Nursing

Tips for eliminating physicians' blanket orders

Nurse Leader Weekly, November 19, 2004

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Communication is critical when writing orders to reinstate a patient's medication. Having a documented policy regarding blanket orders and working with other caregivers will help meet the Joint Commission on Accreditation of Healthcare Organization's (JCAHO) requirements and protect patient safety.

The JCAHO's medication standard MM.3.20 requires organizations to prohibit blanket reinstatement of orders. Blanket orders are dangerous because physicians could forget to include previous medications that could be vital, or nurses and pharmacists could misinterpret the order.

Physicians often issue such blanket orders when a patient arrives at the hospital, says Sarah Moake, RN, nurse manager of the medical-surgical unit at Henderson (TX) Memorial Hospital. Nurses could interpret "obtain home medications" to mean that the patient should bring his or her medications from home and begin taking them, says Moake. However, the physician may have simply wanted to review the medications that the patient takes on a regular basis.

The JCAHO wants physicians to review a patient's medications upon admission, something that often doesn't happen for several days, says Moake. Henderson Memorial created a policy stating that ED physicians cannot write "continue home medication" orders without the attending physician's review and approval.

Tip: Have a policy that clearly defines how physicians should review and reinstate medication orders and make sure pharmacy and nursing staff fully understand the policy.

Train nursing and pharmacy staff to automatically call the physician if they receive a vague order. The phone call leads to better communication among caregivers and can prevent potential errors from blanket orders.

Henderson Memorial Hospital has come up against some resistance from physicians who are reluctant to change-usually because they are used to writing their orders out longhand, says Sandra Fly, RN, Henderson Memorial's director of performance improvement, quality, and JCAHO accreditation.

Tip: Get hospital leadership to understand the importance of prohibiting blanket orders.

Henderson staff follow a chain of command when confronted with blanket orders, says Fly. The five steps include the following:

1. The nurse calls the physician to clarify and rewrite the order
2. The nurse notifies the nurse manager if the physician refuses
3. The nurse manager notifies the house supervisor
4. The medical director speaks with the physician
5. The case goes to the medical executive committee if the physician still refuses

Henderson Memorial provided inservices to staff when the blanket order policy began. Staff also issued reminders in handouts, sticky notes in the medication records, and fliers in the break rooms. Some nurses also used overhead slides to outline the policy changes in staff meetings.

-Adapted from Briefings on Patient Safety (June 2004), published by HCPro, Inc.



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