P&T News: July 2001

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

Pharmacy and Therapeutics Subcommittee of the University Hospital Advisory Committee and the Department of Pharmaceutical Care
Peer Review Status: Internally Peer Reviewed

Handwriting Legibility
Several national organizations, including the American Medical Association, the Institute of Medicine, the Institute for Safe Medication Practices, and the Joint Commission for Accreditation of Healthcare Organizations, 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:

• All aspects of handwritten medication orders must be clearly written using a ballpoint pen. Felt tips and fountain pens do not generate sufficient pressure to transmit the order to the carbon copy from which Pharmacy interprets and dispenses.
• Care should be taken when prescribing drugs with look-alike names, especially when handwritten (examples include Inderal vs. Isordil, Navane vs. Norvasc, or Humulin vs. Humalog). Drug names should be legibly printed.
• Avoid the use of drug name abbreviations and minimize the use of medical abbreviations as these may be misread or misinterpreted (for example, U [for unit] may be mistaken for a zero in the dose; or "qod" may be misinterpreted as "qid," resulting in a significant drug overdose). Write instructions in complete English versus abbreviations. See Table 1, Dangerous Abbreviations When Prescribing Medications.
• Prescriber signatures and CLP codes should be clearly legible, not simply recognizable.

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

Generic Substitutions
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 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 (excluding antiretrovirals) - 7 days; b) clozapine - 7 days; c) ketorolac injection - 5 days; d) rofecoxib 50 mg doses - 5 days; e) fenoldopam injection - 48 hours; and f) 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.
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 decide 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
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. An authorized prescriber must promptly countersign the order.

Dose Standardization
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. Consult the on-line Formulary and Handbook --- www.vh.org/formulary/Form/04Parenteral.html and www.vh.org/formulary/Form/05PedParenteral.html for lists of the standard antibiotic doses.

Parenteral Nutrition Orders
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 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 12-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.

Special Order Drugs
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 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 Pharmacy directly so that emergency measures can be arranged.

Restricted Stock and Protocol Drugs
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 below-"What are Protocol Drugs and How are They Ordered".

Personal Medication Supplies
If patients admitted to 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 medication that is not available at 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 medications as hospital staff may be unfamiliar with dosing and administration.

Medication Order Review
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—or call Dave Weetman, Assistant Director for Acute Pharmaceutical Care at 6-2577.

COMPLETION OF DESIGNATED SECTIONS OF THE A-1a DOCTORS' ORDER FORM
(The capital letters at the beginning of each section refer to a specific section of the A-1a Doctors' Order example in this document.)

A.Patient name, address, hospital number, birthdate, patient care unit, and date. This 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 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 in the on-line Formulary and Handbook --- www.vh.org/formulary/Form/16ApprovedDrug.html

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 Doctors' Order 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 medications (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 the 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 been 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). The drug administration times at the UIHC are published in the on-line Formulary and Handbook --- www.vh.org/formulary/Form/DrugAdminTimes.html

H. Signature. Inpatient medication orders must be signed by authorized prescribers. Medication orders are to include the four-character (alpha-numeric) prescriber's code. Orders written by medical students must be reviewed and co-signed by a licensed physician or dentist. 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. Physician assistants may not write orders for Schedule II controlled substances which are listed as stimulants or depressants.

• Table 1. Dangerous Abbreviations When Prescribing Medications

Anti-Infectives:

Amphotericin B Lipid Complex Aztreonam Caspofungin Cefepime Ceftazidime Ceftriaxone > 1 gram per day Cidofovir* Ciprofloxacin Oral Imipenem/Cilastatin Levofloxacin Intravenous

Linezolid Meropenem Palivizumab* Piperacillin > 12 grams per day Piperacillin/Tazobactam Quinupristin/Dalfopristin Respiratory Syncytial Virus Immune Globulin* Ticarcillin/Clavulanate Tobramycin Vancomycin Oral

Others:

COX-2 Selective NSAIDs* Dofetilide* Doxorubicin Liposomal* Fosphenytoin

Interferon alfacon-1* Ondansetron (use outside Oncology and Perioperative settings) Oprelvekin

The criteria for use of each of these drugs can be found in the drug monograph section of the on-line Formulary as well as on each specific Protocol Drug Order Form.

*These drugs may not be dispensed by Pharmacy until the protocol form is completed.

How to Order a Protocol Drug
To obtain a protocol drug, prescribers are required to forward a completed Protocol Drug Order Form that designates the indication for use to Pharmacy along with the usual A-1a Doctors' Order Form. The Protocol Drug Order Forms may be obtained on each patient care unit or from the local pharmacy satellite. If a completed Protocol Drug Order Form is not received by Pharmacy within 24 hours of the written order, the order will be discontinued and subsequent doses will be withheld until a completed protocol order form has been received. In the case of cidofovir, COX-2 selective agents, doxorubicin liposomal, interferon alfacon-1, palivizumab, and respiratory syncytial virus immune globulin, NO drug will be dispensed until the Protocol Drug Order Form has been received by Pharmacy. Use of the protocol drugs outside the criteria listed on the form requires that the indication for use be clearly stated on the form next to "Other indication" and that the form be signed by the patient's attending physician.

The protocol drug process is necessary in order to collect accurate information regarding the use of high cost, high risk, and high use drugs. This allows the P&T Subcommittee to evaluate usage patterns of these specific agents in order to meet its charge in assuring the safe and cost-effective use of drug products within UIHC.

Key points to the UIHC policy for drug samples include:

STOCKING DRUG SAMPLES

• Clinical Service Chiefs determine whether or not each of their respective clinics is permitted to stock drug samples.
• Each clinic has its own list of approved drug samples. Drug samples found in clinics that are not on the approved drug sample list will be confiscated and destroyed.
• Each clinic site that is approved for drug samples has one physician designated to be in charge of drug samples.
• Each request to add a drug sample to the approved drug sample list is reviewed and approved by the Pharmacy and Therapeutics Subcommittee.
• All drug samples are stored in locked cabinets.

DISPENSING DRUG SAMPLES

• The use of drug samples for inpatient use is prohibited.
• Drug samples must be dispensed in the original manufacturer's package.
• Each drug sample must be labeled with:

  Patient's name Date dispensed Directions for use	Drug name and strength Quantity dispensed Prescriber's name
  Name, address, and phone number of dispensing site

• Written patient information must be provided with each drug sample dispensed.

  Patient information sheets can be obtained from Micromedex® by typing the drug name (generic or brand name) into the "CareNotesTM System."

DOCUMENTING DRUG SAMPLES

• Documentation must be made in patient's chart when drug samples are dispensed. This documentation must include:

  Name of drug Strength of drug Patient instructions

• Each clinic must maintain a Clinic Drug Sample Log that records the date, patient name/registration number, drug sample name, lot number, and the provision of written patient information.

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