P&T News: July 1997
Pharmacy and Therapeutics Subcommittee
Peer Review Status: Internally Peer Reviewed
Inpatient Medication Orders
Inpatient medication orders are to be written on the
structured medication order form
(A-la) 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.
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 la 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 below).
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 7 days; b) clozapine 7 days; c) ketorolac
injection 5 days; and d) all other medications 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.
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.
Parenteral cancer 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.
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 la Doctors' Orders Form. Upon receipt of this order, the "nonstandard" doses will be prepared and dispensed.
Medication orders for adult and pediatric parenteral nutrition solutions are written on separate medication order forms (A la AVN for Adults; A la PVN for Pediatrics; A la NVN for Neonates). These orders must be written daily.
Parenteral nutrition orders for adult patients (A la 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 la PVN for Pediatrics, A-la 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 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 Subcommittee.
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.
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 la example on page 2)
(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 precede 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, LOC, AAOC, TMP SMX, and ddl 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.
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 la 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 ma. 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," or "one ampul," or only the volume amount 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 when 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 alerts 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, not 5.0 mg, as this may be mistakenly interpreted as 50 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).
(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: Designated physician assistants and advanced registered nurse practitioners delineated in specific protocols approved by the Hospital and their employing departments 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, which are listed as stimulants or depressants.
* The pharmacy computer system is an on line patient medication system. The system screens medication orders for dosages, drug interactions, allergies, and therapeutic duplications.