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ISMP develops guidelines for standard order sets

From the March 11, 2010 issue

ISMP has long been an advocate for the use of standard order sets to minimize incorrect or incomplete prescribing, standardize patient care, and ensure clarity when communicating medical orders.(1-3) Whether in electronic or paper format, well-designed standard order sets have the potential to:

  • Integrate and coordinate care by communicating best practices through multiple disciplines, levels of care, and services(4)
  • Modify practice through evidence-based care(4)
  • Reduce variation and un-intentional oversight through standardized formatting and clear presentation of orders(1-4)
  • Enhance workflow with pertinent instructions that are easily understood, intuitively organized, and suitable for direct application to current information-management systems and drug administration devices(1-4)
  • Reduce the potential for medication errors through integrated safety alerts and reminders(1-4)
  • Reduce unnecessary calls to prescribers for clarifications and questions about orders. (1-4)

However, if standard orders are not carefully designed, reviewed, and maintained to reflect best practices and ensure clear communication, they may actually contribute to errors—many of which have been described in our newsletters and still occur today. In fact, the ISMP consulting team often identifies dozens of serious problems related to the content, format, and approval/maintenance of standard order sets when visiting healthcare organizations of all sizes and types. Below we describe the importance of paying careful attention to the design and maintenance of standard order sets as well as provide examples of commonly observed problems that can lead to serious errors. Guidelines for Standard Order Sets to help avoid these problems can be found on our Web site at: www.ismp.org/Tools/guidelines/default.asp.

Content
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.

  • Numerous practitioner-specific order sets for the same conditions resulting in variability in the clinical management of these patients
  • Content that is a compilation of multiple prescribers’ preferences instead of a streamlined, consensus-based order set
  • Outdated order sets that do not reflect current evidence-based or best practices
  • Incorrect or outdated terminology used to prescribe therapy (e.g., prescribing a “heparin lock flush” when only saline is used to flush the port)
  • Mistakes and inaccuracies in the orders, such as incorrect or missing doses (e.g., magnesium sulfate 16 g instead of 16 mEq), routes, frequencies of administration, and rates of infusion; typos; and spelling errors, particularly with drug names
  • Order set includes a medication that is typically contraindicated in the targeted population (e.g., aspirin on pediatric order sets)
  • Order set does not include duration of therapy if appropriate (e.g., ketorolac limited to 5 days)
  • Order set includes potentially dangerous combinations of products (e.g., IV morphine and epidural HYDROmorphone/bupivacaine, with boxes that allow both orders to be activated)
  • Order set includes two or more medications with known drug interactions
  • An exhaustive variety of medications to cover every possible scenario a patient may face (e.g., orders that include multiple analgesics by various routes, laxatives, antacids, a bedtime sedative, antidiarrheal, antiemetic, and others); we’ve previously called these “Don’t bother me” orders, which lead to crowded medication administration records and leave treatment decisions to nurses’ subjective, variable judgment
  • Order set includes organization-prohibited orders or ambiguous blanket orders such as “take home meds” or “resume pre-op orders”
  • “If…then” orders that inappropriately shift responsibility from the prescriber to the nurse or pharmacist to determine whether an order should be activated (e.g., give RhoGAM if indicated)
  • Types and/or frequency of necessary patient assessments (e.g., pulse oximetry) and laboratory monitoring are not specified
  • Orders to address known potential emergencies not specified (e.g., rescue agent available, when to administer the rescue agent or call the prescriber)
  • Single and/or multiple analgesics which, if administered as frequently as prescribed, could result in an overdose (e.g., acetaminophen or opioid toxicity)
  • Dosing guidance not provided (e.g., mg/kg or mg/m2 dose not specified along with the calculated dose, particularly for neonatal/pediatric drugs and chemotherapy; safe dose range or maximum safe doses not specified; dosing parameters for titrated drugs not provided)
  • Chemotherapy order sets that include the total course dose instead of the single, daily dose
  • Medications without indications
  • Medications prescribed by volume or number of tablets
  • Titrated medications without a measurable description of the desired effects, rate of titration, and maximum doses that should not be exceeded and/or the dose at which the prescriber should be called
  • Administration directions not provided (e.g., timeframe for IV push or bolus doses)
  • Critical clinical decision support information, reminders, precautions, and/or safety measures not included, such as: monitoring requirements; administration precautions; adjustments for renal impairment or age; maximum adult total dose of acetaminophen not to exceed 3 to 4 grams per 24 hours

Format
The format of standard order sets can make them easier to read and comprehend, remind staff to document pertinent information about the patient and prescribed therapy, and draw attention to important information. Elements of format include font style and size; use of white space; adequate space for handwritten entries; arrangement of the information; prompts for information; appropriate use of symbols, abbreviations, dose designations, punctuation, and capitalization; layout and design of the orders and other important information; and directions for using the standard orders.1-4 Examples of frequently observed problems with the format of standard order sets are provided below.

Font style and size

  • Elaborate serif fonts are used, which are harder to read
  • Less than a 12-point font size is used

Use of space

  • Order sets are crowded and don’t allow space for handwritten entries
  • 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)
  • Check boxes are too small or too close together, allowing a single check mark to accidentally mark more than one box, thus activating unintended orders

Symbols, abbreviations, dose designations, punctuation

  • Use of error-prone apothecary system or household measurements
  • Brand names listed without generic names; generic names for single brand products without brand name
  • Commas not appropriately placed when using whole numbers over 999 to express a dose (e.g., heparin 1000 units vs. heparin 1,000 units)
  • Large doses expressed using numerous zeros instead of word terminology (e.g., 1,000,000 vs. 1 million)
  • 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: www.ismp.org/tools/errorproneabbreviations.pdf)
  • Use of trailing zeros or decimal points without a leading zero when expressing doses
  • 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: www.ismp.org/tools/tallmanletters.pdf)

Prompts for patient information

  • 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

Layout and directions for use

  • Confusing numbering system for orders; numbers may be misinterpreted as the dose of the medication
  • Randomly grouped treatment, procedure, and medication orders in which medications may be overlooked among other types of orders
  • Orders for two different medications on the same line, increasing the likelihood that one of the orders is overlooked
  • Orders with the drug name and dose/strength on different lines 
  • Multiple pages of standard order sets that are not numbered as “page 1 of 3,” “page 2 of 3,” and “page 3 of 3,” etc.
  • Alphabetized lists of drugs from which to choose, with look-alike names near each other
  • The drug strength/concentration or dosage form most commonly used appears near the bottom of the list where it is less likely to be selected
  • Complex order sets (e.g., TPN) that list additives in a different sequence and doses in different units (e.g., mg vs. mEq) and different concentrations (mg/mL vs. mg/liter) than the pharmacy order entry system
  • Patient-controlled analgesia orders that list dosing and infusion rate parameters in a different sequence and strength presentation than the infusion pumps used to deliver the medications
  • Important patient information (e.g., allergies, weight) appears at the bottom of the screen/form, which the prescriber may fail to observe or notice only after the orders have been activated
  • No directions for completing the order set and activating desired orders
  • Inconsistent placement of check boxes (e.g., at the beginning or end of the listed medication [as on many medication reconciliation forms])
  • List of all possible medication orders not separated with “OR” when only one choice is expected (fosters the use of multiple medications) 
  • 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)
  • Nonstandard location and format for dating/timing the orders; signing the orders; name of the hospital; name of the order set; page number; date of review; placement of a barcode (if applicable) 

Approval and Maintenance
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. Examples of frequently observed problems with the approval and maintenance of standard orders follow.

  • Order set never approved by the organization’s pharmacy and therapeutics (or another appropriate) committee
  • Outdated order sets that have not undergone recent clinical review
  • Old typed preprinted order sets that are copies of copies (information cut off, stray marks on the forms)
  • Outdated order sets that are still in use for months/years after new/revised order sets have been adopted 
  • Staff unable to access updated order sets online via an Intranet
  • Order sets sent or brought into the hospital from physician offices or other hospitals that have never been approved
  • Order sets that include nonformulary items, drugs with therapeutic substitutions not specified, and medications that have been withdrawn from the market or have new boxed warnings that should limit their use
  • Order sets with conflicting instructions that do not coincide with current hospital policy (e.g., drug verification checking processes) and equipment (e.g., types of infusion pumps available)
  • Order sets without a tracking number and approval/revision date

Ensuring consistent use of well-designed order sets and maintaining the orders in accordance with best practices requires vigilance and a team approach.(4) Because standard order sets are often an important component for implementing clinical protocols, algorithms, critical pathways, and guidelines, organizations should establish an interdisciplinary process with rules to help design, evaluate, use, and maintain these orders. Professional staff need clear directions to follow if they encounter order sets that do not comply with these rules.
To assist with the evaluation of order sets, ISMP has created Guidelines for Standard Order Sets in the form of a checklist, which is on our Web site (www.ismp.org/Tools/guidelines/default.asp). Additionally, in the Agency for Healthcare Research and Quality publication, Advances in Patient Safety: New Directions and Alternative Approaches, Ehringer and Duffy have published findings from a study they conducted on preprinted orders and how they can be used to promote best practices (www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Ehringer_17.pdf).4 The authors include several tables and an appendix that can be used to guide the creation and review of standard order sets. With these two resources, hospitals can begin to establish an effective process for designing, evaluating, updating, and enforcing safe use of standard order sets. 

References:
1) ISMP. Design of preprinted cancer chemotherapy order forms is critical for patient safety. ISMP Medication Safety Alert! 1996;1(3):2.
2) ISMP. Designing preprinted order forms that prevent medication errors. ISMP Medication Safety Alert! 1997;2(8):1-2. Available at: www.ismp.org/Newsletters/acutecare/articles/19970423.asp.
3) ISMP. It’s time for standards to improve safety with electronic communication of medication orders. ISMP Medication Safety Alert! 2003;8(4):1,3-4. Available at: www.ismp.org/Newsletters/acutecare/articles/20030220.asp.
4) Ehringer G, Duffy B. Promoting best practice and safety through preprinted physician orders. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: New directions and alternative approaches. Vol. 2. Culture and Redesign. AHRQ Publication No. 08-0034-2. Rockville, MD: Agency for Healthcare Research and Quality; August 2008. Accessed on February 9, 2010, at: www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Ehringer_17.pdf

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