Promoting Best Practice and Safety Through Preprinted Physician Orders

Because physicians' orders for hospitalized patients have the unique characteristic of affecting and bringing together multiple diverse disciplines and processes, designing orders is both an art and a science from which all medical disciplines and patients can benefit. Although physicians may rightfully feel they are responsible for the content of orders, clear, accurate and concise communication requires a coordinated, team approach. Through multidisciplinary involvement, preprinted physician orders (both paper and electronic) provide an opportunity to involve a broad range of perspectives in decisions about the care of a single patient.

In addition to being available for immediate use for commonly performed interventions, other advantages of well designed, preprinted orders include:

• Continued, coordinated and integrated care by communicating “best practice” through multiple disciplines, levels of care and services.

• Modified practice through educated staff and physicians regarding evidence-based care.

• Reduced variation and unintentional oversight through standardized formatting and consistent style in a legible and clear presentation.

• Enhanced time-saving work flow with pertinent instructions that are easily understood, intuitively organized and suitable for direct application to current information-management systems.

• Reduced potential for medication errors through integrated safety alerts and reminders.

• Increased utilization of continued outpatient services post-discharge via appropriate reminders.

• Convenient access to relevant references and other information.

• Simplified data abstraction via indicators for Joint Commission Core Measures and National Patient Safety Goals.¹ 

• Improved documentation for utilization and reimbursement purposes.

• Comprehensive orders that clearly communicate directions and reduce unnecessary calls to physicians for clarifications and questions.

Whether they are printed on paper or available for electronic access, development and implementation of well designed, preprinted physician orders requires engineering, education and enforcement. Because physician orders exist at the intersection where multiple disciplines and services (e.g., case and risk management) converge, they are the ideal medium by which to address concerns pertaining to reimbursement, utilization, patient safety and quality measures. Orders are the initial means that enable physicians to communicate with a variety of interdisciplinary hospital caregivers, and they represent the starting point for action and care. In the health care environment, nothing goes forward without calling on the assistance of and providing direction through physician orders.

Although research supports the effects of electronic reminders and computerized physician (or provider) order entry (CPOE) on patient care,² the present article describes our efforts (some of them through trial and error, some supported by research) to define and refine preprinted physician orders (including paper-based models) that improve interdisciplinary integration and accurate communication, while reducing unnecessary variation. We offer ideas about applying elements and concepts of computerized clinical decision-support systems to paper-based models and considering application of paper-based order structures and criteria to the electronic physician order format.

Advances in technology allow preprinted physician orders to have flexibility and the ability to rapidly adjust and adapt to changes in individual hospital processes, patients and available services. Preprinted orders offer a low cost and simple-to-implement opportunity to affect the functional organization of the health care process, quality of care and, ultimately, patient outcome.

Creating any well-designed physician order requires considerations that can be broadly broken down into the headings of engineering, education and enforcement.

Engineering refers to the most mechanical aspects of developing orders, including items such as content, format and medication safety:

• Content ensures that orders are comprehensive, correct and coordinated. Content may include information beyond what the physician might initially consider, such as venous thromboembolism prophylaxis and influenza vaccination screening.

• Format defines type and layout considerations that can make orders easier to read and comprehend. Elements of format include font, point size, white space, use of symbols, capitalization and adequate space for handwritten entries. Format consistency is improved through attention to standardizing usage, punctuation, arrangement, design and other factors.

• Medication safety recommendations call for presenting medication information or instructions in a clear and consistent manner, which is very important for all aspects of physician orders. Advice from the Institute for Safe Medication Practices, the United States Food and Drug Administration and others as it pertains to writing medication orders is presented later in this paper.

Preprinted physician orders offer an excellent opportunity to provide and implement timely instructions to physicians, staff and patients regarding “best practice” and general patient safety. This information might involve attaching pertinent printed patient education material to the orders for easy and timely distribution by the nurse to the patient. It might also involve printing appropriate reference information on the reverse side of paper orders (or offering an appropriate Internet link to this information in CPOE). This information might include a listing of applicable formulary medications and dosages, indications of appropriate antibiotic use, evidence-based algorithms to guide care and decisionmaking and a list of reportable core measures for a particular diagnosis. Education regarding safety, “best practice,” infection control and outpatient referrals might also be performed through well placed reminders and alerts within the orders.

Managing changes in orders, keeping them current to reflect “best practice,” and ensuring that only the most current versions are available and in use offer a different, but related, set of challenges. Without some control of the mechanics of and access to order changing, the potential increases for miscommunication, unacceptable variations and error. Methods for guiding process standardization are discussed later in this paper.

Generally, orders begin with content. In other words, the physician writes or creates orders for a specific procedure, diagnosis, care or admission. Examples of content criteria are shown in Table 1.

As the population of health care providers ages, it becomes ever more important to make the printed words they rely on to care for their patients as easy to read as possible. Table 2 summarizes several ways to accomplish this.

Further consideration should be given to the way orders look and feel. This involves standardizing the sequence in which information is presented on the order sheet or screen. This method can also be utilized on paper orders to help prepare staff for the transition to an upcoming CPOE implementation. For example, orders may be consistently grouped under headers, as appropriate, in the order shown in Table 3.

Formatting also involves consistency in expressing weights and measures. When abbreviations are used, they should follow the U.S. Pharmacopeia (USP) standard abbreviations for dosage units. The most common abbreviations are shown in Table 4.⁶ In addition, formatting should consider wording to assist unit secretaries in putting orders into hospital-specific information systems. For example, an order to request smoking cessation education for a patient might read as follows:

• RT for smoke cessation if patient has smoked within the past 12 months. (Performance measure).

All preprinted orders should use the same template, which includes specified areas for:

• Date

• Orders

• Name of orders

• Date of latest review

• Facility name

• Allergies or adverse reactions

• Pharmacy code (if used)

• Patient identification information

• Page number (e.g., page 1 of 3)

• Appropriate barcode if applicable

Depending on the information system used within a hospital, the pharmacy may be able to code orders for quick and accurate entry into their system. Placing this code under the name of the orders (e.g., “POLUM” printed under the name of post-op lumbar surgery orders 0707) saves order entry time in the pharmacy. Additionally, to avoid potential inconsistencies, if patient allergies or adverse reactions are handwritten entries on paper order tools, they would be listed only on page 1 of multipage paper orders. Ample space should be provided to describe these reactions.

Perhaps nowhere is safety more important than in orders pertaining to medications. Table 5 lists some common concerns regarding safety and medication orders. Medication safety also includes alerts and reminders as appropriate to the patient's condition or to the medications or treatments being ordered. Studies have concluded that electronic alerts favorably influence physician practice and patient outcomes.^13–17  Reminder systems can easily apply to paper orders and may involve separate checked (⁠⁠) or unchecked (□) orders; or they may be part of an order. Examples include the following:

• Hold HEPARIN and enoxaparin (Lovenox®) while the epidural catheter is in place.

• Do not give narcotics by mouth, IV, IM or by transdermal patch until epidural is discontinued.

• □ Enoxaparin (Lovenox®) 1 mg/kg subcutaneously every 12 hours x ______ doses. (Pharmacy to monitor and adjust dose if patient weight is equal to or greater than 180 kg and/or creatinine clearance less than 30 mL/minute. Hold if patient is going to surgery within 24 hours.)

• □ Clopidogrel (Plavix®)_____mg by mouth x 1 dose. (Hold if going to Cath Lab or CABG within 5 days).”

  • Do NOT mix glargine (Lantus®) with other INSULINs.

  • Administer pneumococcal and influenza vaccines in separate arms.

  • Inform surgeon if the patient has taken warfarin (Coumadin), clopidogrel (Plavix®) or over-the-counter supplements of feverfew, garlic, ginger, ginkgo, vitamin E, kava kava, St. John's wort or valerian within the past five days. (Pre-op testing order.)

Two particularly high-risk, commonly used drugs deserve special attention. There have been several publicized errors involving the accidental switching of HEPARIN and INSULIN.¹⁸ As a result of this risk (and also because these two medications have no secondary names) and to bring more attention to the names, it is recommended that ALL CAPS be used when writing out these medications.

All physician orders provide an excellent opportunity to educate others regarding “best practice” and safety through alerts, reminders, references, attached information and indicators. Examples to consider as appropriate include the following:

Integrating reminders into the process increases effectiveness;^15,17,19  for example:

• This drug may increase risk of falls.

• Do not use a zero AFTER a decimal; always use a zero BEFORE a decimal.

• Do not use the following abbreviations: U; OD; QN; SS; ug; QD; QOD; MS; MS04; MGS04. Instead, write out the intended meaning.

• Provide an indication for each PRN order. (Place this at the top of each order sheet or screen for quick reference.)

• □ Ketorolac (Toradol®) 30 mg IV every six hours. (If patient is 65 years or older, reduce dose to 15 mg IV every 6 hours.) Notify physician if creatinine is greater than 1.8 mg/dL before giving this drug.

• □ Telephone Order Read-Back. (Safety measure) Place this under the nursing signature line.

Indicators are used to provide notice and awareness of core measures and “best practice”. For example: Either an ACEI or ARB is prescribed at discharge unless there is a contraindication or reason for not prescribing EACH. (Performance measure)

If vancomycin is ordered, please indicate reason:

• □ Beta-lactam allergy

• □ Known colonization with MRSA

• □ Nursing home-stay within past year

• □ Chronic wound care or dialysis

• □ Other __________________ (Performance measure)

• Give the patient/family Living with Heart Failure education booklet; instruct on diet, activity, medications, weight monitoring, followup, signs and symptoms (and what to do if they return), smoking cessation/avoidance and hand washing. (Performance measure)

• Beta-blocker for left ventricular systolic dysfunction __________________ Contraindications:

• □ Allergic

• □ Bradycardia (less than 60 bpm)

• □ 2nd or 3rd degree heart block

• □ Systolic blood pressure less than 90 mm Hg

• □ Other _________________________ (Performance measure)

Preprinted orders also provide the opportunity to educate and remind health care providers of the continuation of optional services provided outside of the hospital. For example:

• □ Outpatient diabetes education postdischarge. Unless the patient has another preference, fax this order sheet to Memorial System Diabetes Center at 555-1234 today for followup.

• □ Cardiac wellness/rehab postdischarge. Unless the patient has another preference, fax this order sheet to Memorial System Cardiac Wellness Center at 555-4321 today for followup.

Health care providers should be aware that determining if infections are present on admission (as opposed to whether they were hospital-acquired) is becoming increasingly important for reimbursement and infection surveillance. For example, consider ruling out a urinary tract infection when a Foley catheter is first inserted, as follows:

• □ Insert Foley catheter. Collect and submit specimen for urinalysis with culture and sensitivity, if indicated.

References can be placed on the reverse side of paper orders, or a link to pertinent information may be inserted into electronic orders. Examples of reference information include:

• A list of formulary medications: e.g., ACEI, ARB, beta-blockers. (CHF and AMI orders)

• A list of pertinent core measures and “best practice.”

• Antibiotic usage recommendations for pneumonia, orthopedic surgery patients, et al.

• Recommended treatment algorithms for sepsis, stroke, chest pain, et al.

Attachments provide additional printed information or forms that are specific to the orders. In the electronic environment, there may be a link to educational materials and information within the information system.²⁰ Examples of attachments include specific consent forms and patient education sheets for the nurse to provide to the patient. Attaching these types of documents to orders helps save storage space on the nursing units, and the information may be updated in tandem with the orders.

In an electronic environment, physician orders can offer automated support through links to research, literature, regulatory standards and treatment algorithms. Advances in information systems can also compare orders against dosing standards, check for allergies or adverse drug reactions, perform drug-laboratory value and drug-drug interaction checks and warn about potential errors of omission (e.g., failure to request a partial thromboplastin time [PTT] after ordering HEPARIN) in real time.

Alerts, reminders, references and attachments are helpful and timely job tools that assist with proper care, but they should not become intrusive or hamper the work process. Although they can be quite beneficial, care must be taken to ensure that reminders and alerts are not overused. “Alert fatigue” can occur in both the paper and computer environments, when caregivers start ignoring bothersome and inappropriate aids.²¹ 

Gaining control over preprinted paper orders within a hospital setting can be a challenge. Quite often, physicians create paper orders on their home computers. Frequently, old orders are hoarded, copied and distributed from nursing units. These unreviewed orders show up suddenly on patient charts with confusing directions, outdated medications, unapproved abbreviations, conflicting instructions, poor legibility and even letterhead paper from other hospitals. CPOE eliminates many of these issues.

Managing preprinted physician orders on paper includes limiting the number of copies that can be requested from the print shop at any one time (e.g., 25 copies or a two-week supply). This helps to ensure that old orders are not still in use for months after changes have been made (e.g., waiting until current floor stock of previous form is depleted). Placing blank physician orders on copying machines should be prohibited. (Copying machines are unable to adequately copy barcodes, which disrupts scanning into an electronic record.) Nursing departments can print copies directly from the print shop intranet site until requested print shop copies are delivered.

Our clinical “best practice” (CBP) committee meets for one hour monthly to determine and develop order criteria and review existing and new physician orders. The ability and authority to modify orders has been limited to this committee. The CBP committee also reviews current literature and research as it pertains to, and can be integrated into, physician orders. Depending on the orders being reviewed, input at these meetings may be requested by any clinical area of the hospital—e.g., pharmacy, case management, various physicians, emergency medicine, Joint Commission coordinator, patient safety officer, nursing, dietary, admissions, birth care, unit secretary, radiology, laboratory, stroke coordinator, rehabilitation. Each reviewed order (along with CBP recommendations for changes) is forwarded to the authoring physician for final approval. A brief list of the order criteria created by CBP is also provided to the physician for reference (see Table 6). Final approval by the physician is required before any modified order can be implemented.

The CBP committee names or titles each order in a standardized manner to simplify locating specific orders from the files or print shop. For example, an order from a particular physician might be named: “Dr. Black Post-op Pacemaker Orders 0907.” This title indicates the name of the physician; the type of order (e.g., pre-op, post-op, admission, discharge); the procedure or diagnosis; and the date last approved. Orders used by a specific group of physicians may be named with the group name first (e.g., “Riverside Vascular Post-op AAA Surgery Orders 0807”). Orders used by a diverse group of practitioners may be named, “Pneumonia ICU Admission Orders 0807.” The CBP also reviews orders (and any associated references, information, alerts or attachments) on a routine basis to ensure that they reflect current “best practice” and process.

Whether in paper or electronic format, well developed physician orders have the ability to affect and help with a multitude of concerns within health care today. Furthermore, preprinted physician orders have the potential to benefit all patients and disciplines. These orders do not require new technology (although they might use it), and once defined, they are low in cost and simple to use. However, maintaining orders in accordance with “best practice” does require a fair amount of vigilance and routine reviews. Perhaps the best advantages of preprinted physician orders lie in their ability to modify physician practice, guide care decisions, provide a comprehensive perspective and readily adjust to changes.

CPOE may decrease errors and improve quality, but concerns regarding their high implementation cost, operational disruption and return on investment have proven a major barrier to immediate and widespread adoption throughout the health care industry.^22,23  Fortunately, during this transitional phase of information management, we have an opportunity to share many of the beneficial aspects of paper and electronic formats of physician orders.

Writing good preprinted physician orders is both an art and a science that requires a team approach. When well designed, these orders integrate pertinent reminders, safety measures and “best practice” into a just-in-time process. Whether in an electronic or paper format, preprinted physician orders can transform evidence-based knowledge into practice. As such, they have the potential to influence good practice and promote patient safety through clearly written communications.

We extend special thanks and our appreciation to Sue Cole, RN CPHQ; Tatiana Kosyak, RPh; and Jerry Hood, R.Ph.