Designing preprinted order forms that
prevent medication errors
From the April 23,1997 Issue
To minimize communication system errors, one of the steps
ISMP advocates is standardizing communication by using preprinted
orders. However, if preprinted orders are not carefully designed
and checked, they may actually cause errors. In the March
12, 1997, issue of ISMP Medication Safety Alert! we told you
about a case where a preprinted order listed the dose of magnesium
sulfate as 16 g (130 mEq) instead of 16 mEq (2 g). The pharmacist
assumed it was correct because it was listed on the preprinted
orders, and he dispensed the dose. The patient became hypotensive
Many healthcare professionals feel a certain amount of comfort
with preprinted orders. After all, the orders are usually
approved by one or more committees within the institution
before they are mass-printed. However, even when the review
process is very extensive, errors can slip through or something
on the form can contribute to errors. Because preprinted order
forms are becoming the standard for many hospital-run protocols,
algorithms, critical pathways and guidelines, it is more and
more important for institutions to have some methods and rules
in place to evaluate and use order forms. We recommend the
following when institutions develop preprinted order forms:
- Do not use preprinted orders unless all disciplines are
involved in the process for developing, reviewing and finally
approving the forms
- Do not allow orders if they don't coincide with hospital
policy (e.g., "renew all previous orders" is not permitted
in many hospitals).
- Avoid preprinted hospital orders sponsored or prepared
by pharmaceutical companies because they may promote a specific
product or list non-formulary items. Be sure that blank
order forms are accessible only to authorized personnel.
- Avoid ambiguous statements such as "unless allergic, give..."
because this type of statement transfers clinical and legal
responsibility from the prescriber to others down the line.
Develop and use a uniform system to indicate orders which
should or should not be followed
- Use generic names on forms and specify reason for administration
wherever possible. For single source items, brand name should
also be included.
- Make sure no forbidden abbreviations or dangerous dose
designations are used on the forms. Each hospital should
have a list of these.
- Require the dose per m2 or dose per kg for all chemotherapy
and pediatric orders when a calculated dose must be entered.
- Do not include a list of drugs to choose from because
it's too easy to choose the wrong item (i.e., vincristine
has been confused with vinblastine).
- Force entry of the daily dose and number of days for any
- Express doses by metric weight (e.g., 5 mg) rather than
by number of tablets, mL, etc., unless drug isn't measured
by weight (e.g., milk of magnesia).
- Avoid coined names like "magic mouthwash" or "banana
bag" because they may be misunderstood by people unfamiliar
- Enhance readability by using fonts and print styles that
are of professional quality. Proper spelling and spacing
is important (i.e., propranolol20 mg is easily misread as
propranolol 120 mg).
- Lines on back copies of any order form are unnecessary
and may hide decimal points, or portions of a number or
name. Tell the printer to leave them off.
- Print a tracking number and revision date on the form
to ease replacement.
- Review all preprinted orders every two to three years
or when protocols change.
Having safe preprinted order forms is no accident. A system
must be in place to assure this. [A, D, N, P, Q]