Hi All,
I was asked to share the responses to my questions with everyone. Here
they are.
Question 1. Medication range orders - How are your orders for
medications with a range placed in Pharmacy? I'll give an example. The
order is for Morphine 1-5mg IV. We have 2mg, 4mg, and 10mg Tubex's in
Pyxis. Currently the nurse picks the Tubex that is closest to the amount
given. If 1mg given they would pick the 2mg Tubex, if 5mg given they
pick the 10mg Tubex. Now the problem with this is that Pharmacy will
have to Profile all 3 drug amounts on the patient's eMAR in order for
the nurse to be able to pick whichever dose is closest.
Answers:
1. When ordering the first one, I think you need to use multi-dosage
forms on page 8 of the drug dictionary. If you add the other doses to
each drug, then when ordering hit the right control key at the dose
form and check off the other doses, they should be able to pull out any
dose.
2. Create a new order type that is not included in the MAR access
dictionary. Pharmacy enters multiple orders from a set for these dose
ranges. The first order in the set is the only one that has an order
type that displays on e-MAR, the others are filed without patient
specific dosing information just so they get to the dispensing machine.
The nurse can then profile dispense any item size entered. Next,
activate the 'other dosage forms' on page 8. This allows the nurse to
scan any size and still link back to one e-MAR order so all the
documentation is in one place. Audit works nice too.
The only problem we've had with this is that there is a 'multiple dose
form' screen that presents for the nurse and there are not any
instructions for the user to know how to maneuver past the screen when
finished (can't hit <enter>, must be <F12> or <shift><rt arrow>). Our
nurses tend to get stuck on this screen and think that they have lost
network connection. We're thinking about asking for a custom to either
allow <enter> or at least put some instructions on how to exit the screen.
3. Med ranges , we enter a zero in dose field which opens up to free
text. Morphine, demerol, and a few others, we have on page 7 of the drug
dictionary other dosage "all different strengths" attached. That way any
strength can be scan and is attach to the order. We built sets in
pharmacy to make it easier for the pharmacist. Of course only the
primary drug enter shows in the accudose, so if they do choose a
different strength other than the primary one entered, they have to
override the accudose. We really don't get a lot of complaints.
Sometimes we do enter it in twice, ex: 1-2 tab of percocet, But we have
built sets also, so not a lot more time to enter.
4. We only profile the smallest size that the pt may need for that
dose. In your example above we would only profile the 10 mg vial and
have nursing waste the rest.
Question 2. Same medication but different routes - Sometimes the MD
writes an order that a medication can be given by one route (PO) or
another (IV). Examples: Zofran 4mg PO or IV (if pt unable to take PO).
Tylenol PO or PR. Also these orders may be entered on different dates
(Pt takes PO initially then can't take PO so MD orders IV or PR). Do you
have both orders profiled on the eMAR? If so I'm concerned with the
nurse seeing both routes if they were entered on different dates
(different RX#s).
Answers:
1. We had to have a route called PO/PEG and when they order the med with
this route, the nurse has to document whether it was given PO or PEG in
the site field.
2. We enter a separate order for every drug product that might be needed
for standard PRNs. However, for more conditional type orders (e.g.
thiamine 100 mg popo when able) we do try to determine the appropriate
route for the patient and only enter that order. In an example like
this, we would enter the 'po when able' into Admin Criteria on the IV
order and it would be a reminder. At some point the nurse will Hold
Acknowledge and let the pharmacist know the patient was ready for oral
and then pharmacy would enter the other order instead.
3. Same med different route. We enter both, and one we put on hold if
they are both schedule to give at set times. If prn , we just enter both
and put in notes, remember the nurse sees ( two lines of your label
comment field) Our big thing was our policy for dose range policy. Our
policy basically states smallest dose or less evasive route. We built
"follow dose range policy" and actually enter it in the prn reason
default, kind of our work around. We put "prn pain" or whatever in the
comment field.
We use order sets a lot, saves massive amount of time, as far as
entering multiple drugs. Also after dealing with duplicate orders, iv or
po, we got to know real fast what nurses perferred. Alot came from same
doctor and same floor.
4. If the order is PRN then we profile both with a note in the dose
instructions.
If the order is scheduled then pharmacy calls the nurse and asks which
route the pt is currently using. We profile that route with a note in
the dose instructions that it may be changed to another route. When/if
the patient needs the other route then nursing calls and pharmacy
switches the order.
--
Jo Boyce, RNC
Clinical Analyst
Speare Memorial Hospital
16 Hospital Rd
Plymouth, NH 03264
[EMAIL PROTECTED]
Phone: (603)238-6458
Fax: (603)536-5336
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