POLICY. Medication means prescription and non-prescription products including vitamins, minerals and electrolytes as well as parenteral nutrition.

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POLICY Number: Title: ORDERING OF MEDICATIONS Authorization [ ] President and CEO [X] Vice President, Finance and Corporate Services Source: Vice President, Quality and Interprofessional Practice
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POLICY Number: Title: ORDERING OF MEDICATIONS Authorization [ ] President and CEO [X] Vice President, Finance and Corporate Services Source: Vice President, Quality and Interprofessional Practice Cross Index: Date Approved: November 5, 2007 Date Revised: May 13, 2013 Date Effective: July 17, 2013 Date Reaffirmed: Scope: Acute Care Any PRINTED version of this document is only accurate up to the date of printing. Saskatoon Health Region (SHR) cannot guarantee the currency or accuracy of any printed policy. Always refer to the Policies and Procedures site for the most current versions of documents in effect. SHR accepts no responsibility for use of this material by any person or organization not associated with SHR. No part of this document may be reproduced in any form for publication without permission of SHR. DEFINTIONS Emergent and urgent circumstances are interpreted to mean that, without a verbal/telephone medication order, the patient's safety and care would be compromised and the Most Responsible Physician (MRP) or other approved prescriber is unable to attend to the patient and personally write the medication order. Medication means prescription and non-prescription products including vitamins, minerals and electrolytes as well as parenteral nutrition. NOW or ASAP (as soon as possible) means the need for a faster response than routine, but is not considered an emergency. The order will be handled as an exception, but all other work does not need to be immediately put aside until the request has been handled. The medication will be delivered to the nursing unit within 60 minutes of receipt of the order. Registered or licensed nurse(s) means RNs, GNs, RPNs, LPNs and GPNs throughout the document. ROUTINE means all other written medication orders; medication will be supplied for and started if the administration time is less than half-way to the next scheduled administration time unless otherwise requested. STAT means an emergency or life-threatening situation where an immediate response is required. All other work is put aside until the request has been answered. Stat medication orders do not apply to topical or oral medications or the first dose of a parenteral antibiotic (with the exception of an antibiotic needed for suspected bacterial meningitis or severe sepsis). Telephone Medication Order means orders given over the telephone. Page 1 of 13 Verbal Medication Order means orders given by the MRP or other approved prescriber when they are personally present. 1. PURPOSE The purpose of this policy is to establish SHR s requirements for ordering of medications. 2. PRINCIPLES 3. POLICY 2.1. Many medications require authorization (i.e. a prescription ) from an eligible prescriber Specific information is required for a prescription to be valid Following best practice recommendations surrounding medication management leads to improved safety A consistent approach to ordering of medication enhances medication safety, reduces potential for medication errors and increases efficiency in the medication distribution system. General 3.1. SHR recognizes the following disciplines as approved prescribers1: Licensed physicians (who are members of the SHR Practitioner Staff) Licensed dentists (who are members of the SHR Practitioner Staff) Medical residents Registered nurse (Nurse Practitioners) (RN (NPs)) in accordance with SRNA Bylaws 2003 and the Registered Nurse (Nurse Practitioner) Standards and Core Competencies Registered midwives (RM) in accordance with the Midwifery Regulations 2008 (who are members of the SHR Practitioner Staff) Licensed pharmacists in accordance with The Pharmacy Act 1996 and the Regulatory Bylaws September 2011 of the Saskatchewan College of Pharmacists Those authorized to order medications under the SHR Policy Transfer of Medical Function Medical students are authorized to write orders but the orders must have clear documentation of agreement (i.e. countersignature) by the MRP or other approved prescriber before being acted upon by Pharmacy or Nursing All medications taken prior to admission shall be documented on the Preadmission Medication List Physician Order Form (form # and #102729) or the autopopulated Pharmaceutical Information Program Preadmission Medication List / Physician Order Form. 1 Procedures for ordering medications apply equally to physicians, dentists, RN(NPs), registered midwives, pharmacists and those approved by a Transfer of Function policy however the phrase MRP or other approved prescriber will be used within the document for brevity. MRP refers to the most responsible physician. Page 2 of 13 3.4. Clinically accurate allergies must be documented and reviewed before medications are prescribed, dispensed or administered to patients All medication orders shall be documented, legibly written, signed by the MRP or other approved prescriber and placed in the patient chart on: a Physician s Orders form (form #101091) Preadmission Medication List Physician Order form (form #102728) Autopopulated Pharmaceutical Information Program Preadmission Medication List / Physician Order Form an approved Order Set form a Medication Order Change form (form #102608) or on an approved Medical Directive Order Set form (no prescriber signature required in this case) other approved order forms at the department level The text of the medication order shall include all information necessary to allow for accurate interpretation, dispensing and patient administration Pharmacists are authorized to withhold the dispensing of a medication until all required clarifications are completed. If it is determined patient safety may be compromised, such orders must be discussed with the MRP or other approved prescriber, the medical department head or the Vice-President or Medical Affairs. The clarification process should be documented in the health record Registered or licensed nurses are authorized to withhold processing an order or administering a medication if an order needs clarification. The registered or licensed nurse contacts the prescriber and Pharmacy (as required) to discuss the order. If the concern remains, the registered or licensed nurse contacts the next responsible physician (resident, attending physician, MRP) to clarify the order and advise that the medication will be withheld until the order is clarified. If the concern still remains, the registered or licensed nurse contacts the Manager of Nursing or designate or Patient Care Supervisor for further direction. Document the above actions on the Progress Notes and on a Medication Incident Report. Written Orders 3.9. Written medication orders shall be the preferred method of prescribing medications. Verbal/Telephone orders Telephone medication orders are acceptable when absence of the medication order prior to the MRP or other approved prescriber s arrival would cause patient detriment (e.g. allergic reaction), duress (e.g. analgesia required) or Page 3 of 13 maintenance of the patient s present state is dependent upon the order (e.g. insulin) Verbal orders will be accepted only under emergent and urgent circumstances. Whenever possible the prescriber personally writes the order Verbal and telephone medication orders transcribed onto an appropriate order form shall be countersigned within 24 hours by the prescriber Verbal or telephone medication orders shall be given to SHR employed registered or licensed nurses, licensed pharmacists, registered respiratory therapists, dieticians or Medical Radiation Technologists only when the physician is unable to attend to the patient and write the order, and a delay in ordering the medication would compromise patient safety and care Registered respiratory therapists shall only accept verbal or telephone orders for medical gases and medications given by inhalation (e.g. oxygen, salbutamol, ipratropium) Dieticians shall only accept verbal or telephone orders for those items recommended by the Parenteral and Enteral Nutrition Subcommittee and approved by the Pharmacy and Therapeutics Committee and Practitioner Advisory Committee (e.g. enteral and parenteral nutrition prescriptions, total IV fluids and select medications including sodium bicarbonate and pancreatic enzymes to clear clogged feeding tubes, gastric pro-kinetic and motility agents and anti-nauseants) Medical Radiation Technologists shall only accept verbal or telephone orders for IV contrast media The receiver of the verbal or telephone medication order must re-confirm the identity of the patient and read back the specifics of the medication order. Patient Transfers Medication orders shall remain active when a patient is transferred from one physician to another, one general nursing unit to another, one critical care unit to another, an operating room to a critical care unit or from a critical care unit to a general nursing unit, unless the orders are altered or cancelled by the MRP or other approved prescriber assuming the care of the patient Medication orders shall remain active on patient transfer within and between acute care facilities with the exception of patients who are transferred from a general ward to a critical care unit. Drug orders shall be cancelled automatically when a patient is transferred into a critical care unit and shall be rewritten in full following review of the patient by the MRP or other approved prescriber. Hold Orders All medication orders put on hold for an unspecified length of time will appear on the Medication Administration Record as being ON HOLD and on the Patient Profile in a section specifically for held medications. Page 4 of 13 Top-Up Doses All new orders for an increase in dose should be acted upon at the next scheduled dosing time unless otherwise indicated by the MRP or other approved prescriber. Conditional Orders Orders that are written as conditional (i.e. a suggestion or recommendation) must have clear documentation of agreement (i.e. countersignature) by the MRP or designate before being acted upon by Pharmacy or Nursing Conditional orders which are not agreed to by the MRP or designate must have clear documentation of the disagreement Documentation of agreement or disagreement must occur within 24 hours of writing of the order. Range Orders Medication orders where both the dose and the interval are written as ranges are not permitted. Doses of narcotic written as a range in non-critical care areas should have a maximum dose no greater than 4 times the minimum dose Open ended orders such as titrate to comfort are not permitted Once a dose within the range is chosen and administered, no more medication under this order is permitted until the next time interval. Automatic Stop Order (ASO) ASOs provide the basis for the generation of a Medication Renewal List which lists the drug orders which will be stopped at midnight on the day designated unless reordered The duration of therapy for all drug orders shall be subject to a standard automatic stop order unless the MRP or other approved prescriber specifies a different time limitation or indicates the number of doses to be administered in the text of the medication order The following ASOs govern the duration of drug therapy for all medication orders. Medication Category ASO* Narcotic and Controlled Drugs, IV Ketorolac 5 days** Antibiotics (systemic and topical) 7 days Chronic prophylactic anti-microbials 60 days Antiretrovirals and antituberculosis 60 days All other medications 60 days * The ASO is 1 year in Ambulatory Care Program areas to align with provincial regulations for out-patient prescriptions. ** This ASO is 60 days in the Transitional Care Unit The MRP or other approved prescriber is authorized to override the standard ASO by writing a specific number of doses to be administered or a specific time in the Page 5 of 13 text of the medication order. The maximum override permitted for medication orders is 60 days Medications with specified or recommended durations of therapy will have the applicable automatic stop order applied (e.g. eptifibatide in acute coronary syndrome for 96 hours, pantoprazole infusion for 72 hours). Order Sets Order Sets include options to select routinely prescribed medications (eg. ASA 325mg po od) or medication orders which must be customized for each patient (i.e. dosage/ frequency recorded in blank spaces) Order Sets shall be restricted to situations where a series of standard orders are commonly used Order Sets shall adhere to the standard format for SHR health record documentation Order Sets shall be approved by a medical department head, and be reviewed and approved by pharmacy and nursing (see Appendix A) Order Sets which have wide applicability across many care groups shall also be approved by the Pharmacy and Therapeutics Committee and the Practitioner Advisory Committee Order Sets which are also Medical Directives will have clear documentation of the Medical Department, the name and number of the directive, the form number and approval date (see SHR Policy Medical Directives ). Automatic Substitutions Automatic substitutions will be used to streamline care processes by substituting an equivalent medication, dosage form or schedule of administration when a medication is ordered Automatic substitutions will be recommended by the Pharmacy & Therapeutics Committee and approved by the Practitioner Advisory Committee Medication changes under the automatic substitution policy will be initiated by a pharmacist Pharmacists will document the occurrence of an automatic substitution by leaving a written order in the patient s health record. Nursing will administer medications changed by the automatic substitution policy without requiring the MRP or other approved prescriber to countersign the order. Medications that can be kept at the patient s bedside The following medications are approved to be kept at the patient s bedside if deemed appropriate by the RN: nitroglycerin tablets/spray oral contraceptive tablets Page 6 of 13 inhalers topical medications throat lozenges Medications for Outpatient Use Out-patient prescriptions shall be written whenever possible. In exceptional circumstances a maximum of 12 hours of doses can be sent home with patients from acute care sites. Discharge Medication Documentation The MRP or designate documents all discharge medications in the patient chart prior to discharge The MRP or other approved prescriber writes out-patient prescriptions for all new or changed medications. 4. ROLES AND RESPONSIBILITIES 4.1. Approved Prescribers Write medication orders in accordance with the policy or procedures outlined in this document Nurse/Pharmacist/Respiratory Therapist/Dietician Familiarity with and adherence to the professionally relevant policies and procedures outlined in this document. 5. POLICY MANAGEMENT The management of this policy including policy education, monitoring, implementation and amendment is the responsibility of the Vice President, Quality and Interprofessional Practice. 6. NON-COMPLIANCE/BREACH Non-compliance with this policy will result in a review of the incident. Repeated noncompliance may result in disciplinary action, up to and including termination of employment and/or privileges with SHR. 7. REFERENCES SRNA Bylaws 2003 Registered Nurse (Nurse Practitioner) Standards and Core Competencies 2003 Midwifery Regulations 2008 The Pharmacy Act, 1996 Regulatory Bylaws of the Saskatchewan College of Pharmacists September 2011 Page 7 of 13 PROCEDURE Number: Title: Ordering of Medications Authorization [ ] President and CEO [X] Vice President, Finance and Corporate Services Source: Vice President, Quality and Interprofessional Practice Cross Index: Date Approved: November 5, 2007 Date Revised: May 13, 2013 Date Effective: July 17, 2013 Date Reaffirmed: Cross Index: Scope: Acute Care 1. PURPOSE The purpose of this procedure is to establish the process for ordering of medications and addressing common situations related to medication management. 2. PROCEDURE 2.1. Written Medication Orders (for MRP or other approved prescriber) Confirm allergy status prior to writing medication orders Write medication orders in black pen on an appropriate order form addressographed/stickered with the patient identity Include the following information in the text of the medication order: date and time the medication order is written drug name using generic drug names for single entity drug products dosage (using the metric system where appropriate or possible and avoiding doses expressed in volumes where appropriate or possible) route of administration frequency of administration duration of administration, when necessary signature plus printed name Indicate on the order sheet that necessary criteria have been met when ordering reserve, investigational or study drugs Do not modify a patient order once written and processed Do not use any dangerous abbreviations, symbols and dose designations as per ISMP Do Not Use List (See SHR Abbreviations Policy ). Page 8 of 13 2.2. Verbal and Telephone Medication Orders The MRP or other approved prescriber: Gives verbal and telephone medication orders only in emergent and urgent circumstances and only to those approved to take verbal and telephone medication orders (see Policy 3.13) Provides all the necessary information required for complete documentation of the medication order (see 3.1). Requires the receiver of the verbal or telephone medication order to re-confirm the identity of the patient and read back the specifics of the medication order. Countersigns the verbal or telephone medication order within 24 hours from the initial communication of the medication order The registered or licensed nurse, licensed pharmacist, registered respiratory therapist, dietician or medical radiation technologist: Accepts verbal or telephone medication orders from the MRP or other approved prescriber under urgent or emergent circumstances. Confirms the verbal or telephone medication order by repeating the patient identity and specifics of the medication order back to the MRP or other approved prescriber. Transcribes the verbal or telephone medication order on the appropriate order form including all information required for complete documentation of the medication order (see 3.1). Indicates the medication order is a verbal order (V.O.) or telephone order (T.O.) and signs the order with the name of the prescriber per his/her name and professional designation Automatic Substitution Policy for Medications The pharmacist will document the occurrence of an automatic substitution by leaving a written order in the patient s health record. The order will be written on either the Physician s Orders (form #101091) or Physician s Orders - Medication Order Change form (form #102608). The pharmacist will: discontinue the original medication order write the new medication order write Automatic substitution approved by PAC beneath the new medication order and sign plus print their name Page 9 of 13 Registered or licensed nurses will administer medications changed by the automatic substitution policy without requiring the MRP or other approved prescriber to countersign Order Sets Order Sets being developed or modified must be approved by a medical department head, pharmacy and nursing The Order Set Request form (Appendix A) shall be used for the approval and review of the Order Set The form shall be reviewed and signed by the medical department head and the Manager of Nursing or designate of the clinical area where the form is intended for use and forwarded to the main Pharmacy Office at Royal University Hospital The master copy of the Order Set will be numbered and maintained by SHR Printing Services. Copies of the approved forms will be printed upon request OR Drug Cancellation Procedure For Inpatients: The MRP or other approved prescriber writes orders for medications which are to be administered pre-operatively on the day of surgery. The MRP or other approved prescriber writes orders for me
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