P&T News: July 2000

Essential Elements of Complete, Safe, and Accurate Inpatient Medication Orders

Pharmacy and Therapeutics Subcommittee
Peer Review Status: Internally Peer Reviewed by Bradley Britigan, MD, Kevin Bebout, RPh, Alan Mutnick, PharmD, Mary Ross, MBA

Again this year, we would like to assist in the orientation of new faculty and house staff physicians, dentists, and other prescribers to the guidelines for complete, safe, and accurate medication order writing. This review should also serve as a reminder for all UIHC prescribers previously exposed to these guidelines: completion of all "essential elements" of the medication order will assure that it will be accurately and promptly interpreted; the care you take will ultimately benefit your patient. This issue of the P&T News will review the guidelines for writing inpatient medication orders.

Inpatient Medication Orders
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:

General Guidelines
A ball point pen and a firm writing surface 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 and can lead to medication errors.

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 note 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 (described on page 4).

Automatic expiration of medication orders:

1. Medication order durations default to those predefined by the Pharmacy and Therapeutics Subcommittee at the time the order is entered into the pharmacy computer system* unless otherwise specified by the physician. The current predefined order durations include: a) systemic antibiotics (excluding antiretrovirals) - 7 days; b) clozapine - 7 days; c) ketorolac injection - 5 days; d) rofecoxib 50 mg doses - 5 days; and e) all other medications - 30 days.

2. Physicians are notified of the impending expiration 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 time/date.

Completion of Designated Sections of the A-1a Doctors' Order Form

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.

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 authorized prescriber must then countersign the order within 24 hours.

For selected parenteral antibiotics utilized in adult patients and pediatric patients weighing 20 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 in which 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 usual A-1a Doctors' Orders Form. Upon receipt of this order, the "nonstandard" doses will be prepared and dispensed. The on-line Formulary and Handbook --- www.vh.org/formulary/Form/04Parenteral.html and www.vh.org/formulary/Form/05PedParenteral.html should be consulted for lists of the standard antibiotic doses.

Medication orders for adult and pediatric parenteral nutrition solution 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 by 1400 hours so that orders may be received by the Pharmacy no later than 1500 hours daily. Solutions 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 hours 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 written daily by 1200 hours so that orders may be received by the Pharmacy by 1300 hours. Solutions are hung at 1800 hours. Orders received after 1300 hours may not be available until after 2100 hours.

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 602) stating the reason that the Special Order Drug is needed in lieu of other drugs stocked must be completed, signed by the patient's attending physician, and sent to the Pharmacy. Most Special Order Drugs can be procured within 24 to 48 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.

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 of the Formulary; the conditions of the 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; they are identified by a "(P)" after the generic name in the drug monograph section of the Formulary. See page 5 for additional information on protocol drugs.

If patients admitted to the UIHC bring personal medication supplies with them, these drugs are not administered to the patient while at the hospital, but rather are collected by Nursing personnel and, preferably, returned to the patient's family, or stored in a secure manner and returned to the patient at the time of discharge. Special circumstances (as defined by the responsible physician or dentist) may indicate that the patient's medications should be administered at UIHC, for example, birth control pills or in the instance of medication which is not available at the UIHC. Under these circumstances, it is the responsibility of the pharmacist to examine the medications for proper identification, labeling, and condition prior to permitting the drugs to be administered to the patient. When it is decided that personal medications brought from home by the patient are to be administered by hospital personnel, the physician or dentist is required to specify this intent in the patient's chart at the time the medication is prescribed. Prescribers should keep in mind that there is a potential risk of medication errors with the use of non-formulary medication as hospital staff may be unfamiliar with dosing and administration.

A pharmacist will review all medication orders, and in those instances in which a consultation about a drug order is required, the pharmacist will discuss the issue directly with the prescriber.

For further information on prescribing inpatient medications, please refer to the on-line Formulary and Handbook --- www.vh.orghttp://policies.uihc.uiowa.edu/Governing Body Directives/SectionI/I.23.pdf.

Formulary and Handbook on the Virtual Hospital
www.vh.org/Formulary

The Formulary and Handbook is available as an electronic reference through the Internet on the Virtual Hospital website. Access to the on-line Formularly and Handbook is through a secure website and restricted to UIHC staff on a hospital terminal. The Formulary and Handbook will only be available as an electronic version as of July 1, 2000.

The full text of the Formulary and Handbook can be located on a hospital computer by going into either:

-OR-

The Formulary and Handbook can be searched by keyword (e.g., generic name, brand name), by finding the generic or brand name in the Index of Drug Names, or by scrolling through the Table of Contents. It is organized in the same format as the bound edition.

This site is updated with additions, deletions, and changes in restriction status of stocked mediations every 4 to 6 weeks. If you have any problems accessing the on-line Formulary and Handbook, please contact the Drug Information Center.

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