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Pharmacist Management of Electronic Medication Orders – Adult/Pediatric/Neonatal – Inpatient [74]

Pharmacist Management of Electronic Medication Orders – Adult/Pediatric/Neonatal – Inpatient [74] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols


Delegation Protocol Number: 74

Delegation Protocol Title:
Pharmacist Management of Electronic Medication Orders - Adult/Pediatric/Neonatal - Inpatient

Delegation Protocol Applies To:
All UWHC inpatients

Target Patient Population:
All UWHC inpatients

Delegation Protocol Champions:
Scott Springman, MD - Department of Anesthesiology

Delegation Protocol Workgroup:
Joe Cesarz, PharmD, MS - Pharmacy
Michelle Thoma, PharmD - Drug Policy Program
Steve Rough, MS, RPh - Phamarcy

Responsible Department:
Department of Pharmacy

Purpose Statement:
The purpose of this protocol is to delegate authority from the attending physician to a pharmacist to
manage electronic medication orders in the electronic medical record (EMR) with the objective of
improving the accuracy and interpretability of the EMR.

Who May Carry Out This Delegation Protocol:
Inpatient pharmacists who have been trained in the use of this delegation protocol.

Guidelines for Implementation:
1. The protocol will be initiated for all patients upon admission to UWHC with inpatient status.
2. Duplicate Order
2.1. Definition: A medication order entered into a patient’s EMR that does not differ in route, dose,
frequency, or infusion rate from a medication record that is already active within that patient’s
EMR, and.
2.2. Pharmacists will discontinue the duplicate order using the reason of “Duplicate” and order
mode of Protocol/Policy without cosign.
3. Orders with Conflicting Frequencies
3.1. Definition: An as needed (PRN) medication order entered into a patient’s EMR that possesses
the same medication and dose as an already active medication order within that patient’s EMR,
but differs in frequency.
3.2. Pharmacists will verify the most recently prescribed order and discontinue the pre-existing
order using the discontinue reason of “Change in Therapy” and order mode of Protocol/Policy
without cosign.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org



4. Medication Start Times
4.1. Definition: A medication order entered into a patient’s EMR in which the original start time of
the order conflicts with the typical hospital drug distribution times or the last dose
administered to the patient.
4.1.1. For admission medication orders that the patient was taking prior to admission, the
pharmacist will adjust the medication start times to reflect the scheduled dose time of
care based upon medication history information obtained from the patient, patient family
member/guardian, or other institutional medication administration record (MAR).
4.1.2. For new inpatient medication orders, pharmacists will adjust the medication start time to
accommodate typical drug distribution times.
4.1.3. Pharmacists will not adjust medication start times if the provider assigns a priority of
“STAT” or “Do not adjust start time/date” at the time of order entry.
5. “Note” Orders
5.1. Definition: A “Note” order within a patient’s EMR that supports the delivery and/or
administration of medications that are no longer active within the EMR.
5.2. Pharmacists will discontinue these “Note” orders using the discontinue reason of “Therapy
Complete” and order mode of “Per Orders Management Protocol”.
6. Product Selection
6.1. Definition: A medication order entered into a patient’s EMR in which the specific drug product
selected by the prescriber is manufactured by a company that is different from drug product
available in the institution’s drug distribution system. This results in conflicting drug product
codes between the ordered medication and that available in the institution.
6.2. Pharmacists will reject the conflicting drug product and enter an order for the available drug
product which will be identical in formulation, dose, and route of administration to the product
initially ordered by the prescriber, but manufactured by a different company and with a
different drug product code. The pharmacist will select the discontinue reason of “Change to
Formulary Product” and order mode of Protocol/Policy without cosign”.
7. Incomplete or Empty Administration Instructions
7.1. Definition: A medication order or “Note” order that contains administration instructions that
are incomplete and/or could be improved, or contains unacceptable medical abbreviations; or
a medication order or “Note” order that does not contain administration instructions but safe
administration requires the addition of administration instructions.
7.2. Pharmacists will modify or add the necessary administration instructions based on UW Health
guidelines, policies, or procedures to guide medication use without changing the intent of the
medication order. Modifications will be made using the order mode Protocol/Policy without
cosign”.
8. Distribution Method for Patient’s Own Medications
8.1. Definition: A medication record that is entered into a patient’s EMR with the method of
distribution through the hospital’s drug distribution system, but the patient has provided his or
her own supply of medication for use while in the hospital (or vice versa).
8.2. Pharmacists will modify the medication order’s route of distribution to reflect the appropriate
medication source using the order mode Protocol/Policy without cosign”.
9. Discharge Medication Reconciliation and Refill Authorization
9.1. Definition: Clinical review and comparison of a patient’s inpatient medication list to their prior
to admission medication list. Providers will resume, modify or discontinue medications as
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

clinically necessary and will ensure that the appropriate quantity and number of refills are
available to patients to continue therapy.
9.2. Pharmacists will review and adjust medication refill quantities to meet the patients intended
course of therapy, to ensure sufficient medication supply until the patient can establish and/or
re-establish care with an outpatient prescriber, to apply an inpatient therapeutic interchange
protocols to adjust discharge prescriptions to meet the patient’s outpatient insurance
coverage, to adjust for renal function, and/or to adjust drug formulation to ensure patients
have the correct medications to continue their intended course of therapy.

Order Mode: Protocol/Policy without cosign

References: N/A

Collateral Documents/Tools: N/A

Approved By:
Pharmacy Practice Committee – May 2011, March 2015 (expedited review)
UWHC Pharmacy and Therapeutics Committee – November 2011 – March 2015 (expedited review)
UWHC Medical Board – November 2011, April 2015 (expedited review)

Effective Date: April 2015

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