My facility has recently initiated a Medication Safety Committee which meets monthly to review potential or existing med errors, variance reporting, evaluate and facilitate process changes for medication safety, and, in general, be proactive with measures to assure patient safety.
Our committee recently discussed problems with MDs writing "IV or PO orders". For example, "Dilantin 100 mg PO or IV BID". Apparently a patient received Dilantin both PO and IV, even though the order was entered correctly into the system. How do we avoid this in the future? Some suggestions at the meeting were:
1. Enter the po order as bid (with a note), and the IV order as bid prn (with a note) .
2. Enter the po order as bid (with a note) and have nursing staff call for the IV dose if and when required. Disadvantage here is the delay and extra burden on pharmacy staff.
3. Enter both orders as bid (each with a note), but always make sure they appear together on the MAR.
Several of our floors use MAC for medication dispensing. Some suggestions were to have a box pop up to say "Do not give both IV and PO", or "CAUTION - IV or PO - NOT BOTH".
Does anyone out there have any suggestions on how to avoid this potential life-threatening situation? We meet again regarding this problem on 3/05/02. Any and all suggestion welcomed with open arms.