Essential Elements of Complete, Safe, and Accurate Inpatient Medication Orders: PTNews: Virtual Hospital

P&T News: July 2002

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

Pharmacy and Therapeutics Subcommittee
Peer Review Status: Internally Peer Reviewed

As part of our ongoing educational mission, the Pharmacy and Therapeutics Subcommittee would like to assist in orienting 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 medication orders will assure that they will be safely, 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 are to be written on the structured medication order form (A-1a). The following elements should be considered when writing inpatient medication orders:

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. All verbal orders must be signed by the prescriber delivering the order within three (3) days.

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 page 7 for additional information on protocol drugs.

Personal Medication Supplies
If patients admitted to UIHC bring personal medication supplies (including herbal or alternative medicines) 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

Table 1. Dangerous Abbreviations When Prescribing Medications(1)

Abbreviation/Dose Expression Intended Meaning Misinterpretation Correction

AU

Each ear

Mistaken of OU - each eye.

Use "each ear."

BT

Bedtime

Mistaken as "BID" (twice daily).

Use "bedtime" or "hs."

cc

Cubic centimeters

Misread as "U" (units).

Use "ml."

D or d

Days; doses

Duration of therpay is misunderstood; unclear whether drug should be given for specified numbers of days or doses.

Use "days" or "doses."

D/C or d/c

Discharge; Discontinue

Premature discontinuation of medications when D/C (intended as "discharge") has been misintrepreted as "discontinue" when followed by a list of drugs.

Use "discharge" or "discontinue."

IU

International unit

Misread as IV (intravenous).

Use "units."

o.d. or OD

Once daily

Misinterpreted as "right eye" and administration of oral medications in the eye.

Use "daily."

q.d. or QD

Every day

Mistaken as q.i.d., especially if the period after the "q" or the tail of the "q" is misinterpreted as an "i."

Use "daily" or "every day."

qhs

Nightly at bedtime

Misread as every hour.

Use "nightly" or daily at bedtime."

q.o.d.

Every other day

Mistaken as q.i.d., especially if the "o" is poorly made and resembles an "i."

Use "every other day."

ss

Sliding scale

Mistaken for "55."

Spell out "sliding scale."

TIW or tiw

Three times a week

Mistaken as "three times a day."

Don't use this abbreviation. Use "three times a week."

U or u

Unit

Read as a zero (0) or a four (4), causing a 10-fold overdose or greater (4U seen as "40" or 4u seen as "44").

Unit has no acceptable abbreviation. use "unit."

x3d

For three days

Mistaken for "three doses."

Use for "three days."

ug

Microgram

Mistaken for "mg" when handwritten.

Use "mcg."

Zero after decimal point (e.g., 1.0 mg)

1 mg

Misread as 10 mg if the decimal point is not seen.

Do not use terminal zeros for doses expressed in whole numbers.

No zero before decimal dose (e.g., .5 mg)

0.5 mg

Misread as 5 mcg.

Always use a zero before a decimal when the dose is less than a whole unit.

(1)Taken from ISMP Medication Safety Alert newsletter, Institute for Safe Medication Practices, May 2, 1002.

Herbal Supplements and Other Alternative Medicines Policy and Procedure

The Pharmacy & Therapeutics Subcommittee has determined that herbal supplements and other alternative medicines (collectively referred to as herbal supplements) are usually not recommended for therapeutic use for the following reasons:

The lack of readily available clinical information from research trials demonstrating their effects, doses, and side effects;
The lack of consistent methods for preparation and labeling of herbal supplements, which do not guarantee the amount of substances being taken for any given regimen;
The ability for herbal supplements to interfere with potential treatments, which might be received during a patient's hospital stay; and
The potential for herbal supplements to contain other substances, which might not be labeled on the container, and which might interfere with other treatments or disease states.

For these reasons, hospital policy covering the administration of personal supplies of medications has been revised to include herbal supplements.

If while conducting an admitting patient history a nurse identifies a patient who is currently taking an herbal supplement, he/she will document in the medical record the name(s) of the herbal supplement(s) that the patient is taking.

If the prescriber, based on the assessment of potential risks versus potential benefits, approves the continued use of an herbal supplement, the order should be written on the Physician's Order Form (Form A1-a). The patient will need to provide the prescriber or other member of the health care team with the names of the herbal supplements, doses, and frequency of administration. The Pharmacy will add the herbal supplement to the patient's medication profile and screen for drug interactions, disease state interactions, and potential adverse effects. The herbal supplement in question must be identifiable by Pharmacy (e.g., in the original container and recognizable upon checking with available databases or by calling the manufacturer). If the supplement is not identifiable (e.g., a bag of an unmarked/unverifiable substance), the patient will not be allowed to take it while in the hospital.

The patient is responsible for supplying and administering his/her own herbal medication. Pharmacy will not routinely purchase herbal supplements due to the liability associated with purchasing products with non-FDA regulated contents.

If the prescriber does not approve the continued use of an herbal supplement, the prescriber will explain to the patient why it is not recommended and will document this discussion in the medical record.

Discharge Medications

What Does the Patient Really Need?

While hospitalized, patients have special needs and often require multiple medication orders to meet their acute care needs. However, when patients are discharged and an attempt is made to normalize their lifestyles, it is important to re-evaluate which medications will be needed in the home setting.

Certain classes of medications are particularly prone to being continued unnecessarily upon discharge. Examples of things to consider when writing discharge prescriptions include:

Ointments & creams

Is the patient using the product for a rash/symptom that has since resolved?

Do they already have a supply at home?

Laxatives

Is their constipation resolved?

If laxatives are warranted, how long will the patient need them and are refills necessary?

Analgesics

Are multiple medications from the same therapeutic class necessary?

What length of therapy is reasonable? How many refills will be needed?

If the product is a non-prescription analgesic, does the patient already have a supply at home?

Hypnoptgics

Is the insomnia likely to resolve upon discharge to home?

How many tablets will the patient likely need? Are refills necessary?

Antiemetics

Is the nausea/vomiting resolved? Is the nausea/vomiting likely to persisit upon discharge?

Antihypertensives

If medications given multiple times a day are stablized, can a once-daily formulation be written for upon discharge?

Stress ulcer prophylaxis

If the patient was given medications for stress ulcer prophylaxis, is the medication needed for discharge?

If needed, what is the estimated length of therapy? How many refills are required?

"PRNs"

Did the patient ever require or ask for the medication while admitted?

Did the patient remain asymptomatic without using the medication or use a different agent?

Adapted from P&T News "Bottomline" Edition Feb/March 2002

What are Protocol Durgs and How are They Ordered?

Currently, 27 drugs on the UIHC Formulary are considered "protocol drugs." These medications are denoted by a "(P)" after the generic name in the drug monograph section of the Formulary. Protocol drugs have been approved for use at UIHC for specific criteria that have been developed and approved by the Pharmacy and Therapeutics (P&T) Subcommittee (comprised of physicians, nurses, and pharmacists) in conjunction with the Antibiotic Advisory Subcommittee, Medication Use Evaluation Subcommittee, and the Medical Staff. These criteria have been established to ensure quality patient care (e.g., through the prevention of antibiotic resistance, avoidance of adverse events, etc.) and to encourage cost-effective therapy. The agents included in this "protocol" classification include:

Anti-Infectives:

Amphotericin B Lipid Complex

Aztreonam

Caspofungin

Cefepime

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*
(celecoxib, rofecoxib, and nabumetone)

Dofetilide*

Drotrecogin alfa activated*

Fosphenytoin

Ondansetron
(use outside Oncology and Perioperative settings)

Pantoprazole Intravenous*

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, dofetilide, drotrecogin alfa activated, palivizumab, pantoprazole intravenous, or 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.

Title Page

Table 1. Dangerous Abbreviations When Prescribing Medications(1)
Abbreviation/Dose Expression	Intended Meaning	Misinterpretation	Correction
AU	Each ear	Mistaken of OU - each eye.	Use "each ear."
BT	Bedtime	Mistaken as "BID" (twice daily).	Use "bedtime" or "hs."
cc	Cubic centimeters	Misread as "U" (units).	Use "ml."
D or d	Days; doses	Duration of therpay is misunderstood; unclear whether drug should be given for specified numbers of days or doses.	Use "days" or "doses."
D/C or d/c	Discharge; Discontinue	Premature discontinuation of medications when D/C (intended as "discharge") has been misintrepreted as "discontinue" when followed by a list of drugs.	Use "discharge" or "discontinue."
IU	International unit	Misread as IV (intravenous).	Use "units."
o.d. or OD	Once daily	Misinterpreted as "right eye" and administration of oral medications in the eye.	Use "daily."
q.d. or QD	Every day	Mistaken as q.i.d., especially if the period after the "q" or the tail of the "q" is misinterpreted as an "i."	Use "daily" or "every day."
qhs	Nightly at bedtime	Misread as every hour.	Use "nightly" or daily at bedtime."
q.o.d.	Every other day	Mistaken as q.i.d., especially if the "o" is poorly made and resembles an "i."	Use "every other day."
ss	Sliding scale	Mistaken for "55."	Spell out "sliding scale."
TIW or tiw	Three times a week	Mistaken as "three times a day."	Don't use this abbreviation. Use "three times a week."
U or u	Unit	Read as a zero (0) or a four (4), causing a 10-fold overdose or greater (4U seen as "40" or 4u seen as "44").	Unit has no acceptable abbreviation. use "unit."
x3d	For three days	Mistaken for "three doses."	Use for "three days."
ug	Microgram	Mistaken for "mg" when handwritten.	Use "mcg."
Zero after decimal point (e.g., 1.0 mg)	1 mg	Misread as 10 mg if the decimal point is not seen.	Do not use terminal zeros for doses expressed in whole numbers.
No zero before decimal dose (e.g., .5 mg)	0.5 mg	Misread as 5 mcg.	Always use a zero before a decimal when the dose is less than a whole unit.
(1)Taken from ISMP Medication Safety Alert newsletter, Institute for Safe Medication Practices, May 2, 1002.

Ointments & creams	Is the patient using the product for a rash/symptom that has since resolved? Do they already have a supply at home?
Laxatives	Is their constipation resolved? If laxatives are warranted, how long will the patient need them and are refills necessary?
Analgesics	Are multiple medications from the same therapeutic class necessary? What length of therapy is reasonable? How many refills will be needed? If the product is a non-prescription analgesic, does the patient already have a supply at home?
Hypnoptgics	Is the insomnia likely to resolve upon discharge to home? How many tablets will the patient likely need? Are refills necessary?
Antiemetics	Is the nausea/vomiting resolved? Is the nausea/vomiting likely to persisit upon discharge?
Antihypertensives	If medications given multiple times a day are stablized, can a once-daily formulation be written for upon discharge?
Stress ulcer prophylaxis	If the patient was given medications for stress ulcer prophylaxis, is the medication needed for discharge? If needed, what is the estimated length of therapy? How many refills are required?
"PRNs"	Did the patient ever require or ask for the medication while admitted? Did the patient remain asymptomatic without using the medication or use a different agent?
Adapted from P&T News "Bottomline" Edition Feb/March 2002

Anti-Infectives:
Amphotericin B Lipid Complex Aztreonam Caspofungin Cefepime 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* (celecoxib, rofecoxib, and nabumetone) Dofetilide* Drotrecogin alfa activated*	Fosphenytoin Ondansetron (use outside Oncology and Perioperative settings) Pantoprazole Intravenous*
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.