ATTN Hospital Pharmacists: What is YOUR method of verifying an Order?

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Hi, I'm wondering what method do other hospital pharmacists have when verifying orders. Like do you have a step-by-step list that's you go through with every order? I'm trying to improve my technical skill because I notice that I will look at a different detail with every order and don't have a set method for going through the whole order.

For example, for one order, I would look at allergies first, then for another order, I would look at past history, and so forth. I really want to develop a set step-by-step method so I can be more organized and efficient at what I do. Any experienced hospital pharmacists would like to share?

i briefly thought about this during training (especially after i read the checklist manifesto) but forgot about it until now. my institution has CPOE, EMAR, and some EMR function so YMMV.

so far i usually scan the orders in queue to see if anything weird stands out. weed out the real orders you have to look into like abx versus templates like tylenol/bowel regimen. then make sure labs aren't abnormal, quickly scan an admit/progress note, and then check allergies. from there, hammer away. finally, may need to check EMAR if it's a change order.

i also verify the easy stuff first like pain meds, since they comprise 75% of my "stat" med requests.

• Does the patient have an allergy to the medication? Is it just nausea/vomiting or some other side effect that can be treated (i.e., with antiemetic or with diphenhydramine) or is it a true allergic reaction such as anaphylaxis or angioedema?

• Is it the right patient? Make sure the drug ordered is appropriate for that patient. With RNs and MDs taking care of more than one patient at a time, sometimes a medication gets ordered on the wrong patient.

• Is it the right route? Sometimes drugs get ordered appropriately for unusual routes, and if you haven't seen that route before, just clarify (i.e., docusate in the ear is legit as well as some intranasal or rectal routes for IV sedation).

• Is the dose appropriate? If it's a pediatric order and ordered per weight, make sure the dose doesn't exceed adult dosing? Also, for pediatric orders that are ordered just by strength (i.e., mg), we divide the weight into it and add that to the order comments to show that we did the math to verify the dosing is appropriate (i.e., 500 mg for a 10 kg kid = 50 mg/kg/dose; 10 kg). Is the drug dosed based on actual body weight when it should be ideal or adjusted body weight or vice versa?

• If there needs to be a duration of treatment, is there one and is it correct? I've seen MDs order fluids intended for 24 hours as "24 days."

• Are there any special instructions on the order? We have CPOE with already built entries for most medications. However, not all MDs or RNs know that they can appropriately order NS with 50 mEq of sodium bicarb, for instance, and will instead order plain NS and type that they want 50 mEq of bicarb in the order comments. If you don't typically read order comments, you'll miss that fact.

• Are there any concerns or contraindications with the order? Is it the right/best antimicrobial for the bug? Is heparin being ordered on someone with platelets of 40? How's the patient's renal or liver function? There are a thousand examples that can fit in this category and need to be looked at on a drug-by-drug basis.

• Is the provider legit and appropriate? I've seen an order entered by a RN who listed a pharmacist who was not on duty that day as the provider. Because we have CPOE, if you type in the first few letters of a last name, it'll bring up everyone who fits the criteria, and this pharmacist just happened to have that many letters of his last name in common with the attending MD.

• Is the timing of the order appropriate? I like to be kind to the RNs and adjust most meds to standard scheduled times if possible. I also like to be kind to our technicians and put realistic times on the orders to get them up to the floor in a somewhat timely fashion. Most meds are never a true stat. Look at anticoagulation and antimicrobial timing as well to see if they need retimed (post-op or post-epidural, for example).

• Are there any duplicate orders? If multiple order sets are used, or if the patient transitioned from ED to the floor, there may be multiple saline flushes, antibiotics, pain management, etc. orders.

• Is there any unneccesary therapeutic duplication?

In addition to what Glycerin said, I look at urgency of the med - in other words, do I need to ensure that this is tubed up immediately, or can it wait until the techs are making their regular deliveries?