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Learn three common pitfalls with preprinted order forms

Accreditation Connection, December 28, 2004

Between September 1998 and August 2003, the U.S. Pharmacopeia (USP) MEDMARX error-reporting database collected 4,437 error reports involving preprinted order forms, says John Santell, MS, RPh, director of educational program initiatives at the USP Center for the Advancement of Patient Safety in Rockville, MD. Of those reports, 110 (2.5%) resulted in patient harm.

Check out three common problems with preprinted order forms below and some tips to improve JCAHO compliance with standard MM.3.20-one of the more cited in 2004:

1. Watch your abbreviations
Avoid using abbreviations for drug product names, route of administration, or dose designation on your preprinted order forms. It's one of the common error-prone problems that occur with these forms. See the JCAHO's National Patient Safety Goals Web page at www.jcaho.org for more information on unapproved abbreviations.

2. Don't alter a preprinted order form
Prohibit providers from altering pre-printed order forms. Sometimes providers cross out the medication listed on a preprinted order form and write in a new medication. In some cases, however, they forget to adjust the preprinted dosage, resulting in a mismatch between the drug and the dose. If providers want to deviate from parameters on the form, they should write out or electronically enter the medication order.

3. Look out for typos
Make sure forms are complete and accurate. Sometimes a minor typographical error can result in patient harm because of a misinterpreted dose. Give each form a unique identification number and list the revision date on the form to make sure it is updated. New drug information may become available during the year that will require an organization to immediately review a particular order form.

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