P&T News: July 2004

Ordering Medications Safely for Inpatients and Clinic Patients

Kevin L. Bebout, R.Ph., Administrative Pharmacy Practice Specialist, Department of Pharmaceutical Care
Peer Review Status: Internally Peer Reviewed

The Pharmacy and Therapeutics Subcommittee, the Joint Office for Compliance, and the Department of Pharmaceutical Care would like to take this opportunity to review several key strategies to prevent errors during the medication ordering process for inpatients and clinic patients. This review is important for both new and seasoned prescribers since medication ordering comprises such a significant portion of the care and treatment of patients.

The medical literature, as well as several patient safety organizations and regulatory / accrediting agencies, has extensively reviewed multiple issues associated with the safe ordering of medications. The goal, of course, is to ensure that physicians, dentists, and other authorized prescribers write complete, clear, and safe orders that are accurately interpreted and carried out by other care providers so that patients receive the medication therapy intended by the prescriber.

The following recommendations are based upon input from the Institute for Safe Medication Practices (ISMP), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and medical and pharmacy professional associations. Where appropriate, references to appropriate hospital policies or organizational web sites have been provided.

Handwriting Legibility

Several national organizations, including the American Medical Association, the Institute of Medicine, ISMP, and JCAHO, have warned healthcare providers about the association between poor prescriber handwriting and medical errors. Medication orders written hurriedly and illegibly force other care providers to seek order clarifications or inadvertently lead the care provider to erroneously interpret the order and give medication in a manner not intended by the prescriber. To avoid errors caused by illegibly written orders, the following should be observed:

Additional information about safely writing medication orders may be reviewed at the Institute for Safe Medication Practices web site (www.ismp.org).

Dangerous Medical Abbreviations and Therapy Designations
As part of its National Patient Safety Goals program, the JCAHO requires all accredited health care organizations to improve the effectiveness of communication among all caregivers. One expectation of JCAHO is that organizations standardize abbreviations, acronyms and symbols used in the course of patient care and identify a separate list of abbreviations and designations that may not be used within the organization because they are unsafe, unclear or may lead to errors.

The UIHC maintains a list of approved medical abbreviations that can be used for written/printed medical communications involving patients treated at this institution. This list may be found in the UIHC Formulary and Handbook at: http://www.vh.org/formulary/Hand/11MedAbbr.html. In addition, the Pharmacy and Therapeutics Subcommittee and the Health Information Management Subcommittee developed and approved a list of dangerous medical abbreviations and other unacceptable therapy designations for use within the UIHC. This list is also officially maintained in the UIHC Formulary and Handbook at: http://www.vh.org/formulary/Form/dangerousmedicalabbrev.html.

Prescribers will be notified to rewrite any orders using these dangerous abbreviations or orderdesignations. Verbal orders will not be accepted to correct improperly written orders.

In general, the use of medical abbreviations should be avoided or minimized as they may be misread or misinterpreted by other caregivers. Prescribers are encouraged to write out all instructions in complete English.

Blanket Orders
The use of blanket orders is prohibited at UIHC. Blanket orders are general prescriber directions that do not provide specific information about the medication therapy prescribed (e.g., "continue previous medications," "resume preoperative medications," or "discharge on current medications"); with these types of orders, the medication name, dose, route, frequency, and/or indication for use is not stated. All medication orders must be written clearly including complete medication name, dose, route of administration and frequency of use. 

"As Needed" (PRN) Orders
To ensure that orders for "as needed" medications are carried out safely and in the manner intended, prescribers are encouraged to include an indication for use (e.g., PRN pain; or PRN fever above 38.5o C) for each order. This avoids ambiguities that may arise for medications that have multiple uses. Nurses may carry out PRN orders that do not have qualifiers when they know the parameters for administering the medication based on other patient information available. For example, patient is constipated and milk of magnesia is prescribed PRN. Nurses will consult with prescribers on orders when the indication for use is ambiguous.

Range Orders
Range orders are those medication orders which provide a range of options for administering a specific medication to a patient (e.g., "acetaminophen 325-650 mg every 4 hours PRN pain").

  1. Prescribers are encouraged to write specific orders that define the dose to be given and the maximum frequency of administration.
  2. Prescribers are encouraged to not write orders with a range of administration intervals, e.g., "acetaminophen 325 mg every 4-6 hours PRN pain." This type of order will be interpreted as being administered no more frequently than every four hours. Prescribers are encouraged to write orders that specify the minimum interval for medication administration ("acetaminophen 325 mg every 4 hours PRN pain").
  3. When range orders are written and there are no specific policies and procedures to govern dosing parameters, the nurse will use his/her clinical judgment to select the proper dosage and frequency of administration within the established range. This dosage/frequency selection will be made after careful assessment of the patient's clinical condition, taking into consideration the patient's response/lack of response to previous doses and the expected onset of action of the medication. Nurses should contact the prescriber if questions related to administration of the specific dose exist.
  4. Range Orders lacking a medication therapy indication may represent a situation for potential medication misadventures. Nurses must use their clinical judgment in determining whether orders provide enough clarity to proceed with therapy. If questions exist related to specific medication therapies, the nurse must contact the prescriber prior to proceeding with medication administration.

Verbal Orders
Orders for medication or treatment should be in writing, dated, and signed by the practitioner giving the order, with the following exceptions:

  1. Verbal orders shall be given by a licensed independent practitioner (LIP). LIP includes physicians and dentists, physician assistants (PA), advance registered nurse practitioners (ARNP) and optometrists who have been granted clinical privileges by UIHC.
  2. The following personnel are approved to accept verbal orders related to their scope of practice: registered nurses, licensed pratical nurses, registered pharmacists, physical/occupational/ speech therapists, registered dietitians, radiology technologists, nuclear medicine technologists, respiratory therapists, psychologists, sonographers, laboratory technicians, and social workers.
  3. When a verbal order is received, it must be placed in print; after it is placed in print, the staff member must read back the order verbatim to the LIP for verification of accuracy. Medication order recipients should read back the written order and request or provide correct spelling. All numbers should be stated; for example, 16 should be stated as "one six" to avoid confusion with the number 60. Medication orders should include the drug name, dosage, strength or concentration, frequency and route.
  4. No verbal order may be given or accepted for an initial dose of sedation. For chemotherapy, verbal orders are only acceptable in the case of a dose modification (see Antineoplastic Orders policy V.23 at http://policies.uihc.uiowa.edu/Governing Body Directives/SectionV/V.23AntineoplasticOrders.pdf).
  5. The staff member will document the read back and verification process by recording "RBAV" and signing his/her name.
  6. Verbal orders must be documented in the patient's medical record as soon as possible by the individual receiving the order. Information must include the name of the LIP, CLP, date, and time.
  7. The order must be signed and dated by the LIP before the medical record becomes deliquent.

UIHC Policy V.40, Verbal Orders (see http://policies.uihc.uiowa.edu/Governing Body Directives/SectionV/V.40.pdf), provides complete guidelines for the use of verbal orders for inpatients.

Summary
Prescribers are encouraged to review the information regarding ordering medications for inpatients and clinic patients in the Formulary and Handbook. The full text of the Formulary and Handbook can be located on a hospital computer by going into either:

-OR-

This site is updated with additions, deletions, and changes in restriction status of stocked medications on a weekly basis. If you have any problems accessing the on-line Formulary and Handbook, please contact the Drug Information Center.

 

Table 1: Dangerous Medical Abbreviations

Abbreviation
Common Error
Appropriate Action
IU

Mistaken as "IV" (intravenous) or 10 (ten).

Write international unit(s)
MgSO4

Misinterpreted as morphine sulfate, resulting in the wrong medication being administered.

Write magnesium sulfate
MS / MSO4 / MSO4

Misinterpreted as magnesium sulfate, resulting in the wrong medication being administered.

Write morphine
Q.D. / QD / q.d. / qd

Mistaken for Q.O.D./ qod, resulting in an inappropriate dosing schedule.

Write daily
Q.O.D. / QOD / q.o.d. / qod

Mistaken for Q.D./qd, resulting in an inappropriate dosing schedule.

Write every other day
T I W

Misinterpreted as "three times a day" or "twice a week."

Specify days of the week
U / u

Mistaken as a zero or a four (4), resulting in overdose. Also mistaken for "cc" (cubic centimeters) when poorly written.

Write unit(s)
µg

Mistaken for "mg" (milligrams) when written, resulting in an overdose.

Write microgram(s) or mcg

Similarly, chemotherapy drug name abbreviations are never permitted to be used. The following abbreviations are particularly prone to misinterpretation if used in printed communications and must always be avoided:

Table 2: Dangerous Chemotherapy Abbreviations

Abbreviation
Complete Drug Name To Be Written/Printed Out
2-CDA
Cladribine
5-FU
Fluorouracil
6-MP
Mercaptopurine
CPT-11
Irinotecan
IL-2
Aldesleukin
VP-16
Etoposide
CDDP
Cisplatin
MTX
Methotrexate

Table 3: Decimal Numbers and Zeros


Medication doses may be misinterpreted when decimal numbers are not written out properly. The following actions should be taken to ensure that doses are written clearly and completely:

  • Never use a "trailing zero" (e.g., 10.0 mg) after a decimal point, because the decimal point may not be seen by others, leading to a significant drug overdose (e.g., 10.0 mg is seen as 100 mg).
  • Always use a "leading zero" (e.g., 0.1 mg) before a decimal point, because the decimal point may not be seen by others, also leading to a significant drug overdose (e.g., .1 mg is seen as 1 mg).

PHARMACY AND THERAPEUTICS SUBCOMMITTEE ACTIONS

DRUGS ADDED TO STOCK

ATOVAQUONE/PROGUANIL
Tablets: 250 mg/100 mg
This combination product (Malaron® - GSK) is indicated for the prophylaxis and treatment of malaria.

BENZONATATE
Capsules: 100 mg
Benzonatate (Tessalon Perle® - Forest, generic) is a peripherally acting anesthetic agent indicated for the symptomatic relief of cough.

BEVACIZUMAB
Injection: 100 mg, 400 mg
Bevacizumab (Avastin® - Genentech) is indicated for use in combination with fluorouracil-based chemotherapy for the treatment of metastatic carcinoma of the colon and rectum.

CETUXIMAB
Injection: 100 mg
Cetuximab (Erbitux® - BMS/IMClone) is indicated for the treatment of metastatic colorectoral cancer.

DAPTOMYCIN
Injection: 500 mg
Daptomycin injection (Cubicin® - Cubist) is an antibiotic that is used for the treatment of resistant gram-positive organisms.
Note: The prescribing of daptomycin is restricted to Infectious Diseases Service approval.

ELETRIPTAN
Tablets: 20 mg, 40 mg
Eletriptan (Relpax® - Pfizer) is indicated for the treatment of migraine with and without aura.

EPLERENONE
Tablets: 25 mg, 50 mg
Eplerenone (Inspra® - Pfizer) is a selective aldosterone receptor antagonist indicated for the treatment of hypertension and heart failure.

FOSAMPRENAVIR
Tablets: 700 mg
Fosamprenavir (Lexiva® - GSK) is a protease inhibitor indicated for the treatment of HIV infections.

GANIRELEX
Injection: 250 mcg
Ganirelex (Antagon® - Organon) is a reversible inhibitor of gonadotropin-releasing hormone that is used for women undergoing controlled ovarian hyperstimulation.

GATIFLOXACIN
Ophthalmic Solution: 0.3%
Gatifloxacin ophthalmic solution (Zymar® - Allergan) is indicated for the treatment of bacterial conjunctivitis.

LARONIDASE
Injection: 2.9 mg
Laronidase (Aldurazyme® - Genzyme) is indicated for the treatment of Hurler, Hurler-Scheie, and Scheie diseases.
Note: The prescribing of laronidase is restricted to Pediatric Hematology/Oncology.

PEMETREXED
Injection: 500 mg
Pemetrexed (Alimta® - Lilly) is an antifolate indicated for use in combination with cisplatin for the treatment of malignant pleural mesothelioma.

RISPERIDONE
Long-Acting Injection: 25 mg, 37.5 mg, 50 mg
Risperidone long-acting injection (Risperdal Consta® - Janssen) is an atypical antipsychotic agent that is administered every 2 weeks.
Note: Prescribing is restricted to Psychiatry.

TADALAFIL
Tablets: 5 mg, 10 mg, 20 mg
Tadalafil (Cialis® - Lilly) is indicated for the treatment of male erectile dysfunction.

TIOTROPIUM
Powder for Oral Inhalation: 18 mcg
Tiotropium (Spiriva® - Pfizer) is indicated for once-daily maintenance treatment of bronchospasm associated with COPD, including chronic bronchospasm and emphysema.

TOSITUMOMAB AND I-131 TOSITUMOMAB
Injection
This product (Bexxar® - GSK/Corixa) is indicated for the treatment of patients with refractory CD20 positive, follicular non-Hodgkin's lymphoma.

ADDITIONAL ACTIONS

AMOXICILLIN/CLAVULANATE
This combination product (Augmentin ES®) that contains 600 mg of amoxicillin and 42.9 mg potassium clavulanate per 5 ml has been added to stock.

CHLORTHALIDONE
A 25 mg tablet has been added to stock.

ENOXAPARIN
A 100 mg/ml, 3 ml multidose vial has been added to stock.

ERYTHROMYCIN ETHYLSUCCINATE
This 40 mg/ml suspension has been added to stock. It replaces erythromycin estolate suspension 50 mg/ml which is no longer manufactured.

KETOROLAC
A 0.4% ophthalmic solution (Acular LS®) has been added to stock.

METHYLPHENIDATE
10 mg and 20 mg extended-release capsules (Metadate® CD) have been added to stock.

METOPROLOL
A 25 mg tablet has been added to stock.

NORGESTIMATE AND ETHINYL ESTRADIOL
Ortho Tri-Cyclen Lo® tablets have been added to stock.

SODIUM CHLORIDE
A 1 gm capsule has been added to stock.

SODIUM HYALURONATE
A 23 mg/ml injection (Healon 5®) has been added to stock.

DRUGS DELETED FROM STOCK

ACETAMINOPHEN 325 mg, BUTALBITAL 50 mg, AND CAFFEINE 40 mg TABLETS (FIORICET®)
Deleted due to low use and addictive properties of butalbital. NSAIA and "triptans" are available.

ALPROSTADIL URETHAL SUPPOSITORIES (MUSE®)
250 mcg
Deleted due to low use. 500 mcg and 1000 mcg strengths are available.

ALTRETAMINE CAPSULES
Deleted due to low use. Other antineoplastic agents are available.

ALTEPLASE INTRAOCULAR INJECTION 6 mcg/0.1 ml
Deleted due to low use. 24 mcg/0.1 ml strength is available.

ASPIRIN 325 mg, BUTALBITAL 50 mg, AND CAFFEINE 40 mg TABLETS (FIORINAL®)
Deleted due to low use and addictive properties of butalbital. NSAIA and "triptans" are available.

CHLORAL HYDRATE CAPSULES 500 mg
Deleted due to low use. Oral liquid is available.

CONDOMS
Deleted due to low use.

DIDANOSINE CHEWABLE TABLETS 25 mg and 100 mg
Deleted due to low use; 200 mg chewable tablets are available. 

EDROPHONIUM INJECTION 10 mg/ml, 1 ml
Deleted due to low use; 10 mg/ml, 15 ml injection is available. 

ERYTHROMYCIN ESTOLATE 50 mg/ml SUSPENSION
Discontinued by the manufacturer. Replaced by erythromycin ethylsuccinate 40 mg/ml suspension. 

ESTRADIOL CYPIONATE INJECTION
Deleted due to low use. Estradiol valerate injection is available. 

FLURBIPROFEN (OCUFEN®) OPHTHALMIC SOLUTION
Replaced with ketorolac 0.4% and 0.5% ophthalmic solution. 

GRISEOFULVIN ULTRAMICROSIZE TABLETS 330 mg
Deleted due to low use; 125 mg and 250 mg strengths are available. 

HYDROCORTISONE HEMISUCCINATE TROCHES
Deleted due to low use. Triamcinolone oral solution is available. 

INSULIN HUMAN BUFFERED INJECTION (VELOSULIN®)
Deleted due to low use. Insulin human injection (Humulin®, Novolin®) is available. 

INSULIN PORK NPH INJECTION
Deleted due to low use. Human NPH Injection is available.

INTERFERON ALFACON-1 INJECTION 9 mcg VIAL
Deleted due to low use; 15 mcg injection is available. 

KAOLIN AND PECTIN SUSPENSION
Deleted due to low use. Loperamide, Lomotil®, and paregoric are available. 

LOXAPINE CAPSULES
Deleted due to low use. Haloperidol, olanzapine, risperidone, and other atypical antipsychotics are available.

METHYLDOPATE INJECTION
Deleted due to low use. Methyldopa tablets and hydralazine injection are available. 

NEFAZODONE 100, 150, 200, AND 250 mg TABLETS (SERZONE®)
Deleted due to reports of hepatotoxicity. Citalopram, paroxetine and other antidepressants are available. 

NELFINAVIR POWDER FOR ORAL SUSPENSION
Deleted due to low use; 250 mg tablets are available.

NITROFURAZONE SOLUBLE DRESSING
Deleted due to low use. Silver sulfadiazine cream and mafenide acetate cream are available.

PERPHENAZINE TABLETS 8 mg
Deleted due to low use; 4 mg tablets are available. 

PENTAZOCINE WITH NALOXONE TABLETS (TALWIN NX®)
Deleted due to low use. Tramadol tablets and hydrocodone with acetaminophen tablets are available.

SALICYLIC ACID GEL 6% (KERALYT®)
Deleted due to low use. Salicylic acid ointment is available.

SALICYLIC ACID 2% WITH SULFUR 2% SHAMPOO (SEBULEX®)
Deleted due to low use.

SKIN REFRIGERANT SPRAY (FRIGIDERM®)
Deleted due to low use. Fluori-Methane® skin refrigerant is available.

STANOZOLOL TABLETS
Deleted due to low use. Testosterone injection, patches, and topical gel are available.

SULFACETAMIDE 10% WITH PREDNISOLONE ACETATE 0.25% OPHTHALMIC SOLUTION
Deleted due to low use. Tobramycin with dexamethasone ophthalmic solution and Cortisporin® ophthalmic solution are available.

TENECTEPLASE INJECTION
Deleted due to low use. Alteplase injection is available.

OVULATION THERMOMETER
Deleted due to low use.

THIABENDAZOLE TABLETS
Deleted due to low use. Albendazole, mebendazole are available.

VITAMIN A 50,000 UNIT CAPSULES
Deleted due to low use; 25,000 unit capsules are available.

ZALCITABINE TABLETS 0.375 mg
Deleted due to low use; 0.75 mg tablets are available.

ZEASORB® TOPICAL POWDER
Deleted due to low use. Corn Starch and colloidal oatmeal are available.

IODINE "ALLERGIES"
Abstracted from an American Academy of Allergy Asthma & Immunology Position Statement

Based upon data from natural disasters in which radioactive iodine was released into the atmosphere, the effectiveness of potassium iodide (Kl) as a specific blocker of radioiodide uptake is well established when used for phophylaxis. KI is the same compound used, in smaller quantities, to iodize table salt. While the FDA considers Kl to be safe and effective, persons with known iodine sensitivity should avoid KI. This document describes the risks of allergic reactions to oral administration of KI to persons with "iodine sensitivity" and "allergic reactions" to iodine and clarifies the types of "allergic" reactions that may occur with iodine-containing substances.

Definitions
The term "allergy" is typically used to describe a specific adverse immune response to (usually) a protein, more specifically an IgE antibody response. In a typical allergic reaction, the target protein binds to previously formed IgE antibodies specific to the protein. These IgE antibodies are bound to high affinity IgE receptors on mast cells/basophils. The binding of protein to IgE results in aggregation of high affinity IgE receptors, the transduction of cellular signals and the release of mediators such as histamine that result in clinical symptoms (e.g., anaphylaxis). "Anaphylactoid" reactions occur when similar mediators are released through mechanisms other than through IgE antibodies. There are no studies to demonstrate IgE antibodies to small molecules or salts such as iodine/iodide. "Sensitivity" is a term usually used to refer to non-immunologic adverse events. Hypersensitivity is a term usually used to indicate a response that is abnormal and out of proportion to expected adverse reactions, and the term is sometimes used to imply an immune basis for the reaction (of a variety of types such as cell-mediated, IgG antibody mediated).

Iodine "Allergy" and Radiocontrast Media
Radiocontrast media (RCM) containing organic iodine may cause adverse reactions such as urticaria, angioedema, bronchospasm, laryngospasm and shock. These reactions are not attributable to specific immune responses (e.g., IgE antibodies) to iodine, and although the exact mechanism is unknown, it is apparently related to the high osmolarity of these agents (lower osmolar preparations are less likely to cause reactions). Thus, such reactions are "anaphylactoid" in nature. Reactions to RCM should not be construed as an indication of an IgE antibody-mediated iodine allergy and should not be considered evidence of KI allergy.

Iodine Sensitivity and Topical Antibacterial Treatments
Topical antibacterial preparations containing iodine (providone-iodine) sometimes cause allergic contact dermatitis or irritant reactions. Patients with allergic contact dermatitis appear to respond to the providone-iodine component but not to potassium iodide solution on patch testing. Contact dermatitis caused by topically applied iodine-containing antibacterials does not indicate an allergy to iodine or KI. Anaphylaxis to these preparations is exceedingly rare and not proven to be due to iodine.

Iodine in Relation to Seafood Allergy
Seafood may contain iodine. However, IgE antibody mediated seafood allergy has never been attributed to iodine, but rather to specific proteins in fish and shellfish that also do not contain iodine. Thus, fish or shellfish allergy does not indicate a sensitivity/allergy to iodine or KI.

Kl Preparation Allergies
Current approved formulations of KI for prophylaxis of radiation emergencies are not known to contain allergens. But healthcare professionals should ensure that individuals with allergies are not allergic to the inactive ingredients/components of the formulation prescribed.

References
Abstracted from American Academy of Allergy Asthma & Immunology Position Statement: The Risk of Severe Allergic Reactions from the Use of Potassium Iodide for Radiation Emergencies. The complete document can be viewed at: http://www.aaaai.org/members/academynews/2004/01/potassium_iodide.stm

 

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