ISMP: Guidelines for Standard Order Sets

On March 11, 2010, the Institute for Safe Medication Practice (ISMP) published guidelines for creating standard order sets. The document can be found here.

The following are excerpts from the guidelines document:

Content
Careful attention to the content of standard order sets helps ensure they:

1. are complete,
2. include important orders beyond what the prescriber may initially consider (e.g., specific monitoring requirements),
3. reflect current best practices, and
4. are standardized among various practitioners who provide care to patients.

Examples of frequently observed problems with the content of standard orders follow.

• Numerous practitioner-specific order sets for the same conditions resulting in variability in the clinical management of these patients
• Content that is a compilation of multiple prescribers’ preferences instead of a streamlined, consensus-based order set
• Outdated order sets that do not reflect current evidence-based or best practices
• Incorrect or outdated terminology used to prescribe therapy (e.g., prescribing a “heparin lock flush” when only saline is used to flush the port)
• Mistakes and inaccuracies in the orders, such as incorrect or missing doses (e.g., magnesium sulfate 16 g instead of 16 mEq), routes, frequencies of administration, and rates of infusion; typos; and spelling errors, particularly with drug names
• Order set includes a medication that is typically contraindicated in the targeted population (e.g., aspirin on pediatric order sets)
• Order set does not include duration of therapy if appropriate (e.g., ketorolac limited to 5 days)
• Order set includes potentially dangerous combinations of products (e.g., IV morphine and epidural HYDROmorphone/bupivacaine, with boxes that allow both orders to be activated)
• Order set includes two or more medications with known drug interactions
• An exhaustive variety of medications to cover every possible scenario a patient may face (e.g., orders that include multiple analgesics by various routes, laxatives, antacids, a bedtime sedative, antidiarrheal, antiemetic, and others); we’ve previously called these “Don’t bother me” orders, which lead to crowded medication administration records and leave treatment decisions to nurses’ subjective, variable judgment
• Order set includes organization-prohibited orders or ambiguous blanket orders such as “take home meds” or “resume pre-op orders”
• “If…then” orders that inappropriately shift responsibility from the prescriber to the nurse or pharmacist to determine whether an order should be activated (e.g., give RhoGAM if indicated)
• Types and/or frequency of necessary patient assessments (e.g., pulse oximetry) and laboratory monitoring are not specified
• Orders to address known potential emergencies not specified (e.g., rescue agent available, when to administer the rescue agent or call the prescriber)
• Single and/or multiple analgesics which, if administered as frequently as prescribed, could result in an overdose (e.g., acetaminophen or opioid toxicity)
• Dosing guidance not provided (e.g., mg/kg or mg/m2 dose not specified along with the calculated dose, particularly for neonatal/pediatric drugs and chemotherapy; safe dose range or maximum safe doses not specified; dosing parameters for titrated drugs not provided)
• Chemotherapy order sets that include the total course dose instead of the single, daily dose
• Medications without indications
• Medications prescribed by volume or number of tablets
• Titrated medications without a measurable description of the desired effects, rate of titration, and maximum doses that should not be exceeded and/or the dose at which the prescriber should be called
• Administration directions not provided (e.g., timeframe for IV push or bolus doses)
• Critical clinical decision support information, reminders, precautions, and/or safety measures not included, such as: monitoring requirements; administration precautions; adjustments for renal impairment or age; maximum adult total dose of acetaminophen not to exceed 3 to 4 grams per 24 hours

Approval and Maintenance

Managing the initial approval of standard order sets and keeping them current present numerous challenges to organizations. Without a standard process to address the approval and revision of standard orders, unacceptable variations in care and errors are possible. Examples of frequently observed problems with the approval and maintenance of standard orders follow.

• Order set never approved by the organization’s pharmacy and therapeutics (or another appropriate) committee
• Outdated order sets that have not undergone recent clinical review
• Old typed preprinted order sets that are copies of copies (information cut off, stray marks on the forms)
• Outdated order sets that are still in use for months/years after new/revised order sets have been adopted
• Staff unable to access updated order sets online via an Intranet
• Order sets sent or brought into the hospital from physician offices or other hospitals that have never been approved
• Order sets that include nonformulary items, drugs with therapeutic substitutions not specified, and medications that have been withdrawn from the market or have new boxed warnings that should limit their use
• Order sets with conflicting instructions that do not coincide with current hospital policy (e.g., drug verification checking processes) and equipment (e.g., types of infusion pumps available)
• Order sets without a tracking number and approval/revision date

Ensuring consistent use of well-designed order sets and maintaining the orders in accordance with best practices requires vigilance and a team approach. Because standard order sets are often an important component for implementing clinical protocols, algorithms, critical pathways, and guidelines, organizations should establish an interdisciplinary process with rules to help design, evaluate, use, and maintain these orders. Professional staff need clear directions to follow if they encounter order sets that do not comply with these rules.

To assist with the evaluation of order sets, ISMP has created Guidelines for Standard Order Sets in the form of a checklist, which is on our Web site (www.ismp.org/Tools/guidelines/default.asp). Additionally, in the Agency for Healthcare Research and Quality publication, Advances in Patient Safety: New Directions and Alternative Approaches, Ehringer and Duffy have published findings from a study they conducted on preprinted orders and how they can be used to promote best practices (www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Ehringer_17.pdf) The authors include several tables and an appendix that can be used to guide the creation and review of standard order sets. With these two resources, hospitals can begin to establish an effective process for designing, evaluating, updating, and enforcing safe use of standard order sets.