HELP! Suggestions for IV (OR) PO orders?

**SKM-NURSIEPOOH, BSN, RN** · Apr 2, 2002

Originally posted by MLL
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.

Thanks guys,
MLL:D

I believe the first suggestion above would be the best suggestion if the MDs want to have the medication available in alternate routes. Some patients aren't always able to take dilantin PO; therefore, it should be given IV or IM instead.

NurseDennie, BSN, RN · Apr 2, 2002

The last place I worked when I was floor nursing STILL used paper MAR's, believe it or not. When the doc wrote a "PO or IM" type of order, the nurse taking the order off would write in one line PO and then a Big OR with a circle around it and the other route in the next line down. Also a bracket connecting the two, bringing the fact that there were two routes. We all just knew that "or" means "or" as opposed to "and"

I have to admit that's not fool-proof, though. I wonder if any other hospital is still using non-computerized MARs???

Love

Dennie

Agnus · Apr 2, 2002

Personally I would enter the order as written with EITHER of the caution notes that you suggested.

I see your suggestion #3 as being potentially very confusing and dangerous.

I answered this according to what would be most helpful to me personally, if I were working from this MAR. I can only speak for myself, as a nurse who gives meds daily working from a very confusing MAR system where I work.

galenight, BSN, RN · Apr 2, 2002

We still use paper MAR (we call 'em Medex's). We don't have a computerized system for entering meds at all. The pharmacy tech comes and picks them up out of a basket. Very archaic. But we are small and to computerize would not be cost effective. We are a 32 bed hospital (inpatient) with a 4 bed ER. We do incidently, have computerized lab and xray system, as well as computerized Kardex's and care plans (what a joke). We even used to chart vitals via the puter and print them off q shift. Docs hated them and they went to the wayside quickly. Oh well.. so much for advancement. If we have such an order as this (which is rarely), we write it in the PO section and the IV section (IV on top page, PO inside folded Medex) with big red OR on it and usually an asterick next to each also. Here's to hoping we get into the 20th (at least) century soon!

P_RN, ADN, RN · Apr 2, 2002

I really don't like any of the options much. All it would take is one person to misread and there is a tragedy.

It should be incumbent on the DOCTOR to give one order and for the nurse to clarify any other reasons for other routes.

I can just see what happens if the two are separated, or one has the brand name and the other generic, or one has a 9AM time and the other has a 6AM time......

There are too many potentials. I also don't like the IV/PO/IM/SQ post op orders that docs give for nausea or pain. How on earth are you to KNOW what the doctor wants? That seems a lazy way out. We are not dispensers, we are administers.

Reabock · Apr 2, 2002

Our facility still uses handwritten paper medexes also. We often get PO or IM or IV or PR orders depending on the med. We write it as Dilantin 100 mg PO or IV q 12 hours as one entry on the med sheet. When we give the med, we write in a tiny po or IV next to your initials used to sign out the med on the med sheet. We still use different colored inks for the different shifts too. Blue or black for days, green for 3-11 and red for nights. It's easrier to tell at a glance what meds are for our shift. Do others do this?

Doey, BSN, RN · Apr 2, 2002

We still use paper MAR's. Computerized ones coming soon though.

We transcribe these orders just as NurseDennie said. The po in one box and the IV in the one below it with an OR written between them in red and brackets connecting the two also in red. Everything transcribed is written in black ink except the above or specific parameters for meds (HR BP etc) or anything out of the ordinary that we want to draw attention to. Those are signified with red ink.

aimeee, BSN, RN · Apr 2, 2002

Originally posted by NurseDennie
I wonder if any other hospital is still using non-computerized MARs???

You won't find any computerized MAR's in this area.

Home Health Columnist / Guide · Apr 2, 2002

Check out the The Institute For Safe Medication Practices (ISMP):

You'll find a wealth of information there.

http://www.ismp.org/

You could send a query to Hedy Cohen RN, Vice President of Nursing [email protected](Hedy Cohen) on what she would recommend.

Tell her I sent you!

My humble opinion is that this is a DANGEROUS practice, especially with a med like Dilantin. The bioavailability (how fast drug is absorbed throughout the body) differs in each form of the drug and could lead to toxicity if three nurses give it po (slower absorption), drug level done then dose increased and suddenly next three nurses give IV form.

Agree with P_RN on this:

It should be incumbent on the DOCTOR to give one order and for the nurse to clarify any other reasons for other routes.

MQ Edna · Apr 2, 2002

Originally posted by Reabock
Our facility still uses handwritten paper medexes also. We often get PO or IM or IV or PR orders depending on the med. We write it as Dilantin 100 mg PO or IV q 12 hours as one entry on the med sheet. When we give the med, we write in a tiny po or IV next to your initials used to sign out the med on the med sheet. We still use different colored inks for the different shifts too. Blue or black for days, green for 3-11 and red for nights. It's easrier to tell at a glance what meds are for our shift. Do others do this?

We do this at my hospital, as well, but we circle the time in the appropriate color. We also have the IV/PO or PO/PR, but really just for PRN meds like phenergan or tylenol. I haven't seen a Dilantin IV/PO. Usually if there is an issue about taking PO, we call the doc and get a new order, either as a one time order or a new standing order.

MQ Edna · Apr 2, 2002

Originally posted by NurseDennie
I wonder if any other hospital is still using non-computerized MARs???

PS We still use paper MARs too! We keep being told SOON it will change, but seeing as how all improvements revolve around whether or not the DOCTORS like it, I don't see it happening any time soon.