Medication Management Standards - Excel

							Incorporating JCAHO Medication Management Standards into MHUMC’s Standing Orders
                               Data Collection Form
      Order Number: ________      Unit: _______              Physician/Serice:_________

Criteria                                                           Yes   No   N/A   Comment
Range orders
Order contains criteria to determine which route to use if
multiple routes are listed.1&2
Order contains specified dose (ex. 10mg vs 5-10 mg).1
Order contains specified interval (ex. q 4 hour vs q 4-6 hour).1
Order contains dose per m2 or dose per kg for all
chemotherapy and pediatric orders that requires calculation for
doses.3
Order contains dose written in weight (ex. 5mg) rather than
number of tablets, mL, etc. unless the drug is not measure by
weight (ex. Milk of magnesia).3
Order does not contain multiple ranges (ex. Demerol 25 to
50/Phenergan 25 to 50 IM or IV q 4 to 6 hrs PRN pain)1&2
Abbreviations

Order does not contain prohibited abbreviations and dose
designations (U, mg, IU, AU, AS, AD, OU, OD, OS,
MS, MSO4, MGSO4, trailing zero, QD, QOD, TIW).1,4,5
Order does not contain trailing zero; order does contain
              4&5
leading zero.
Order does not contain inappropriate symbols (>, <,
arrow up, arrow down).1&4
Order does not contain unapproved acronyms or phrases
(ex. 1/2 PSS for 0.5% Normal Saline).1&4
Ambiguous Orders
Order is clear and not ambiguous (ex. Resume med,
continue home med, continue pre-op meds, or transfer
med orders are prohibited; give unless allergic).3
Orders contain instructions on how to use pre-printed
order sets (ex. Order contains criteria to determine which
medication to use if multiple meds are listed for the same
indication).1
Order does not contain coined names that may be
misunderstood by people unfamiliar with them (ex.
Magic mouthwash or banana bag).3
Order contains proper spelling and spacing and uses fonts
and prints of professional quality (ex. propranolol20mg
can be misread as propranolol 120mg).3
There are critieria for use for as needed (prn) orders
containing multiple indication for use.1&2
Miscellaneous
Acetaminophen use is monitored (ex. List max dose of
acetaminophen use or # of tablets/day).6
Time frame is written for IV bolus/ IV push on orders.6
Generic medication name is written on orders.1&3
Medications are listed together or are easy to find.
The back copies of pre-printed orders are on unlined
paper because it may hide decimal points or drug
number.3
Order contains drug name, dose, route, and frequency.1
Order does not contain a list of drugs to choose from
because it is easy to choose the wrong item (ex.
Vincristine and vinblastine).3
Pre-printed orders contain tracking number and revision
date for ease of replacement and to determine need for
          3
revision.
There are indication for use or documented diagnosis for
each drug prescribed (including PRN orders).1&2
Order contains space for physician signature and
date/time.3

References
1
    2004 JCAHO Medication Management Standards. www.jcaho.org. Accessed on June 17, 2003.
2
    Rich DS. Ask the Joint Commission. Hospital Pharmacy 2003;38(9):878-882.
3
    ISMP Medication Safety Alert! April 23, 1997.
4
    ISMP Medication Safety Alert! November 27, 2003;8(24).
5
    JCAHO Issues ‘Do-Not-Use’ List of Dangerous Abbreviations. www.ashp.org/news. Accessed December 16, 2003. 

6
    ISMP Medication Safety Alert! August 7, 2003; 8(16).