I practice at Hennepin County Medical Center, a large inner city academic Level 1 Trauma Center. Like all such facilities we have been under a tremendous pressure to reduce costs, and pharmaceutical costs have been a large target. To make us physicians more aware of our prescribing patterns, the Pharmacy has provided us two fascinating lists.

The first list is the top 30 drugs ordered in the emergency department during 2012. It is not very surprising that 6 of the top 10 medications are pain relievers. Interestingly, droperidol (often combined in the same syringe with diphenhydramine) was our #4 used medication, often being given for headache, nausea/vomiting, and agitation. Of note, quetiapine is primarily ordered by psychiatric emergency physicians and is not a typical ED medication.

The second list however, shows the top 30 medications by cost. To protect confidential pricing information, I have normalized the data to $100. Alteplase tops the list and is used almost exclusively for stroke and pulmonary embolism. Surprising to me was tetanus-diptheria-acellular pertussis which is given nonchalantly for our trauma patients. Our first line pain medication is liquid oxycodone (to prevent cheeking), and no surprise it comes in #3. Droperidol, despite being generic is given in large quantities making its total bill high enough to place it #4 on the list. Olanzapine which is only #24 on the frequency list, has been alternative for us when droperidol has been on shortage, and given is patent status, has cost our hospital just about as much as droperidol despite being used 1/2 less frequently.

Medication Number of Orders
Ibuprofen 27279
Oxycodone 19971
Hydrocodone-APAP 14260
Acetaminophen 13854
Ondansetron 12272
Droperidol 10799
Sodium Chloride IV Soln 0.9% 9725
Diphenhydramine non topical 9362
Hydromorphone 6702
Oxycodone-APAP 6367
Ipratropium-Albuterol 6306
Albuterol 5132
Prednisone 5089
Penicillin 4954
Tramadol 3589
Lidocaine Viscous Soln 2% 3334
Tetanus-Diphtheria-Acellular Pertussis Inj 2769
Lorazepam 2558
Diazepam 2504
Azithromycin 2357
Hydroxyzine 2332
Ranitidine 2324
Aluminum and Magnesium Hydroxide 2195
Olanzapine 2086
Doxycycline 1849
Alum-Mag Hydroxide-Simethicone 1821
Quetiapine 1778
Aspirin 1760
Cephalexin 1688

Cost estimates are based on drug purchase cost only. For pharmacy-prepared medications, this does not include cost of labor or supplies. Includes medications dispensed by omnicell machines, ED floor stock items and items commonly sent to ED from pharmacy. For compounded items, cost was only based on active drug ingredient.

Medication Cost
Alteplase $23.02
Tetanus-Diphtheria-Acellular Pertussis $19.58
Oxycodone $11.53
Droperidol $6.37
Olanzapine $6.19
Lidocaine $3.64
Fosphenytoin $3.13
Hydromorphone $3.11
Pantoprazole $2.90
Azithromycin $2.40
pink lady enema $1.78
Vancomycin $1.40
Magnesium $1.34
Piperacillin/Tazobactam 1.25
Levofloxacin $1.14
Ondansetron $1.14
Levetiracetam $1.03
Tetracaine $0.98
Ceftriaxone $0.95
Thiamine $0.93
Nicardipine $0.93
Diphenhydramine $0.81
Lorazepam $0.79
Phenytoin oral $0.74
Propofol $0.52
Etomidate $0.51
Esmolol $0.51
Articaine 4% w/ Epinephrine Dental $0.46
Tetracaine/Benzocaine/Butambend $0.46
Ipratropium/albuterol Neb $0.43