Given the financial incentives recently made available through the federal government and many other sources to help establish EMR’s (electronic medical records), most healthcare organizations are scrambling to get their EMR’s up and running and meet criteria for “meaningful use” or to qualify for certification as a PCMH (patient-centered medical home). CPOE (computerized physician order entry) is a key part of the EMR and use of standardized order sets is extremely important in CPOE.
Most people are concerned about making sure their standardized order sets are evidence-based. But an equally important goal is making sure that standardized order sets do not inadvertently introduce errors (unintended consequences). We have seen a few examples of the latter. As we implemented the more extensive list (i.e. ISMP list) of dangerous abbreviations we had to go through all sorts of software packages to ensure they had been purged of such dangerous abbreviations. Yet a few kept popping up and we were able to trace them to CPOE order sets. Similarly, when a decision to cease automatic stop orders for certain drugs was made we had to go into the pharmacy computer system to remove all those automatic stop orders. Yet they occasionally popped up anyway – they were embedded in some CPOE order sets.
So you can see there are many considerations for order sets that extend far beyond inclusion of all evidence-based interventions. ISMP (Institute for Safe Medication Practices) has recently put out a great new tool: ISMP’s Guidelines for Standard Order Sets. The guideline is in a checklist form so that you can go over each standardized order set to ensure that it meets all these important criteria. It applies to both paper-based order sets and electronic ones.
While it has the usual medication safety items you’d expect from ISMP (eg. excludes dangerous abbreviations, coined names, drugname abbreviations, and avoids trailing zero’s, uses tall man lettering for drugs from look-alike/sound-alike pairs, etc.) it has a whole host of practical recommendations for other things such as format, font style, consistency, prompts, multidisciplinary oversight, maintenance of order sets, etc.
It, of course, stresses the importance of using a standard format so that the look and feel and manner of use is consistent across order sets. But it also stresses the importance of differentiating order sets from each other. For example, you might have several anticoagulation order sets for different purposes and you need to ensure that the wrong one is not inadvertently selected and used. Similarly, the header of the order set should specify the population for whom the order set is intended (eg. pediatrics vs. adult, etc.).
It even has good recommendations about the method of selecting items in an order set. For example, they note that yes/no checkboxes may be problematic and that, particularly with paper-based order sets, a single check box to activate the order may be preferable.
It’s advice about ensuring that medication orders do not span multiple lines is a good one (so the drug name and dose/strength do not appear on separate lines). And it emphasizes the need for adequate space between the end of the drug name and the beginning of the dose for those drug names ending in the letter “l” (eg. so “propranalol 20 mg.” does not look like “propranalol20 mg.” resulting in dispensing a 120 mg. dose). Note that one of our own recommendations when using paper-based order sets is to use separate columns for drug name and drug dose to prevent the terminal letter “l” from running into the dose.
In their discussion of prompts they recommend only using metric measurements for inputting height and weight. Numerous medication errors have occurred when drug dosage calculations are done after pounds and kilograms have been confused during entry of patient’s weights.
The guideline even stresses the importance of proof-reading and spell-checking for typos. A favorite example we use of unintended consequences: your spell checker in your word processor may be configured to automatically “correct” certain frequently made errors. Our favorite is “EHR” for electronic health record often gets “corrected” to “HER”. (Just try that in your word processor – we be it will happen to you, too!). Since most order sets, whether paper-based or electronic, are developed in some form of word processor they are prone to the same unintended consequences. So proof-read very carefully.
The guideline calls for inclusion of the indication for each medication. We have long been advocates of mandating the indication for each medication (see our October 23, 2007 Patient Safety Tip of the Week “Medication Reconciliation Tools”). Many of the available medication order entry tools or medication reconciliation forms currently in use lack a field to clarify the indication for which the medication was prescribed. Knowing the indication is extremely important in avoiding look-alike/sound-alike medication errors. Many medications (eg. beta-blockers) also may have several indications and you need to know which one applies to your patient. And the dosage of the medication may vary depending upon the indication for use. Also, your clinical decision support tools may need to know whether an antibiotic is being ordered for prophylaxis vs. treating an actual infection. Similarly, most medication forms and lists fail to include reason for discontinuation. It is important to know if a medication was discontinued because of lack of efficacy, side effect, allergy, or formulary or economic reasons. So we would like to see order entry tools include prompts when an order to discontinue a drug is entered.
Speaking of prompts, the ISMP guideline has some very good recommendations about prompts. They recommend prompts for stopping for specific drugs (eg. hold insulin if enteral feedings held) and prompts for renal dosing.
The ISMP guideline also recommends avoiding drug dose range orders unless accompanied by very specific objective parameters that will be used to determine the correct dose (This has been a big problem for many insulin orders. For a great discussion of that problem, see the March 2010 issue of the Pennsylvania Patient Safety Advisory). And the ISMP guideline cautions against including blanket-type orders (eg. laxatives, sleep meds, antiemetics, antidiarrheals, antacids, etc.) that often get written more so that the physician does not get awakened.
It also includes sections on specific issues such as chemotherapy, intravenous and epidural medications, pediatric dosing, Beer’s list in the elderly, and analgesics. It has specific recommendations for “rounding of doses” (see our September 9, 2008 Patient Safety Tip of the Week “Less is More….and Do You Really Need that Decimal?” for a discussion about problems related to decimal points that were not really needed).
The ISMP guideline has some great practical tips on paper-based order sets such as not printing out reams of order sets such that an old order set might eventually be used after the order set has been revised. And it has recommendations about taking care that lines are not present on the back copies of order forms (which lead to problems if copies are faxed) and avoiding NCR forms that might pick up unintended marks on back copies.
ISMP, as usual, has done a great job putting together this useful guideline. We hope that all healthcare organizations will use it as they develop standardized order sets and that the large order set vendors out there will incorporate these guidelines into their processes for order set development.
Institute for Safe Medication Practices. ISMP’s Guidelines for Standard Order Sets. 2010
Pennsylvania Patient Safety Authority. Medication Errors with the Dosing of Insulin: Problems across the Continuum. Pa Patient Saf Advis 2010; 7(1): 9-17