Why are medication orders written this way?

katielea · Jul 30, 2013

I haven't seen an order written that way before. I've found that doctors I've worked with don't really care what kind of tab it comes in as long as the patient gets the right dose. For example, something like "3 mg warfarin qHS PO" would be written, and then pharmacy can figure out how they want to do that - by sending up one 3 mg tab or making us split a 6 mg tab, depending on what they've got.

Meriwhen, ASN, BSN, MSN, RN · Jul 30, 2013

Joint or another agency may require orders to be written for medications that are actually stocked (e.g., 3mg Coumadin tablets). Or so our pharmacy tells us.

1.5mg Coumadin tabs do not exist...nor do 1.5mg warfarin tabs.

MunoRN, RN · Jul 30, 2013

Orders should always be written with the actual dose prominently stated. You are correct that when other doses are written into the order that aren't actually the patient's dose, it's asking for trouble.

The reason why orders are written this way, such as "metoprolol 50mg 1/2 tab BID" is because the patient's dose is 25mg BID but the Doctor/patient want it dispensed as 50mg tabs which the patient will then cut in half because one 50mg metoprolol is cheaper than two 25 mg metoprolols.

Our med rec process used to just carry over how patient's prescriptions were written as an outpatient, which includes many of these "metoprolol 50mg BID 1/2 tab" orders. After a ridiculous amount of errors where the "1/2 tab" part was getting missed, we changed it to a format where the dispensed dosage size and patient's actual dose are separated: "metoprolol 25mg BID, dispense as 50mg tabs". Much safer. Your Coumadin order should read "Coumadin 1.5mg daily, dispense as 3mg tabs."

NSALVADORE · Jul 30, 2013

Our orders are written half tab as the pp described!

KelRN215, BSN, RN · Jul 30, 2013

I have seen orders written this way for the outpatient world so that when the pharmacy writes out the instructions the patient understands that he is to take 1/2 tab (because, let's be honest, most patients who are not nurses know they take 1/2 tab not 1.5 mg). This type of order would not have been allowed in my hospital and I would never transcribe an order like this in my home care job. I would transcribe the order as 1.5 mg coumadin. If necessary you could write under instructions something like 3 mg/tab, give 1/2 tab BID or something like that but the way it's written in the OP leaves too much room for confusion and error, IMO.

VANurse2010 · Jul 31, 2013

Agreed with KelRN215. That order is appropriate for outpatient orders/dosage/prescription labels. It is NOT acceptable for in-patient orders intended for RNs or other dispensers

allnurses Guide · Jul 31, 2013

I write all my outpatient scripts this way.

MunoRN, RN · Jul 31, 2013

One thing that gets forgotten is that there often isn't any difference between outpatient and inpatient scripts anymore. The med reconciliation process is how a patient's outpatient meds are continued as an inpatient, and most med rec processes include a Doc signing off on a list of the patient's outpatient's meds and however the order was written as an outpatient is how they are written as an inpatient, since it's essentially just copied and pasted. There's no disadvantage to separating the patient's actual dose and how it is to be dispensed, but there are serious safety risks associated with not doing so. Med orders should be effectively communicated to those dispensing and administering the meds, and it's a little ridiculous that an order for 25 mg of metoprolol, written as 50mg metoprolol 1/2 tab, doesn't include the actual correct dose anywhere in the order.

allnurses Guide · Jul 31, 2013

One thing that gets forgotten is that there often isn't any difference between outpatient and inpatient scripts anymore. The med reconciliation process is how a patient's outpatient meds are continued as an inpatient and most med rec processes include a Doc signing off on a list of the patient's outpatient's meds and however the order was written as an outpatient is how they are written as an inpatient, since it's essentially just copied and pasted. There's no disadvantage to separating the patient's actual dose and how it is to be dispensed, but there are serious safety risks associated with not doing so. Med orders should be effectively communicated to those dispensing and administering the meds, and it's a little ridiculous that an order for 25 mg of metoprolol, written as 50mg metoprolol 1/2 tab, doesn't include the actual correct dose anywhere in the order.[/quote']
Metoprolol is available in 25mg form. Coumadin, as in the OP, is not available in 1.5mg.
When a dosage is not available, as a prescriber I was taught to and continue to, use the appropriate instructions for use (I.e Coumadin 3mg PO Take 1/2 tab my mouth once per day.).
If I hand write it I include a "(1.5mg)". Our eScripts do not allow this.

BrandonLPN, LPN · Jul 31, 2013

Yes, it should be written as "coumadin 1.5 mg PO daily".

Writing it as "coumadin 3 mg 1/2 tab PO daily" is how instructions are written to be dispensed for the patient to take home. It doen't need to be this way on the MAR! To do so is begging for a med error where the nuse gives the full 3mg.

As a third shift nurse, I'm responsible for checking the new MAR each month. when pharmacy prints out the "3mg 1/2 tab" order, I yellow it out and rewrite it the correct way.

MunoRN, RN · Jul 31, 2013

Metoprolol is available in 25mg form. Coumadin, as in the OP, is not available in 1.5mg.
When a dosage is not available, as a prescriber I was taught to and continue to, use the appropriate instructions for use (I.e Coumadin 3mg PO Take 1/2 tab my mouth once per day.).
If I hand write it I include a "(1.5mg)". Our eScripts do not allow this.

Our EMR which doubles as an E-script had the same problem, it's an easy fix though, you just need to have them separate the "dispense as" drop down box (which will be limited to available dosages) from the "dose" box which shouldn't have defined limits.