Physician’s Order Policy Revision: Range Orders and Superseding Orders

The Duplicate Therapy Team of the Medication Safety Council has been evaluating the frequency and causes of duplicate and overlapping medication orders. Random audits reveal the majority of duplicates involve PRN pain medication orders. Even though established order set utilization may decrease the chance this will occur, orders are still added outside of the order set. In an effort to decrease the frequency of duplicate or overlapping PRN orders, the Physician’s Order Policy is revised.

Range Orders

To establish a process for interpreting medication orders that express the dose with a lower and upper limit so that the prescriber, pharmacist and nurse all have the same understanding about the patient treatment. This process will serve as the interpretation of range orders unless a practitioner specifies another desired interpretation within the order.

Example Order Transcribe to
Percocet 1 – 2 tabs po q4h prn for moderate to severe pain Percocet 1 tab po q4h prn for moderate pain and Percocet 2 tabs po q4h prn for severe pain

Superseding Orders (pain medications only)
In the absence of clear instruction, when a new order for a medication with the same indication/pain level is written (regardless of route of administration) the new order will supersede the initial medication and the initial medication will be discontinued from the patient’s medication profile.

Example #1 MAR Percocet 1 tab po q4h prn moderate pain Percocet 2 tabs po q4h prn severe pain Example # 2 MAR Percocet 1 tab po q4h prn moderate pain Percocet 2 tabs po q4h prn severe pain Example #3 MAR Oxycodone 5mg po q6h prn moderate pain Morphine 2mg IV q4h prn severe pain
A new order is placed Morphine 2mg IV q4 hours prn severe pain A new order is placed Morphine 2mg IV q4 hours prn severe pain not relieved by oral medication New orders are placed Percocet 1 tab po q4h prn moderate pain Percocet 2 tabs po q4hprn severe pain
New MAR Percocet 1 tab po q4h prn moderate pain
Morphine 2mg IV q4h prn severe pain
Discontinued by pharmacist per policy
Percocet 2 tabs po q4h prn severe pain
New MARPercocet 1 tab po q4h prn moderate pain Percocet 2 tabs po q4h prn severe pain Morphine 2mg IV q4h prn severe pain not relieved by oral medication New MARPercocet 1 tab po q4h prn moderate pain Percocet 2 tabs po q4hprn severe pain
Discontinued by pharmacist per policy
Oxycodone 5mg po q6h prn moderate pain Morphine 2mg IV q4h prn severe pain

Range orders with incomplete information will require a verbal/telephone clarification. An example of this is Percocet 1 to 2 tablets q4h for moderate pain (4-6). The handling of one-time orders will not change.

 

Glucose (oral) for hypoglycemia

An SBAR for Glucose Replacement for Hypoglycemia (available upon request) was presented to Trinity Health P & T Committee. The SBAR describes the efficacy and operational issues for liquid, tablet and gel glucose formulations.

Based upon efficacy and operational efficiency, liquid glucose (DEX4) will become formulary and tablets will become nonformulary. Glutose gel will be restricted to neonates. The Restricted Medication List and Automatic Therapeutic Substitution policies have been revised (see page 2).

 

Vaccine Formulary Changes

The Trinity Health P & T Committee reviewed meningococcal, hepatitis A, haemophilus influenzae type b and rotavirus vaccines. Bexsero, Vaqta, Rotateq, Twinrix and ActHIB are formulary. All others are nonformulary. The Splenectomy downtime form #16658 and order set will be revised.

The following are interchangeable

  1. Meningococcal B: Bexsero & Trumenba – patients already started on Trumenba will complete their vaccination series with Trumenba
  2. Hepatitis A: Vaqta & Havrix
  3. Rotavirus: Rotateq & Rotarix
  4. Haemophilus influenza type b: Hiberix, PedvaxHIB & ActHIB

 

Restricted Medication List Policy Revisions

Doravirine (Pifeltro)

Antiretroviral, NNRTI

Nonformulary, not stocked. Patients may use own medication.

New starts will require fast track approval.

Letermovir (Prevymis) Antiviral, anti-CMV Restricted to prophylaxis of adult patients undergoing allogenic stem cell transplantation with recipient sero-positivity for cytomegalovirus.

Patients may use own medication.

New starts will require fast track approval.

Glucose (oral) Oral glucose for hypoglycemia is managed as follows: Neonates: Glutose Gel

Bariatric surgery patients up to 3 months from surgery: glucose tablets All other patients: DEX 4 glucose liquid (60ml)

Esketamine (Spravato nasal spray) Nonformulary, not stocked, no patient’s own medication. No exceptions, no fast tracks (including 3-6 and CPEP).

James St location only.

Acyclovir (Zovirax) IV During the critical nation-wide shortage, all orders must be approved by

Infectious Disease.

 

 

Automatic Therapeutic Substitution Policy Revisions

If Ordered Interchange Notes/Exceptions
Glucose oral tablets Glucose oral liquid (same dose/frequency) 1. Tablets may be used in bariatric surgery patients less than 3 months post-op

2. Maintain glucose gel on formulary for management of neonatal hypoglycemia

Any H2 antagonist liquid Famotidine oral suspension 1. Famotidine suspension is the preferred Trinity Health Formulary liquid H2 antagonist

2. All ranitidine syrup has been recalled due to contamination

3. The Automatic IV to PO Conversion Policy is also revised

 

For more information on Pharmacy & Therapeutics Committee actions, please contact Karen Whalen, Drug Information Pharmacist 448-6519.