Medication Orders

Medication ordering is common in all clinical contexts. Developing medication order skills can speed workflows, improve patient safety and simplify medication reconciliation at care transitions. Inpatient medication orders are constrained by AHS formulary considerations, and possibly facility availability. Outpatient orders have fewer limitations, although it remains important to consider regulatory and insurance constraints.

Medication Order Search Lists

A medication order is initiated by performing a search for the desired item, form and dose. Order search results default to present any matching personalizations ("favourites" organized in a "Browse" tab in order search) first. The next "Preference List" tab gathers search results commonly ordered by one's specialty. Finally, a "Facility List" shows results matching those available at one's local facility.

It is important to appreciate the difference between Preference and Facility lists:

  • Preference List
    This seeks a match of the search term within a list of medications selected to reflect common usage by the "Department" (specialty) of the currently signed-on user. Only one set of preferences is maintained for each specialty in the province.

  • Facility List
    This seeks a match of the search term within a list of medications and mix options available within the clinical facility where the order is being placed.

It is possible for a medication appearing in the Preference tab to not be locally available, and so not listed in the Facility tab. It is also possible for an item to be available via the Facility tab when that item is not included in the Preference tab listing of search results. This can be easy to forget, especially for prescribers who work infrequently at a particular facility. Resulting delays, and re-checks with the ordering physician, could affect care.

Effective mitigations include:

  • Familiarity with local ordering options
    Prescribers familiar with a facility will have developed awareness of any limitations to what can be ordered and promptly provided at that facility. Prescribers less familiar can always ask a colleague, or check with the facility on-call pharmacist.

  • Preference personalizations
    Saving specific medications, including details of the form, dose, route and frequency, can build up a highly relevant quick-list that makes ordering easier and also ensures a good fit with fast facility medication provisioning.

Medication Order Challenges

Prescribers moving from a paper to a digital health record may find certain types of medication orders challenging. These are easy to write when one can rely solely upon pharmacist interpretation of prose instructions. It can take a bit more effort, and skill, to enter complex medication orders using CPOE. The benefits are worth the effort (decision supports, safety checks, interaction checks, etc.) and the effort is dramatically reduced if personalizations are used to save the initial work of order-entry so that it is automated at next need.

Dose Range Orders

  • It may be desirable for patients to be provided a medication dose that falls within a pre-determined range, with discretion provided for adjustments based upon symptoms or other considerations (e.g., laboratory results).

  • Most dose range requests are best handled through two linked orders. The first sets a regular baseline dose at consistent intervals. The second sets an as-needed (PRN) dose that can supplement the baseline, possibly at a different administration frequency.

  • When prescribers order a single scheduled medication with ranged dosing, system restrictions (such orders cannot work well with decision supports) cause delays as extra pharmacist resources are required to interpret the prescriber's intent. Accordingly, AHS medication policy stipulates that ranged dosing should be restricted to the very few situations where a combination of regular and as-needed orders is not possible or appropriate.

  • Prescribers who enter range-dosing requests inappropriately can expect to receive an In Basket message requesting correction:
    "Range dosing is not allowed for scheduled orders. Please modify your order to use one dose. If appropriate, you may wish to use the lower dose in this scheduled order and place an additional linked PRN order for *** to allow for dosing flexibility."

Dose Range Size

  • When dose ranges are provided in PRN orders, these should be kept as narrow as possible.

  • Wide does ranges can be clinically dangerous, especially with pain management medications. Wide ranges also create challenges within Connect Care and pharmacy services because the range may exceed what can be covered with a particular medication vial concentration.

Medication Order Personalization

Personalizing medication orders with a well-organized list of favourites is one of the best ways to speed Connect Care order workflows.

      • Use chart search (or Epic menu) to find and open the "Preference List Composer".

      • Select the "Show Empty Lists" button at the bottom of the Preference List Selector if Medications are not already shown. Preferences can be managed for Inpatient and Outpatient medications independently.

      • Once in either the Inpatient or Outpatient medications preference composer, follow usual order personalization guides to build any sections and/or subsections desired to categorize medication personalizations.

      • Add items to categories, setting dose, route, frequency, duration and other details as desired.

      • Any added items should reflect what is available where one usually works.

      • Prescribers working in multiple facilities can set up sections for each in the Preference List Composer and so be rapidly reminded, during ordering, of any facility differences in medication formulations frequently ordered.

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