Presentation on Medication Ordering Errors

1. Common Medication
Ordering Errors
Niloofar Alikashani RPH, BCPS
Medication Safety Pharmacist

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Objectives
Learn about common medication
ordering errors that can be dangerous
to the patient
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Medication Administration Times
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Default Start times
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EXCEPTIONS:
Frequency Defaults to next
administration time
if within
Daily 12 hours
Every morning 12 hours
Every evening 12 hours
Q12 HR 6 hours
Q8 HR 4 hours

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Default Start Times
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Review Requested Start
Date/Time
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Review Next administration time to
avoid doses being given too close
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When entering order details, the Requested Start Date/
Time, is by default closed
Clicking within the entry field or clicking the review schedule
link at the top of the details section will expand the
Requested Start Date/ Time to view subsequent
administration times

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Medication Priority
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Medication Priority
• When an order is placed as a STAT or NOW order, a dose
will be timed to be given NOW and the subsequent dose will
be given when the next scheduled administration is due.
This could cause a situation where the patient is over
medicated.
• It is vital that when placing a STAT or NOW order that the
Requested Start Date/Time field is expanded and
addressed.
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Medication Priority
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Skip Administration
You will also see a red exclamation mark icon also highlighting
that next dose is too close
The next administration will likely need to be skipped. This
can be indicated in the Request Start Date/ Time window by
checking the box for Skip Administration
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Medication Priority
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Medication Administration Times
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Can change standard administration
times by:

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Medication Administration Times
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Scenarios
What is the default start time?
1. 0800H order Lisinopril 10mg po daily?
0900H
2. 0800H order Lisinopril 10mg po daily NOW
0800H & 0900H
3. 1300H order metoprol 25mg po q12HR?
1300H
4. 2000H order metoprol 25mg po q12HR?
2100H
5. 1900H order insulin glargine 10 units subq bid
before bkfst and dinner
0730H next am
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Changes in Dose
If a change to a dose is made after the scheduled time, the dose
modification will ONLY be made for doses scheduled in the future.
That past due dose will NOT be modified. If this modification is
meant for that past due dose, you MUST alert the RN
Important to look at MAR to see when the dose was scheduled
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Changes in Dose
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Old doseNew dose

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Continuous Infusion-Stop orders
• When placing an order for
continuous medications (for example
heparin, eptifibatide, insulin…), the
RN will NOT get an alert/task for the
Stop Date/Time.
• The provider must call RN and
communicate when the continuous
drip should be stopped.
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How are “Additional Instructions”
seen by MD vs RPH vs RN
MD
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How are “Additional Instructions”
seen by MD vs RPH vs RN
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RPH

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How are “Additional Instructions”
seen by MD vs RPH vs RN
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How are “Additional Instructions”
seen by MD vs RPH vs RN
RN
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How are Order Comments seen by
MD vs RPH vs RN
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MD

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How are Order Comments seen by
MD vs RPH vs RN
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RPH

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How are Order Comments seen by
MD vs RPH vs RN
RN
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Banner Weight
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Who can order chemo?
Initiated by an authorized prescriber
• Attendings
• Physician’s assistants, ARNPs, and
pharmacists with appropriate
privileging
NOT MEDICAL INTERNS OR
RESIDENTS
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Transitioning patients on Direct Oral
Anticoagulants to Heparin Infusion
• At VMMC, we monitor heparin infusion
using anti-Xa (goal: 0.3-0.7)
• Patients who are on Xa inhibitor DOACs
(apixaban, rivaroxaban & edoxaban) and
transitioned to heparin infusion end up
having high anti-Xa levels resulting in the
RN stopping the drip & calling provider for
next step
• Patients on either apixaban, rivaroxaban
or edoxaban need to be transitioned to
PTT monitored heparin to avoid lab
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Heparin Weight Based Order Set
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Transitioning patients on Direct Oral
Anticoagulants to Heparin Infusion
• Pharmacist orders baseline PTT
• Based on renal function, timing of last
dose & indication, determines when to
start heparin gtt and when to transition
back to anti-Xa monitoring heparin
protocol
• Expect to see a pharmacy progress note
on start of heparin gtt and transition to
anti-Xa monitoring heparin infusion
• Rate adjusted by RN using the infusion
adjustment chart
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Why transitioning back to anti-Xa
monitoring ASAP?
• Anti-Xa is more accurate
• No validated heparin reagent curve so goal PTT is an estimate of
therapeutic values
• PTT can be prolonged by
 Lupus anticoagulant positive
 Liver disease
 DIC
 Factor deficiencies
 Von Willebrand disease
 Circulating factor inhibitors
• PTT response to UFH may be reduced by
 inflammation
 elevated factor VIII levels due to malignancy, acute
thrombosis and major surgery
• PTT may be shortened by Antithrombin deficiency
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Pharmacy to Dose Vancomycin
Choose the appropriate goal and renal function
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Summary
• When placing orders, review start time and next
administration time
• Can skip administration times & determine
associated administration time with each
frequency
• Additional Instructions->RN
• Order Comments->Pharmacist
• When transitioning patients from factor Xa
inhibitor DOACs to heparin infusion, consult
pharmacy
• When having to dose meds based on weight,
double check weight history. Do not rely on
banner weight
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Questions
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