Orders to "continue previous meds" continue a long standing problem

From the November 1, 2000 issue

PROBLEM: How do you interpret those dreaded orders to "resume all pre-op medications" or "continue home medications?" While complete drug orders are basic to medication safety, prescribers may transfer this responsibility to patients, nurses, and pharmacists at the most vulnerable periods in the healthcare continuum: admission, post procedure, transfer to a different level of care, and discharge. Too often, orders to simply resume or continue medications have led to errors. We've previously reported that an order to "continue same meds" upon transfer from a critical care unit has led to continued use (sometimes fatal) of neuromuscular blocking agents for restless, but extubated, patients. In the following case, an order to "resume all meds" led to a serious drug omission. A woman with a history of atrial fibrillation and stroke was admitted to the hospital with nausea, vomiting, anemia, and rapid atrial fibrillation. She had been taking COUMADIN (warfarin) 2.5 mg daily before admission and the same dose was prescribed in the hospital. A few days later, an order was written to "hold Coumadin" in preparation for a colonoscopy scheduled the following day. In response, the pharmacist discontinued Coumadin so it would not appear on the computer-generated MAR, risking accidental administration. The next day after the colonoscopy, the physician wrote an order to "resume all meds." Since Coumadin had been discontinued, the pharmacist did not resume it along with the patient's other ongoing medications. After six days without Coumadin, the patient suffered an embolic stroke. In another case, orders to "resume home medications" were written for a lung transplant patient who had just undergone minor surgery. When the patient was first admitted, the physician had ordered only two of the "home medications" listed on the admission assessment. A pharmacist had to call the physician to determine if the same two drugs were to be resumed, or if all drugs on the unverified "home medication" list were to be ordered.

SAFE PRACTICE RECOMMENDATION: Prescribers should always write complete medication orders. Yet, policies that prohibit orders to "resume" or "continue" therapy may not be successful and may simply transfer responsibility to nurses and pharmacists to clarify incomplete orders. Indeed, one pharmacist told us that clarifying orders for "take home medications" constituted the largest portion of all pharmacy interventions! Therefore, it's important to convene a small group of prescribers to identify the underlying reasons that it may be difficult to write complete admission, transfer, and discharge orders. For example, prescribers may not know all the drugs patients are taking at home, especially if prescribed by several physicians. Likewise, they may not have easy reference to all prescribed therapy in the hospital, or may lack comprehensive knowledge about certain classes of drugs. Ask prescribers for feedback on how the organization can help. For example, we know of hospitals that have established a process where nurses, pharmacists, and physicians work together as a team within the first few hours of inpatient admission to verify all medications taken at home and reconcile their use during hospitalization. An initial list of "home medications" should not be used to guide the prescribing process until it has been verified. Educate patients to bring a current list of medications (or actual drug containers) to the hospital when admitted to help with the verification process. Have pharmacy print a daily summary of each patient's medications, which lists both active and discontinued drugs for prescriber reference (perhaps this would have alerted staff to the inadvertent discontinuation of Coumadin in the above cited error and minimized patient harm). We'd like to hear from you if you have additional suggestions. Write to ismpinfo@ismp.org.