Medication Orders with Future Start Dates: How Far Away Is Too Far?

Problem: We received a report about an error that occurred when a pharmacist mistakenly scheduled a daily antibiotic to start the following year instead of the next day. The scheduling error led to omitting one of two prescribed antibiotics, which was not identified until the patient was discharged. Medications with a future start date are needed for hospitalized patients in certain circumstances. For example, there may be weekly or monthly infusion orders, preoperative antibiotics to be administered the day of surgery, vaccines for infants with a prolonged neonatal intensive care unit stay, long-acting antipsychotic injections, and contrast media for radiographic examinations scheduled in advance. However, we cannot think of a single situation in which medication orders would require a future start date of a year or more. Unfortunately, in this case, the electronic health record (EHR) failed to alert the pharmacist to the scheduling error.

The Event

While being treated in the emergency department (ED) and waiting for admission to the hospital, an elderly patient with abdominal pain and diverticulitis received a dose of intravenous (IV) cefTRIAXone and IV metroNIDAZOLE. The admitting physician placed orders to continue the intermittent infusions of IV cefTRIAXone every 24 hours and IV metroNIDAZOLE every 8 hours. Since the first dose of cefTRIAXone had already been administered in the ED, the pharmacist intended to advance the cefTRIAXone start date to the following day, which was the first day of a new month. Instead, the pharmacist entered and verified a start date of the first day of the new month in the following year.

While hospitalized, the patient received IV metroNIDAZOLE every 8 hours as ordered. However, the prescribed daily dose of IV cefTRIAXone was never administered, although the hospitalist managing the patient thought it was being given. Many nurses also thought the antibiotic was being administered during other shifts since only the medications due on their shift were prominently visible on the electronic medication administration record (MAR). While the hospital had implemented pharmacist rounding on certain high-acuity units, during which each patient’s medication profile was reviewed, this patient was in a unit without rounding. During the week, the patient’s condition deteriorated and the patient underwent exploratory abdominal surgery. Postoperatively, the surgeon discontinued the IV cefTRIAXone and IV metroNIDAZOLE orders, and the hospitalist then prescribed IV cefepime and IV metroNIDAZOLE. The patient’s condition improved, and therapy was switched from IV to oral antibiotics, which were continued upon discharge.

A pharmacist reviewing the patient’s antibiotic history prior to discharge discovered that the IV cefTRIAXone had not been administered. After review of the event, the organization determined that the omission of cefTRIAXone did not play a role in the patient’s deteriorating condition or the need for surgery. However, a prescribed medication with a future start date that has been omitted due to a scheduling error can potentially harm patients, particularly if the medication is critical to the patient’s treatment regimen.

How Scheduling Errors Happen

The primary methods used to schedule medications with a future start date in a hospital’s EHR are outlined below. Our goal is to describe how each methodology capitalizes on human factor characteristics that might assist users in scheduling medications, and then describe the error risks associated with using that methodology.

Calendar tool. Many EHR vendors incorporate a calendar to assist users in modifying the start date of an order. The calendar tool uses visual cues in conjunction with a mouse click to select the correct date, rather than relying on the user to manually type the date using a keyboard. However, the calendar tool can contribute to selecting the wrong date, especially if the arrows to advance the month and year are both provided on the same line or directly above and below each other (Figure 1). During investigation of the event, the pharmacist recalled using the calendar tool, intending to advance to the first day of the following month but inadvertently advanced the year, as well. Calendar tools used for home computers are often designed to advance 1 month at a time, which reduces the risk of errors associated with inadvertently advancing the year.

T+1 keyboard shortcut. Pharmacists and prescribers may use the shortcut, T+1 (today plus 1 day), if available to advance the start date of a medication to the next day. (Other shortcuts may include T+2 [2 days from today], M+1 [same day next month], and so on.) Using the shortcut T+1 instructs the computer to advance the start date to the next day, making it easy and efficient for the user. However, if you look at a standard QWERTY computer keyboard, you will notice that the T and Y keys are right next to each other, making it easier to strike the wrong key due to their proximity. If Y+1 is entered instead of T+1, the order date advances by 1 year rather than 1 day.

Manually entering the start date. Another option for advancing the start date is to manually type over the current default date to the desired future date. This may require up to 10 keystrokes in various order formats (e.g., YYYY_MM_DD, MM/DD/YYYY, DD/MM/YY, D/M/YY). Manually entering the date or typing over the default date risks a keystroke error, resulting in the incorrect start date.

Difficulty Detecting the Error

While omission errors are common, future date errors may be underreported because errors with medications that start in the future are not easy to detect. For example, the EHR in the hospital involved in the error above employs a hard stop that will not allow the user to proceed if a medication is ordered or scheduled with a start date in the past. However, if a medication order is entered or scheduled with a start date in the future, no warning appears on the screen, and a hard stop does not exist. If the month and day are correct, users may not even notice that an incorrect year has been selected.

Also, in the hospital where the error occurred, prescribers and pharmacists can use certain tabs in the EHR to view a list of all active medication orders, which includes medications with a future start date; however, medications with future start dates do not stand out in any way, and all orders on the active MAR are displayed in a similar color and font. Also, links that automatically pull text into progress notes included a list of all current medication orders, including cefTRIAXone with the notation “[START ON XX/XX/2023].” But the incorrect year was not noticed, and the provider’s progress notes stated that the patient was receiving cefTRIAXone when he was not. For nurses, medications with a future start date appeared on the MAR in a separate section below the active orders; however, the customizable time frame excluded medications with start dates far in the future, so medications starting a year or more away were not displayed at all.

Safe Practice Recommendations: To reduce the risk of errors when scheduling medications with a future start date, consider the following recommendations.

Assess for Risk

• Run queries in your EHR and conduct a failure mode and effects analysis (FMEA) to assess the risk for this type of error in your organization, closely reviewing the answers to the following questions:

  • Capability. Run a test to determine if the EHR accepts orders for medications with a future start date. How long in the future does your EHR allow start dates for medications? A year or more? Do any alerts or hard stops fire?

  • Scope. How often are medications with a future start date prescribed, which medications are involved, and how far in the future have medications with future start dates been scheduled? Is it a reasonable time frame?

  • Appropriateness. Are the involved medications appropriate for a future start date?

  • Process. What methodologies have been used to schedule medications with a future start date? Are there any error-prone shortcuts that can be used to advance a medication order start date? If your system has a calendar function, what does it look like? Is it intuitive for users to advance the month without changing the year? Is it easy to simply advance by a year instead of a day? Does the workflow allow for pharmacists to verify orders months in advance, or do future orders need to be activated closer to the start date? At what point does the automated dispensing cabinet (ADC) allow a medication with a future start date to be retrieved?

  • Appearance. In the EHR, what does a medication with a future start date look like to prescribers, pharmacists, and nurses? Is it different than current orders? Is the information confusing, or is the information hard to find or missing? How is this information communicated to others on the care team?

  • Scheduling. Have medications with future start dates been correctly scheduled for administration?

  • Administration. Have medications with future start dates (that have already passed) been correctly administered or fulfilled as prescribed?

Restrict the “Year” Shortcut

• Work with your informatics team and EHR vendor to restrict the “Y+1” or “Y+__” shortcut, if available, from being applied to the medication order start date field. Confirm that the shortcut will not work if practitioners accidentally select the “Y” key instead of the “T” key when scheduling medications with a future start date.

• If the shortcut cannot be disabled, use ergonomic keyboards that separate the T and Y.

Create Alerts and a Hard Stop

• Consider building an interactive alert for inpatient medications with an organization-defined future start date (e.g., 1 to 11 months in advance), which requires the prescriber and verifying pharmacist to confirm the accuracy of the future start date.

• Create a hard stop for inpatient medications prescribed or scheduled with a future start date of 1 year or more, which will not allow the prescriber or pharmacist to proceed.

Display Future Medications

• Ensure all prescribed medications, including discontinued/completed medications and medications with a future start date, appear on electronic medication lists, and all active medication orders, including medications with a future start date, appear on MARs. On the MAR, also ensure that future medications display the start date and time, ideally with a visual cue (e.g., grayed out) that the medication should not be administered prior to the future start date.

Differentiate Future Medications

• On both the MAR and an electronically compiled list of all medication orders, prominently differentiate (e.g., using color, bolding, other type of highlighting) medications with a future start date of more than 24 hours from medications currently being administered and medications that have been discontinued or completed.

Reconcile Medications

• During transitions in care, conduct medication reconciliation to identify any prescribed medications that have not yet been administered because of a future start date. This includes reconciling medications prescribed upon admission with medications the patient took at home as well as medications they received in the ED or another transitory location in the health system.

Review Medications Daily

• Encourage prescribers, pharmacists, and nurses to conduct a daily review of their patients’ medication orders, including active medications that are being administered currently, medications with future start dates, and discontinued medications. Using the MAR for this review provides an additional opportunity to identify the frequency of administering PRN medications or the patient’s (or family’s) refusal of prescribed medications to ensure appropriate follow-up in the plan of care.

• Organizations may use software systems, often integrated with the EHR, to automatically generate daily reports of future orders beyond a certain time frame for practitioners to review to help identify these types of errors.

Conduct Interdisciplinary Rounds

• Conduct interdisciplinary team rounding during which completed, current, and future medications for each patient are discussed. Rounding with an interdisciplinary team to discuss the care of a patient in real time can be a valuable tool that detects errors and improves quality and safety.

Communicate and Educate

• Include the time that medications were last administered during transitions of care handoffs, between shifts and between hospital units, using a standardized method to enhance communication (e.g., SBAR [situation, background, assessment, recommendation]), and document pertinent information discussed in the EHR.

• During nursing orientation, stress the importance of completing the MAR medication order acknowledgment step, which could help identify scheduling errors.

• If the medication with a future start date is an antibiotic, ensure your antimicrobial stewardship surveillance program will detect an error of omission due to an incorrect future start date.

• Communicate the plan of care with the patient and provide them with a copy of their medication list (including discontinued, current, and future medications) to serve as a layer of redundancy and another chance to catch medication errors including omissions.

• Alert staff to this type of medication error and the steps taken by the organization to prevent these errors.

^{Suggested citation:}

^{Institute for Safe Medication Practices (ISMP). Medication orders with future start dates: how far away is too far? ISMP Medication Safety Alert! Acute Care. 2022;27(14):1-4.}