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 firstname.lastname@example.org.