulary
1. High-Alert medication list access
This is JC's #1 tracer question ("do you have a list and can users easily access it?") and sits directly on top of a core platform with easy access. Easiest, highest-impact opener.
| Drug class | Observed or anticipated errors | Medication | Separate storage | Restricted ordering | Active alerts | Dispense in patient-specific, unit of use, or unit-dose packaging | Dispense from pharmacy only | Auxiliary label | Level of care restriction | Required monitoring | Independent double check | Certify/privilege staff | Specific guidelines for use/monitoring | Other |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Adrenergic agonists, IV | Improper compounding | Adrenergic agonists, IV | ◆ Crash cart | ◆ Prefilled syringes and premixed bags | ◆ Pharmacy code competency | ◆ Dilution instructions on crash cart | ||||||||
| Anesthetic/sedation agents, IV | Improper compounding | Anesthetic/sedation agents, IV | ◆ Crash cart Pharmacy-prepared rapid sequence intubation kit | ◆ Prefilled syringes, premixed bags, and infusion vials | ◆ Pharmacy code competency | ◆ Dosing card in rapid sequence intubation kit | ||||||||
| Anticancer agents, parenteral and oral | Improper compounding | Anticancer agents | ◆ Stored and compounded in select pharmacies | ◆ | ◆ Centralized compounding locations | ◆ Pharmacist product verification | ◆ Automated and weight-based compounding technology | |||||||
| Antithrombotics | Improper compounding | Alteplase | ◆ Pharmacy-prepared thrombolytic box for stroke | ◆ | ◆ | ◆ Pharmacy stroke competency | ◆ Dosing chart and preparation instructions in stroke kit | |||||||
| Antithrombotics | Improper compounding | Tenecteplase | ◆ Pharmacy-prepared tenecteplase kit for STEMI | ◆ | ◆ | ◆ Pharmacy STEMI competency | ◆ Dosing chart and “How To” for preparation | |||||||
| Cardioplegic solutions | Improper compounding | Stanford #3 and #4, extracorporeal heparin, del nido | ◆ Stored and compounded in select pharmacy | ◆ Del nido premix | ◆ Centralized compounding location | ◆ Standard dispense times | ◆ Prospective pharmacist visualization during compounding | |||||||
| Epidural and intrathecal agents | Improper compounding | Epidural agents | ◆ Stored and compounded in select pharmacies | ◆ Non-standard concentrations require administrator approval | ◆ Prefilled cartridges | ◆ Centralized compounding locations | ◆ Prospective pharmacist visualization during compounding Preparation Tip sheet | |||||||
| Epidural and intrathecal agents | Improper compounding | Intrathecal agents | ◆ Stored and compounded in select pharmacy | ◆ | ◆ Centralized compounding location | ◆ Pharmacist product verification | ◆ Preparation tip sheet | |||||||
| Opioids: IV, oral, PCA, transdermal | Improper compounding | PCA | ◆ Prefilled syringes | ◆ | ||||||||||
| Prostacyclins | Improper compounding | Prostacyclins | ◆ Stored and compounded in select pharmacies | ◆ | ◆ Centralized compounding locations | ◆ Standard dispense times | ◆ Prospective pharmacist visualization during compounding | |||||||
| Total parenteral nutrition | Improper compounding | Total parenteral nutrition | ◆ Stored and compounded in select pharmacy | ◆ | ◆ Centralized compounding location | ◆ Standard dispense times | ◆ Automation with Epic interface and daily set up verified by pharmacist Prospective pharmacist visualization of all manual additives |
Note. ◆ = implemented safeguarding strategy; ♢ = recommended safeguarding strategy, not yet fully implemented; IV = intravenous; PCA = patient controlled analgesia; STEMI = ST-elevation myocardial infarction.
Reference: https://pmc.ncbi.nlm.nih.gov/articles/PMC10786060/
High Alert
Please review each of these drugs carefully.
- aldesleukin
- alemtuzumab
- alteplase
- amikacin
- amivantamab
- amivantamab-hyaluronidase
- amphotericin B
- anastrozole
- arsenic trioxide
- asparaginase Erwinia chrysanthemi
- atezolizumab
- avelumab
- axatilimab
- axicabtagene ciloleucel
- azaCITIDine
- baclofen
- baricitinib
- belantamab mafodotin
- belinostat
- bendamustine
- berahyaluronidase alfa-pembrolizumab
- bevacizumab
- bicalutamide
- bivalirudin
- bleomycin
- blinatumomab
- bortezomib
- brentuximab vedotin
- brexucabtagene autoleucel
- BUPivacaine
- BUPivacaine-fentaNYL
- busulfan
- cabazitaxel
- calaspargase pegol
- capecitabine
- CARBOplatin
- carfilzomib
- carmustine
- cemiplimab
- cetuximab
- cisatracurium
- CISplatin
- cladribine
- clofarabine
- cycloPHOSphamide
- cytarabine
- cytarabine liposomal-DAUNOrubicin liposomal
- dabigatran
- dacarbazine
- DACTINomycin
- DAPTOmycin
- daratumumab
- daratumumab-hyaluronidase
- dasatinib
- datopotamab deruxtecan
- DAUNOrubicin
- decitabine
- degarelix
- denileukin diftitox
- dinutuximab
- DOCEtaxel
- dostarlimab
- DOXOrubicin
- DOXOrubicin liposomal
- durvalumab
- elotuzumab
- elranatamab
- enfortumab vedotin
- epcoritamab
- epiRUBicin
- epoprostenol
- eriBULin
- etoposide
- etoposide phosphate
- everolimus
- exemestane
- fam-trastuzumab deruxtecan
- fentaNYL
- fentaNYL-ROPivacaine
- floxuridine
- fludarabine
- fluorouracil
- fulvestrant
- gemcitabine
- gemtuzumab ozogamicin
- gentamicin — Intrathecal
- glofitamab
- goserelin
- heparin
- hyaluronidase-atezolizumab
- hyaluronidase-nivolumab
- hyaluronidase-riTUXimab
- hyaluronidase-trastuzumab
- hyaluronidase/pertuzumab/trastuzumab
- HYDROmorphone
- hydroxyurea
- ibritumomab tiuxetan
- IDArubicin
- idecabtagene vicleucel
- ifosfamide
- imatinib
- imetelstat
- inebilizumab
- inotuzumab ozogamicin
- insulin glargine
- insulin isophane (NPH)
- insulin isophane-insulin regular
- insulin lispro
- insulin lispro-insulin lispro protamine
- insulin regular
- iohexol — Intrathecal
- iopamidol — Intrathecal
- ipilimumab
- irinotecan
- irinotecan liposomal
- ixabepilone
- ketamine
- lenalidomide
- letrozole
- leuprolide
- lidocaine
- linvoseltamab
- lisocabtagene maraleucel
- lomustine
- loncastuximab tesirine
- LORazepam
- lurbinectedin
- magnesium sulfate
- margetuximab
- megestrol
- melphalan
- mercaptopurine
- mesna
- methadone — PCA
- methotrexate
- midazolam
- midostaurin
- mirvetuximab soravtansine
- mitoMYcin
- mitoMYcin ophthalmic
- mitoXANTRONE
- mogamulizumab
- molnupiravir
- morphine
- mosunetuzumab
- nadofaragene firadenovec
- naxitamab
- nelarabine
- niCARdipine — Intrathecal
- nirmatrelvir-ritonavir
- nivolumab
- nivolumab-relatlimab
- nusinersen
- obecabtagene autoleucel
- obinutuzumab
- ofatumumab
- onasemnogene abeparvovec (Itvisma) — Intrathecal
- oxaliplatin
- oxytocin
- PACLitaxel
- PACLitaxel protein-bound
- pancuronium
- panitumumab
- parenteral nutrition solution — Dextrose 20% or greater
- pegaspargase
- pembrolizumab
- PEMEtrexed
- pentostatin
- pertuzumab
- physiological irrigating solution
- polatuzumab vedotin
- porfimer
- potassium chloride
- PRALAtrexate
- procarbazine
- quizartinib
- radium Ra 223 dichloride
- ramucirumab
- remifentanil
- retifanlimab
- riTUXimab
- rocuronium
- romiDEPsin
- ruxolitinib
- sacituzumab govitecan
- SARS-CoV-2 (COVID-19) mRNA-LNP vaccine (cvx 308)
- SARS-CoV-2 (COVID-19) mRNA-LNP vaccine (cvx 309)
- SARS-CoV-2 (COVID-19) mRNA-LNP vaccine (cvx 310)
- SARS-CoV-2 (COVID-19) mRNA-LNP vaccine (cvx 311)
- SARS-CoV-2 (COVID-19) mRNA-LNP vaccine (cvx 312)
- siltuximab
- sipuleucel-T
- sodium acetate
- sodium bicarbonate
- sodium chloride
- succinylcholine
- SUFentanil — Epidural
- tafasitamab
- tagraxofusp
- talimogene laherparepvec
- talquetamab
- tarlatamab
- tebentafusp
- teclistamab
- telisotuzumab vedotin
- temozolomide
- temsirolimus
- tenecteplase
- thioguanine
- thiotepa
- tisagenlecleucel
- tislelizumab
- tisotumab vedotin
- tobramycin — Intrathecal
- tofacitinib
- topotecan
- toripalimab
- trabectedin
- trastuzumab
- tremelimumab
- treprostinil
- tretinoin
- vancomycin — Intrathecal
- vecuronium
- venetoclax
- vinBLAStine
- vinCRIStine
- vinorelbine
- zanidatamab
- ziconotide — Intrathecal
- ziv-aflibercept
- zolbetuximab