10 Questions from the Resident and Fellow Affairs Committee
Drs. Ernie Ring (CMO) and Adrienne Green (Associate CMO)
Respond to residents’ questions about telephone orders and medication order writing.
1. What are the changes affecting the residents at UCSF because of CMS compliance requirements?
Ernie Ring states: “Order writing needs to be unambiguous, legible, and complete. There needs to be complete documentation for allergies and adverse drug reactions.”
2. What are the differences between a telephone order and a verbal order?
Ernie Ring states: “A verbal order is given during a procedure to a nurse who administers the drug. At the end of the procedure, the physician signs off the list of drugs that where given during the procedure. Telephone orders are called in to a nurse (sleeping medication). Previously, our bylaws only allowed telephone orders for pain relief and emergencies. We changed the bylaws at an Executive Medical Board in November 2007 to indicate that telephone orders are allowed for any urgent clinical need. This was in response to a resident who was called regarding a patient who was nauseous and ordered Zofran, but the nurse would not accept the order since it was not an emergency. It was strictly within the letter of the rule at that time. This change in bylaws
was directly related to resident input.”
3. What is a medication safety nurse? What is his/her role?
Adrienne Green states: “The primary focus of the medication safety nurses is to double check that orders are written and transcribed compliantly. They do additional tasks on the floor such as checking for expired medications. Medication orders on the MAR need to exactly match the physician’s orders. Ernie Ring states: Historically, nurses have interpreted orders for what they meant instead of what they said. CMS doesn’t accept that.”
4. What percentage of orders are written correctly?
Adrienne Green states: “80% of orders are written completely and correctly. When there are problems, it is generally because the dose, frequency or other details are omitted. Duplicate orders are also a problem.”
5. Are telephone orders handled consistently throughout the hospital?
Ernie Ring states: “In the past, they have not been consistent because, although the policy is the same, the interpretations have not been the same in all areas. Adrienne Green states: Currently, our major efforts are directed at standardizing interpretations and practices throughout the hospital.”
6. A current workaround for a resident who is not in the hospital is to ask another resident who’s in-house to transcribe an order and sign it even though the resident may not be familiar with the patient or medication prescribed. Are there any concerns about this?
Adrienne Green states: “This is not appropriate. When you find yourself in workaround situations that do not make sense, it should be a trigger to use the resident email suggestion box - residentfeedback@ucsfmedctr.org. Currently, our major efforts are directed at standardizing practices throughout the hospital.”
7. Residents receive many pages from the pharmacy about medication orders that need clarification, but they are unable to take telephone orders which increase the number of steps and people involved. Why is this, and doesn’t it increase the chance for error?
Adrienne Green states: “Because most pharmacists are currently located in the basement pharmacy, far away from the patient’s chart, they are unable to write a telephone order. If a resident receives a medication clarification call from a pharmacist who is in a satellite pharmacy or who is located on a nursing unit, the pharmacist can write a telephone order for the change. The resident will need to countersign the order per the telephone order policy. Over the next several months many of the pharmacists who are located in the basement pharmacy will be relocated to nursing units. We anticipate that this will streamline and simplify the medication clarification process for all providers (this system has already been rolled out on 12L and 14L).”
8. When can a RNs defer paging a resident regarding medication clarification and for what period of time?
Adrienne Green states: “When paging physicians at night, nurses have been trained to use their best judgment in light of the clinical situation. The issues related to medication clarification have obviously complicated the issue and have prompted us to start looking into this with nursing leadership.”
9. Implementing a computerized order writing system is the ultimate solution handling medication orders. What is the timeline for implementing this?
Ernie Ring states: “Approximately 18 months.”
10. What is being done to address problems residents are having with telephone orders and medications?
Adrienne Green states: “I meet weekly with pharmacy and nursing to bring concrete examples to the table and then to problem solve. It would be invaluable if the residents could give me unbiased, unemotional, factual and concrete examples of the problems they run into with medication orders. For this reason, we have established an email suggestion box - residentfeedback@ucsfmedctr.org. where residents can inform medical center administration of systems’ issues that they would like to be addressed.”
