P&T News: July 1994, Vol. 15, No. 1
Holli Windhorst, Pharm.D.
Peer Review Status: Internally Peer Reviewed
Inpatient medication orders are to be written on the structured medication order form (A-1a) shown on page 2. The following elements should be considered when writing inpatient medication orders:
I. General Guidelines
A. A ball point pen should be used to assure clarity and legibility.
Felt tips and fountain pens do not generate sufficient pressure to
transmit the order to the carbon copy from which Pharmacy interprets
and dispenses.
B. In accordance with Hospital Bylaws, the pharmacist is authorized to dispense, and the nurse is authorized to administer generic brands of drugs approved for stock by the Pharmacy and Therapeutics Subcommittee whether or not it is the same brand specified in the medication order. If the generic medication stocked is not acceptable, the prescriber must not on the A-1a medication order that only the brand specified is acceptable. To obtain the desired brand of medication, the prescriber must also complete an Inpatient Special Order Request for a Non-Stock Drug Form described in Section I.H. below.
C. Automatic expiration of medication orders:
Adult Patient Care Units and Pediatric Intensive Care Unit (PICU)
1. Medication order durations default to those predefined by the Pharmacy and Therapeutics Subcommittee at the time the order is entered into the Pharmacy Medication Information System (PMIS)* unless otherwise specified by the physician. The current predefined order duration include:
- systemic antibiotics - 7 days
- ketorolac injection - 5 days
- all other medication - 30 days
2. Physicians are notified of the impending expiration of orders via an Expiring Orders Summary (EOS). The EOS is placed on the patient's chart at least 24 hours prior to the assigned expiration date/time.
3. It is important that medication orders be rewritten in a timely manner before the end of their assigned expiration date. If this is not done, Pharmacy and Nursing staff may be placed in a position of having to make a decision on whether to dispense without authorization or to withhold medication (which may have a deleterious effect on continuity of patient care).
4. Medication orders also expire and must be rewritten when a patient is transferred to a different clinical service or when the patient returns from the operating or delivery room.
Pediatric Units (2JCE, 2JCW, 3JCE, 3JCW, 4INSY, NNSY, NICU) and 4Tower
1. Medication orders are valid for a maximum of six days after the initial order is entered on the patient's chart (they all expire at midnight on day six). Thus, if the initial drug is prescribed on day one of the patient's hospitalization and an additional order for that patient is written on day three, all of the orders for that patient expire on day six. Therefore, it is necessary to rewrite all inpatient orders every six days.2. Orders for Schedule II narcotics are valid for a maximum of 72 hours. Schedule II narcotic orders may expire in less time if the chart form expires due to the six day limit.
3. It is important that medication orders be rewritten before the end of the six day period. If this is not done, Pharmacy and Nursing staff may be placed in a position of having to make a decision on the midnight shift on whether to dispense without authorization or to withhold medication (which may have a deleterious effect on continuity of patient care).
4. Medication orders also expire and must be rewritten when a patient is transferred to different clinical service or when the patient returns from the operating or delivery room.
D. Verbal orders for inpatient medications are discouraged except in those instances when a written order cannot be obtained. Verbal orders should be transmitted to a nurse or pharmacist who must immediately transcribe the order into the patient's medical record. The prescribing physician or dentist must then countersign the order within 24 hours. Physician assistants and advanced registered nurse practitioners may not dictate verbal orders for inpatient medication orders.
E. Parenteral can chemotherapy drugs often have short expiration times due to limited stability. Therefore, it is important to indicate the intended administration times on the medication order form. These drugs are also time consuming to prepare and should be ordered several hours in advance to assure delivery in a timely manner.
F. For selected parenteral antibiotics utilized in adult patients weighing 40 kg or more, standardized doses have been established. When an antibiotic order is received for a nonstandard dose size, the dose will be rounded to the nearest standard size. The prescriber and the nurse will subsequently be notified. In situations where the prescriber determines that the patient's dosage requirements cannot be met by a standard dose size, a "PATIENT ORDER FOR NONSTANDARD ANTIBIOTIC DOSES" (Form 602a) must be completed by the prescriber in addition to the usually A-1a Doctors' Orders Form. Upon receipt of this order, the "nonstandard" doses will be prepared and dispensed. Page 20 of the 1994 Formulary and Handbook should be consulted for a list of the standard antibiotic doses.
G. Medication orders for adult and pediatric parenteral nutrition solutions are written on separate medication order forms (A-1a--AVN for Adults; A-1a--PVN for Pediatrics; A-1a--NVN for Neonates). These orders must be written daily.
Parenteral nutrition orders for adult patients (A-1a--AVN for Adults) must be written so that orders may be received by the Pharmacy no later than 1500 hours daily. Solution are hung at 2100 hours.
If there are extremely unusual situations, an order for parenteral nutrition can be compounded up to 2100 hours. Pharmacy requires a minimum of two hours to compound a parenteral nutrition solution. Orders for parenteral nutrition cannot be processed after 2100 hours. In these situations, 10% dextrose with electrolytes should be used until a twelve-hour bag of nutrition solution can be prepared for a 0900 hour dose the following morning.
Parenteral nutrition solution orders for pediatric and neonatal patients (A-1a--PVN for Pediatrics, A-1a--NVN for Neonates) must be received by the Pharmacy by 1300 hours. Solutions are hung at 1800 hours. Orders received after 1300 may not be available until after 2100.
H. If a drug needed for a specific patient is not stocked by Pharmacy, and no alternative stocked drug is suitable, the drug will be acquired on a one-time basis as a Special Order Drug. In order to initiate the acquisition of a Special Order Drug, the prescriber must write a chart order in the usual fashion, indicating that the drug should be special ordered. Additionally, an Inpatient special Order Request for a Non-Stock Drug Form (Form 602) stating the reason that the Special Order Drug is needed in lieu of other drugs stocked must be completed and sent to the Pharmacy. Most Special Order Drugs can be procured within 24 to 38 hours. If unusual circumstances make it imperative that a Special Order Drug be obtained in less than 24 to 48 hours, the prescriber must contact the Pharmacy directly so that emergency measures can be arranged.
I. There are several drugs that have been approved for stock by the Pharmacy and Therapeutics Subcommittee with specific restrictions on their use. Restricted Stock Drugs are identified by an "(R)" after the generic name in the drug monograph section for the Formulary; the conditions for restriction are also included in the monograph. Drugs approved for stock by the Pharmacy and Therapeutics Subcommittee for use according to specific criteria are termed Protocol Drugs. Protocol Drugs are identified by a "(P)" after the generic name in the drug monograph section of the Formulary. The monograph also includes the criteria for use. In accordance with the procedures to obtain a protocol drug, either the prescriber must complete a specific protocol drug order form (available on the patient care areas) before the drug is dispensed, or the use of the drug will be monitored by the Drug Use Evaluation Program.
J. A pharmacist will review all medication orders, and in those instances in which a Special Order Drug is requested, or a consultation about a drug order is required, the pharmacist will discuss the issue directly with the prescribing physician.
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*Pharmacy Medication Information System (PMIS) is an on-line patient medication system which operates in the hospital mainframe environment. The system is currently operational on all patient care units except 4Tower and the 2JCE, 2JCW, 3JCE, 3JCW, 4INSY, NNSY, and NICU pediatric units. For the areas on which PMIS has been implemented, the system provides to physicians, nurses, and pharmacists on-line access to patient medication profiles from any CRT in the hospital. The system screens medication orders for dosages, drug interaction, allergies, and therapeutic duplications.
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II. Completion of Designated Sections of the A-1a Form
(The capital letters at the beginning of each section refer to a
specific section of the A-1a example on form shown above)
A. Patient name, address, hospital number, birthdate, patient care unit, and date. The demographic information should be transmitted to the medication order by using the patient's addressograph plate.
B. Allergies. Patient's medication allergies should be specified in this space. If there are no known allergies, please check the box next to "NKA-No Known Allergies."
C. Date. As each series of medication orders is written, the date should p recede the order. Prescribers are encouraged to include the time when writing medication orders.
D. Medication Column. Medications should be ordered by the generic name, not by the proprietary or trade name. Hospital policy and the Joint Commission on Accreditation of Healthcare Organizations standards permit the use of drug name abbreviations in medication orders only if the abbreviation has been specifically approved by the hospital and it appears on a published list. "Coined" abbreviations such as HCTZ, AZT, TMP-SMX and ddI are not acceptable abbreviations, may be misinterpreted, and may cause drug errors. Medication orders that contain nonapproved drug name abbreviations are not valid. Pharmacists are authorized to withhold dispensing and nurses are authorized to withhold administration of medications ordered via nonapproved abbreviations. The list of drug name abbreviations approved for use at UIHC is provided on pages 49-50 in the 1994 Formulary and Handbook.
If it is necessary to modify or discontinue a medication order, it is important that this be done on the next open line on the A-1a form. Do not alter an existing order which Pharmacy and Nursing have accepted onto their profiles. For example, if the existing order is for digoxin 0.25 mg PO daily, and you wish to change it to digoxin 0.125 mg PO daily, on the next open line write: "Discontinue digoxin 0.25 mg. Begin digoxin 0.125 mg PO daily."
E. Dose Column. Dosages should be prescribed in the metric system. The number of units of medication (e.g., 2 capsules) is only acceptable for combination products that are commercially available in only one strength. If a single ingredient medication is available in only one strength it is still important to write that strength on the order. The terms "one tablet," "one ampul," or only the volume for oral liquids should not be used because the strength or concentration of the dosage unit periodically changes. a zero should always be placed before a decimal expression less than one to prevent misinterpretation of drug orders. For example, .5 mg may be mistaken for 5 mg especially on carbon copies or if the decimal point is written on a line of the order form. The correct way to express this value is 0.5 mg. The leading zero alters the pharmacist and the nurse if the decimal point is not visible. Never place a decimal point and zero after a whole number as the decimal point may not be seen. Write 5 mg and not 5.0 mg.
F. Route Column. The route of administration is indicated in this column, e.g., PO or IM.
G. Interval and Remarks Column. Indicate the schedule on which the medication is to be administered. This section should also be used when prescribing a specific number of doses or days of therapy. The "PRN" designation should include the medication's purpose (e.g., PRN sleep, PRN pain). The drug administration times at the UIHC are published inside the front cover of the 1994 Formulary and Handbook.
H. Signature. Inpatient medication orders must be signed by licensed physicians or dentists. Medication orders are to include the four character (alpha-numeric) prescriber's code. Orders written by medical students or physician assistants must be reviewed and co-signed by a licensed physician or dentist. EXCEPTION: Certain physician assistants and advanced registered nurse practitioners delineated in specific protocols approved by appropriate Clinical Service Heads may sign orders for medications and treatments. The designation "PA" or "ARNP" must follow the signature of the prescribing physician assistant or advanced registered nurse practitioner on all inpatient medication orders. In addition, the name of the supervisory physician shall be recorded on all such medication orders. Within the UIHC such authorized physician assistants may not write orders for Schedule II controlled substances, while the authorized advanced registered nurse practitioners may not write orders for any controlled substances.
For further information on prescribing inpatient medications, please feel refer to pages 43-50 of the gray-colored section of the 1994 Formulary and Handbook or call Steve Nelson, Associate Director, Pharmacy Department, 356-2577.
Erythromycin-Associated Torsades de Pointes
A 29-year-old woman was admitted for control of repeated episodes
of torsades de pointes. The patient had a history of episodes of
lightheadedness lasting for 30 to 60 seconds since the age of 12. She
had never lost consciousness as a result of the episodes and had
never sought medical treatment. Three days prior to admission, the
patient began taking erythromycin 500 mg by mouth four times a day
for a nonproductive cough. She presented at the hospital where her
ECG showed sinus rhythm at 70 beats/min with frequent, short salvos
of polymorphic ventricular tachycardia. The QT interval of the sinus
beat was 560 msec. Serum electrolytes were normal on admission and
remained so throughout her hospital stay. Shortly after admission,
the patient had several, prolonged episodes of torsades de pointes.
One of the episodes degenerated into ventricular flutter and required
direct-current cardioversion for termination of the arrhythmia.
Lidocaine was not effective in prevention of this arrhythmia. Two
days after admission, the lidocaine and erythromycin were
discontinued and a transvenous pacemaker was positioned in the right
ventricular apex. The episodes of torsades de pointes were suppressed
with pacing at 100 beats per minute.
On the third of hospitalization, the pacemaker was turned off. The patient was observed in sinus rhythm with rate of 56 beats per minutes and a QT interval of 600 msec. There were no ventricular premature beats or rhythm abnormalities during two hours of observation. With her permission, ht patient was rechallenged. Two infusions, one of normal saline and one of 250 mg or erythromycin lactobionate, were infused by central venous catheter with a one hour electrocardiographic observation period after each. The patient was unaware of the order of the infusions and no arrhythmias were noted after the normal saline infusion. fourteen minutes after the erythromycin infusion, T wave alternans was noted. A short time later, multiform ventricular premature beats occurred; they persisted for 40 minutes, and then the ECG returned to baseline.
Abstracted from: Freedman RA, Anderson KP, Green LS, Mason JW. Effect of erythromycin on ventricular arrhythmia and ventricular repolarization in idiopathic long QT syndrome. Am J Cardiol. 1987;59:168-9.
Erythromycin administration should be used cautiously in patients with a history of a prolonged QT syndrome. Although the number of cases reported in the literature is small, it may be useful to begin to routinely consider erythromycin among the list of drug entities which can cause torsades de pointes.
Increased awareness of adverse drug reactions can assist the clinician in differential diagnosis of medical problems and events.