Rx Update: September 2005

Preprinted Medication Order Sets

Joan Murhammer, R.Ph., Mary Ross, R.Ph., M.B.A., Kevin Bebout, R.Ph.
Peer Review Status: Internally Reviewed

The Pharmacy and Therapeutics Subcommittee has recently implemented a hospital-wide policy entitled, “Development and Approval of Preprinted Medication Order Sets.” This policy was created as part of a concerted effort based upon JCAHO recommendations to standardize the process for using preprinted medication order forms (A-1a forms). This process ensures that all preprinted medication order sets are thoroughly reviewed for correctness, clarity and consistency with hospital policies and care standards prior to their use in the patient care environment. The new policy also spells out how approved preprinted order sets should be used by staff.

While the policy for the development and approval of medication order sets is new, there has actually been a formal review process in place for these documents since 1990. Individuals from the Departments of Pharmaceutical Care, Nursing, Pathology, and Health Information Management review each new order set and every revision to previously approved order sets. Nearly 500 different medication order sets have gone through this review process (not including subsequent updates and revisions). Approved order sets are assigned a date and code number which is placed on the lower left-hand corner of all approved forms. If an order set is subsequently revised, the originally assigned code number does not change, but the recent review date (month/year) is added. This permits users to distinguish older out-of-date versions from current order sets. [Please note that a tracking matrix maintained on the UIHC policy web site (found within the Checklists and Non-Medical Records Forms of the Nursing policy section) shows the most recent revision date for all preprinted medication order set approved for use within the UIHC. Any versions with older review dates should be disposed of.]

The new policy also outlines how preprinted orders should be used once approved. In general,

• If the order set has multiple pages, ensure that all pages are available for use.
• Imprint the patient’s name and hospital number in the addressograph space.
• Fill in all date spaces in the indicated boxes.
• Cross-out any orders on the preprinted A-1a order sheet that are not to be carried out by drawing a straight line through the order and initialing.
• Fill in any blanks that allow for specific patient parameters or dosages.
• Select between any choices of orders by circling the order that is to be carried out and discontinuing the order that is not selected by drawing a line through it and initialing.

The policy “Development and Approval of Preprinted Medication Order Sets” (V.51) may be accessed at http://policies.uihc.uiowa.edu/Governing%20Body%20Directives/SectionV/V.51.pdf on the UIHC policy web site. If you are using preprinted forms that have not undergone formal review and approval, please submit a copy of the form to Linda Chase’s office which coordinates the preprinted medication order set approval process. Questions may be directed to Shellee Laubersheimer at 6-2400 or Kevin Bebout at 6-4284.

Epinephrine is the treatment of choice for acute anaphylaxis. Intramuscular injection of epinephrine into the thigh has been reported to provide more rapid absorption and higher plasma levels in children and adults than intramuscular or subcutaneous injection administered in the upper arm (deltoid area). Studies comparing intramuscular to subcutaneous injection of epinephrine administered into the thigh have not been done. Although these studies were not conducted in patients experiencing anaphylaxis and the clinical significance is not known, more rapid absorption and higher epinephrine levels would seem desirable.

The Nursing Policy (08.120) has been revised and now recommends administering epinephrine by the intramuscular route into the anterolateral thigh (vastus lateralis) for the treatment of acute anaphylactic reactions.

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