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Let's put a stop to problem-prone automatic stop order policies



From the August 9, 2000 issue

PROBLEM: Automatic stop order policies can help safeguard patients against unnecessary and prolonged drug therapy. Yet, they can also inadvertently add to the risk for drug-related problems. This has become more apparent as hospitals have implemented electronic systems with computerized Medication Administration Records (MARs). For example, many times automatic stop orders lack specificity and fail to consider "exceptions to the rule" for designated drugs and indications. Examples include warfarin for atrial fibrillation, enoxaparin in patients awaiting cardiac surgery, and phenobarbital for epilepsy. Problems result if orders for these drugs are governed by automatic stop policies and discontinued by the computer system without warning. ISMP-Canada recently reported such a situation. A hospitalized patient with persistent chest pain was prescribed enoxaparin 100 mg subcutaneously every 12 hours while awaiting cardiac surgery. The hospital had a 7-day automatic stop order for heparin, including enoxaparin. The medication was not reordered prior to the stop date and all the usual "system-checks" failed to catch the computer system's automatic discontinuation of enoxaparin for this patient. Other factors contributing to the error included the prescriber's lack of knowledge about the automatic stop order policy and a weekend stop date. Fortunately, the error was discovered 24 hours later and enoxaparin was immediately restarted, resulting in no injury to the patient.

SAFE PRACTICE RECOMMENDATION: Years ago, automatic stop orders played an important role. But today, with the patient's shorter length of hospitalization and the expanding role of clinical pharmacists, this tool from the past likely needs adjustment. After reviewing applicable state regulations, evaluate the list of drugs currently governed by automatic stop policies to determine if there is a valid need to continue enforcing the policy. It's likely that you will be able to reduce the list considerably. One hospital concluded that only four drugs required such a policy: TORADOL (ketorolac) -5 days to prevent gastrointestinal bleeding; DEMEROL (meperidine) -4 days to prevent normeperidine accumulation; paralytic agents -48 hours to prevent adverse effects on nerve conduction that may cause prolonged paralysis or problems weaning patients off ventilators; and antibiotics -7 days, a more realistic time frame considering the average length of stay. Another option may be to identify exceptions, such as the ones listed above, exclude them from the policy, and encourage prescribers to include the drug's indication and duration for medications governed by automatic stop orders to prevent unintended discontinuation. Computerized systems make policy exceptions a realistic option. When possible, incorporate the duration of drug therapy in diagnosis-specific protocols/standardized orders. Clinical pharmacists should review drug therapy daily and take a leading role in contacting prescribers when necessary to confirm continuation or discontinuation of an order. Consider providing clinical pharmacists with hospital-endorsed authority to extend or remove automatic stop dates for specified drugs and indications. Configure computer systems (and MARs) so that drugs are not automatically discontinued without notice. It is equally important to examine the systems in place for notifying prescribers about automatic stop orders, the timing of the notification, and the process for review. Print a daily drug summary from the pharmacy computer system (listing current drug therapy first, then discontinued medications below) and place it in the medical record with the most recent progress notes. As prescribers and nurses review it, unintended discontinuation or continuation of drugs may be promptly recognized and corrected. Patients should also be encouraged to ask questions when a medication is suddenly stopped.

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