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Maximum and Minimum Dose Adjustments Using Order Sets - Pediatric - Inpatient/Ambulatory [15]

Maximum and Minimum Dose Adjustments Using Order Sets - Pediatric - Inpatient/Ambulatory [15] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols





Delegation Protocol Number: 15

Delegation Protocol Title:
Maximum and Minimum Dose Adjustments Using Order Sets – Pediatric – Inpatient/Ambulatory

Delegation Protocol Applies To:
Inpatient pediatric patients in the American Family Children’s Hospital (AFCH) and University Hospital Clinics
who have medication orders entered as part of an order set.

Target Patient Population:
Pediatric patients defined as ≤18 years of age or those patients being cared for by the pediatric service in the
AFCH and University Hospital receiving medications ordered as part of an order set.

Delegation Protocol Champions:
Shannon Dean, MD – Department of Pediatrics – Hospitalists
Peter Popic, MD – Department of Anesthesia

Delegation Protocol Reviewer:
Josh Vanderloo, PharmD – UWHC Drug Policy Program

Responsible Department:
Department of Pharmacy

Purpose Statement:
To improve the safe dosing of pediatric medications by ensuring doses are above minimum and below maximum
dosing recommendations. Health Link allows for weight based dosing but the total calculated weight‐based dose
may exceed evidence based maximums or fall below evidence based minimums. Approved order sets establish
maximum and minimum doses for medications within the order set. This protocol delegates authority from the
ordering provider to pharmacists to adjust medication doses ordered via an order set to maximum or minimum
recommended doses stated in the order set without contacting the prescriber.

Who May Carry Out This Delegation Protocol:
All AFCH and UWHC inpatient pharmacists.

Guidelines for Implementation:
1. This protocol is initiated by a provider entered medication order generated in Health Link using an order
set.
2. The pharmacist will evaluate the total prescribed dose of medications included in an order set as part of
medication order verification.
3. If the dose exceeds the maximum dose listed in the ordering instructions, the pharmacist will modify the
order to match the maximum dose indicated in the order set.
4. If the dose falls below the minimum dose listed in the ordering instructions, the pharmacist will modify the
order to match the minimum dose indicated in the order set.
5. The pharmacist modification of orders will occur using the “per previous order” ordering mode within
Health Link. This order mode does not require prescriber cosignature.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


6. If a medication is part of an order set, the pharmacist will indicate the change was made per this protocol by
typing “Modification made per Pediatric Maximum and Minimum Dose Adjustments Using Order Sets
Protocol” in the administration section.
7. This dose conversion may be overridden, at any time, by the prescriber writing “Dose as Written” or other
equivalent orders with the medication order.

Order Mode: Protocol/Policy, Without Cosign

References:
1. Phelps SJ, Hak EB, Crill CM. Pediatric Injectable Drugs ‐ The Teddy Bear Book. 10
th
Edition Bethesda:
American Society of Health‐System Pharmacists, 2013
2. Taketomo C, Hodding, JH, Kraus, DM. Pediatric Dosage Handbook 22ndedition: Lexi‐Comp; 2015
3. Young TE, Magnum B. NeoFax 2015. Montvale: Thomas Reuters, 2015.
Collateral Documents: NA
Approved By:
UWHC Pharmacy and Therapeutics Committee: February 2012, June 2014, August 2016 (expedited review)
UWHC Medical Board: March, 2010, March 2012, July 2014, August 2016 (expedited review)
UWHealth Chief Medical Officer: July 2014, August 2016 (expedited review)

Effective Date: August 2016

Scheduled for Review: August 2019
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org