Microsoft word - audit_reviewer_guide_june12 08.doc

Medication Order Writing Audit – Guide for Reviewers This document is a reference for those auditing prescription orders in an institutional setting (hospital or personal care home). The guide is designed to be comprehensive in assessing orders both for completeness and for use of abbreviations known to increase the risk of medication errors. Depending on whether a facility or region plans to implement an entire medication order writing standard, or just a banned abbreviation list, all of the audit points may not be relevant. It will be up to the individual facilities or regions to decide how comprehensive an audit is to be undertaken. Although, it should be noted that collecting more data the first time is easier than going back to re-collect data, so it may be wise to err on the side of collecting more information although it may not be used. The reviewer should treat each medication ordered as a separate prescription. For example although the following drugs are ordered as a group, they should be audited as 3 separate orders: Dimenhydrinate 25mg tab PO q4h PRN for nausea Reviewers should utilize the document entitled “Audit_Worksheet_June12.08” to record information on each of the audited orders. The row numbers provided in brackets indicate in what row of the spreadsheet (Audit_Spreadsheet_Jun12.08) the information is to be entered. Audit Items for Banned Abbreviations Orders Without Leading Zero (.x) Any order written without a leading zero (the zero before the decimal place of a numerical value that is less than 1). Orders Written with Trailing Zero (x.0) Any order written with a trailing zero (the zero after the decimal place of a numeric value that is greater than 1 but still a whole number). Order Written With Abbreviated Drug Names Any order written using an abbreviated drug name. Common examples include AZT, CPZ, HCTZ, MSO4. Total Number of Once Daily Orders Any order written for a medication dosed once daily. Once Daily Orders Written: QD, qd, OD, od Any order written for a medication dosed once daily that utilizes any of the banned abbreviations; QD, qd, OD, od. Total Number of Every Other Day Orders Any order written for a medication dosed every other day. Every Other Day Orders Written as: QOD, qod, eod Any order written for a medication dosed every other day that utilizes any of the banned abbreviations; QOD, qod, eod. Any order written for a medication dosed in units. Unit Orders Written: U, u, iu, IU Any order written for a medication dosed in units that utilizes any of the banned abbreviations; U, u, iu, IU. Total Number of Sublingual Orders Any order written for a medication via the sublingual route. Any order written for a medication via the sublingual route that utilizes the banned abbreviations; SL. Any order written for a medication via the subcutaneous route. Subcutaneous Orders Written: SC, SQ, sub q Any order written for a medication via the subcutaneous route that utilizes any of the banned abbreviations; SC, SQ, sub q. Total Number of Eye/Ear Drop Orders Eye/Ear Drop Orders Written: AU, AS, AD, OU, OS, OD Any order written for eye or ear drops that utilizes any of the banned abbreviations; AU, AS, AD, OU, OS, OD. Total Number of Microgram Orders Any order written for a medication dosed in micrograms. Any order written for a medication dosed in micrograms that utilizes the banned abbreviation ug. Audit Items for Order Correctness and Completeness Illegible Prescriptions It is impossible to determine all or some aspect of the order due to illegibility. The order is written using a non-metric unit such as ounces, pounds or drams. Note that a drop (gtts) is technically considered a metric unit and is an acceptable unit of measurement for medication dispensed by a dropper. Dosage Form Used Instead of Metric Units The dosage form (ex. # of ampoules, # of pills) has replaced the metric units as the dosage designation. The dosage designation can be used in addition to the metric units. For example: acetaminophen extra strength ii tabs PO q4h PRN for pain acetaminophen 500mg ii tabs PO q4h PRN for pain Any aspect of the order is written over to correct information that was written incorrectly. In cases where an order is written incorrectly, a line should be placed through the incorrect component of the order and the information re-written. Patient’s name is absent from the order. From the example at the top of the page, if “Dean Smith” was not listed then for all 3 orders would be considered to have the patient name missing. Any patient identification number (hospital, MHSC, PHIN) is absent from the order. From the example at the top of the page if the PHIN was not listed then for all 3 orders would be considered to have the patient number missing. The order is not dated. From the example at the top of the 1st page, if “June 06, 2008” was not listed then for all 3 orders would be considered to have the date missing. The order has not included the time written. From the example at the 1st top of the page, if “1000h” was not listed then for all 3 orders would be considered to have the time missing. Order is written for the trade name of the drug and the generic drug name is not provided anywhere on the order. For example: Losec (omeprazole) 20mg PO Daily (also acceptable if the trade name is entirely absent) Order is written without the designation of a route. Order is written without a dose indicated for administration. In many orders the dose is represented by the strength of the medication. An example of where the dose is required is when the metric quantity designation does not describe the dose. For example: Ciprofloxacin 0.3% liquid to left eye BID Ciprofloxacin 0.3% liquid 2 gtts to left eye BID Order is written without the drug’s strength. Dilution & Rate or Time of Administration Missing Orders for intravenous bolus and infusion are written without dilution instruction, in other words what the base solution of the infusion should be (NS, D5W) and a rate of administration or a time over which the infusion should run. As a rule, many facilities maintain a standardized set of IV monographs (ex. the WRHA IV Monograph) which dictates what base solutions can be used and what maximum rates of infusion are. If a policy is in place that defers to this type of reference, then the prescription order would not require these instructions. However, in specialized settings orders may have to be written with this degree of specificity at all times. The order has not included how often the drug should be given or can be given in the case of as-needed therapy. Prescriber Identification Missing The prescriber has not been identified on the order. In the case of verbal orders, the nurse or pharmacist that took the verbal order and the name of the physician providing the verbal order should be included. Any order written for a medication on an as-needed basis. Any order written for a medication on an as-needed basis that does not contain the desired therapeutic outcome, indication for prescribing or treatment goal. Total Number of Orders for Patients < 50kg Any order written for a pediatric patient who weighs 50kg or less. Orders for <50kg Missing mg/kg Any order written for a pediatric patient who weighs 50kg or less that does not provide the dosage by weight (mg/kg/dose) or body surface area.

Source: http://www.mbips.ca/assets/audit_reviewer_guide_june12-08.pdf