Design a mistake-proof preprinted order form
Collaborations produce best results
As more and more health care systems switch to preprinted forms for algorithms, protocols, critical pathways, and guidelines, many are enjoying an accompanying decline in medication errors. But not always.
The Institute for Safe Medication Practices (ISMP) warns that preprinted forms can easily be a source of errors. In the March 12 issue of Medication Safety Alert!, the Institute’s editors described a case in which a preprinted order listed the dose of magnesium sulfate as 16 g (130 mEq) instead of 16 mEq (2 g).
Because it was on a preprinted order, the pharmacist assumed it was correct and dispensed the dose. The patient became hypotensive but recovered.
Even if preprinted forms are approved by committees in an extensive review process, errors can get into print. The ISMP recommends these guidelines when evaluating and using order forms:
• Don’t use preprinted orders unless all disciplines are involved in the process of developing, reviewing, and approving the forms.
• Don’t allow orders unless they coincide with hospital policy. (The directive, "renew all previous orders," for example, is not permitted in many hospitals.)
• Avoid preprinted hospital orders sponsored or prepared by pharmaceutical companies, because they may promote a specific product or list nonformulary items. Be sure that blank order forms are accessible only to authorized personnel.
• Avoid ambiguous statements such as "unless allergic, give . . ." because they transfer clinical and legal responsibility from the prescriber to others down the line. Develop and use a uniform system to indicate which orders should be followed.
• Use generic names on forms and specify the reason for administration whenever possible. For single-source items, brand name also should be included.
• Make sure no forbidden abbreviations or dangerous dose designations are used on the forms. Each hospital should have a list of these.
• Require the dose per M2 or dose per kg for all chemotherapy and pediatric orders when a calculated dose must be entered.
• Do not include a list of drugs to choose from, because it is too easy to choose the wrong one. (Vincristine, for example, has been confused with vinblastine.)
• Design the form so physicians must enter the daily dose and number of days for any multiple-day regimens.
• Express doses by metric weight (such as 5 mg) rather then by number of tablets, mL, or other measurements, unless the drug isn’t measured by weight (such as milk of magnesia).
• Avoid coined names like "magic mouthwash" or "banana bag" because they may be misunderstood by people unfamiliar with them.
• Enhance readability by using type styles that are of professional quality. Proper spelling and spacing are important. (Propranolol20 mg, for instance, is easily misread as propranolol 120 mg.)
• Lines on back copies of any order form are unnecessary and may hide decimal points or portions of a number or name. Tell the printer to leave them off.
• Print a tracking number and revision date on the form to ease replacement.
• Review all preprinted orders every two to three years or when protocols change.
[Editor’s note: For more details, contact the Institute for Safe Medication Practices, 300 W. Street Road, Warminster, PA 18974. Telephone: (215) 956-9181. Or access ISMP’s newsletter at www.ismp.org.]
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