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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 but recovered

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 multiple-day regimens.
  • 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 with them.
  • 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]

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