Q&A: Addressing unclear medication orders

Q: What process should I have in place for clarifying incomplete medication orders?

A: When speaking with staff members on-site, the surveyor will expect that they can clearly articulate the process for clarifying incomplete orders. It’s disturbing to hear that “sometimes the nurse clarifies incomplete medication orders and sometimes pharmacy does it, depending on the issue.” You should establish a process that specifically addresses how to approach unclear orders. Typically, nursing would be the first level of clarification, followed by pharmacy. Nursing should be clarifying incomplete orders at a minimum; it’s amazing how many telephone orders are incomplete when the RN taking the order had the physician on the phone and could have clarified the order on the spot. The pharmacy should be clarifying any dosing, formulary, or drug interaction issues. This creates a built-in system of double-checks.

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