P&T News: June/July 2003

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

Pharmacy and Therapeutics Subcommittee
Peer Review Status: Internally Peer Reviewed

Inpatient medication orders are to be written on the structured medication order form (A-1a Doctors' Order Form). The following elements should be considered when writing inpatient medication orders:

Safety First: Handwriting Legibility and Use of Abbreviations
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 much 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, Lantus vs Lente, 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, "qod" may be misinterpreted as "qid," resulting in a significant drug overdose). As a safety precaution, the UIHC has developed a list of dangerous medical abbreviations that may not be used in the course of patient care (see Table 1); prescribers will be required to rewrite any orders using a dangerous medical abbreviation included in this list. Write instructions in complete English.
• Prescriber signatures and CLP codes should be clearly legible, not simply recognizable.

Additional information about safely writing medicaiton orders may be reiewed 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; f) dexmedetomidine - 24 hours; g) coagulation factor VIIa - 24 hours; and h) 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.

___________________________
^* The pharmacy computer system is an on-line patient medication system. The system screens medication orders for dosages, drug interactions, allergies, and therapeutic duplications.

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.

Range Orders
Range orders encompass those medication orders which provide a range of options for administering a specific medication to a patient (e.g., "hydroxyzine 25-50 mg every 4-6 hours") as well as medication orders with undefined indications for use (e.g., "Maalox 15-30 ml PRN"). The use of range orders is contingent upon established policies and procedures related to specific clinical situations. In the absence of specific policies and procedures, general guidelines related to the use of range orders should be utilized.

• 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 or a pharmacist if questions related to medication therapy exist.
• Range orders (particularly "PRN" orders) lacking a medication therapy indication may lead to medication administration errors. Nurses must use their clinical judgment in determining whether such orders provide enough clarity to proceed with therapy. If questions exist related to the intent of the order, the nurse must contact the prescriber prior to proceeding with medication administration.

Verbal Orders
Verbal orders for inpatient medications are discouraged, and should be used infrequently as there is greater potential for medication errors when they are used. Verbal orders may only be used in cases of emergency or when the prescriber is unable to be present to write the necessary order and delaying administration of the medication or performing the treatment would be adverse to the patient's welfare. 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. The entire order must be repeated back to the prescriber to ensure accuracy and completeness. 

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.

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. 

Table 1. Dangerous Medical Abbreviations
Abbreviation	Intended meaning	Common Error/Corrective Action
AAOC	Antacid of choice	Ambiguous. Requires other caregivers to determine what prescriber intended. May lead to the unintended administration of large amounts of magnesium, aluminum, or calcium. Write specific antacid, dose, route, interval and indication for use.
LOC	Laxative of choice	Ambiguous. Requires other caregivers to determine what prescriber intended. May lead to the unintended administration of large amounts of sodium or magnesium. Write specific laxative, dose, route, interval and indication for use.
T I W	Three times a week	Misinterpreted as "three times a day" or "twice a week." Write specific days of the week.
U	Unit / Units	Mistaken as a zero or a four (4) resulting in overdose. Also mistaken for "cc" (cubic centimeters) when poorly written. Write Unit or Units.
µg	Micrograms	Mistaken for "mg" (milligrams) when written, resulting in an overdose. Write microgram(s).

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.

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.

Currently, 25 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
• Ceftriaxone > 1 gram per day
• Cidofovir*
• Ciprofloxacin Oral
• Imipenem/Cilastatin
• Levofloxacin Intravenous
• Linezolid*
• Meropenem
• Palivizumab*
• Quinupristin/Dalfopristin*
• Respiratory Syncytial Virus Immune Globulin*
• Ticarcillin/Clavulanate
• Tobramycin
• Vancomycin Oral
• Voriconazole Intravenous and Oral

Others:

• COX-2 Selective NSAIDs*
  (celecoxib, rofecoxib, and nabumetone)
• Dofetilide*
• Drotrecogin alfa activated*
• Fosphenytoin
• Ondansetron (> 4 mg IV or 8 mg Oral outside Oncology and Perioperative settings)
• Recombinate Factor VIIa (NovoSeven®)*
• 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, linezolid, palivizumab, pantoprazole intravenous, quinupristin/dalfopristin, recombinant factor VIIa 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