Dating and signing physician orders

The medication being prescribed must fall within the practitioner’s scope of practice and listed in the formulary set forth by the collaborating physician.

Careful attention to the content of standard order sets helps ensure they: 1) are complete, 2) include important orders be-yond what the prescriber may initially consider (e.g., specific monitoring requirements), 3) reflect current best practices, and 4) are standardized among various practitioners who provide care to patients.(1-4) Examples of frequently observed problems with the content of standard orders follow.No space is provided between the drug name and dose (e.g., propranolol20 mg can be misread as 120 mg), or the numerical dose/volume measure and the unit of measure (e.g., 3Units can be misread as 30 units) Use of error-prone symbols, abbreviations, drug name abbreviations, drug name stems, undefined drug protocol acronyms, or coined names (e.g., magic mouthwash) (see ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations at: org/tools/errorproneabbreviations.pdf) Look-alike drug names listed without using standardized tall man letters to help differentiate them (see the FDA and ISMP Lists of Look-Alike Drug Name Sets With Recommended Tall Man Letters at: org/tools/tallmanletters.pdf) Lack of prompts for patient allergies with description of the reactions; actual weight (in kg or grams only); body surface area for oncology patients; diagnosis/comorbid conditions (e.g., diabetes mellitus, liver or renal impairment, behavioral health disorders, hypertension); and pregnancy/lactation status Complex order sets (e.g., TPN) that list additives in a different sequence and doses in different units (e.g., mg vs. mg/liter) than the pharmacy order entry system No prompts on neonatal, pediatric, and oncology order sets to require the prescriber to include the mg/kg or mg/m2 dose for drugs prescribed according to weight or body surface area, the calculated dose, the actual dates of administration, and the cycle number (for chemotherapy regimens) Managing the initial approval of standard order sets and keeping them current present numerous challenges to organizations.Without a standard process to address the approval and revision of standard orders, unacceptable variations in care and errors are possible.They see changes here and there as situations arise in their lives, especially in health care.They hear stories about what is happening and mistakenly assume they are isolated incidents.

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