MEDICATION ORDER REVIEW

MEDICATION ORDER REVIEW (MOR)

SHPA standards of Practice for Clinical

Pharmacy

 “It is a fundamental responsibility of pharmacists

to ensure the appropriateness of medication
orders”
GOALS OF A MEDICATION ORDER REVIEW
1) To optimise patient health outcomes
• Cure disease
• Eliminate/reduce symptoms
• Arrest/slow disease processes
• Disease/symptom prevention
GOALS OF A MEDICATION ORDER REVIEW
(CONT)
2) To optimise drug therapy, by ensuring safety and
appropriateness of prescribed medicines:
 the patient receives the most appropriate:
 Drug
 Dose
 Dose-form
 the timing of the dosing is optimised
 drug related problems are minimised
GOALS OF A MEDICATION ORDER
REVIEW (CONT)
In depth assessment of current medicines should
take into account:
 patient’s medication history

 Patient’s medication management plan (MMP)

and data from the medication administration
record.
 A clinical review including therapeutic drug
monitoring.
GOALS OF A MEDICATION ORDER REVIEW
(CONT)
3) In addition, medication order review “….serves as
a starting point for other clinical pharmacy
activities including patient counselling, TDM,
clinical review and assessment/management of
ADRs
• Pharmacist input into appropriate choice of
medicines and assessment of patient’s current
medication management helps to:
– Optimise the quality of patient care and clinical
outcomes
– Ensure that the selection of medicines follows local
guidelines, formulary and availability limitations.
– Promote quality and cost-effective use of medicines
 WHEN TO DO MEDICATION ORDER REVIEW?

As part of
medication Presentation or Admission
reconciliation

Throughout
episode of care

On discharge or
transfer
DRUG-RELATED PROBLEMS
• Drug without indication
• Inappropriate choice of drug
– Contraindication
– Consider efficacy, safety or cost-effectiveness
• Dose too low
• Dose too high
• Drug interactions
– Drug-drug, drug-food and drug-laboratory
• Inappropriate route/method of administration
• Inappropriate duration of treatment
• Drug-induced medical condition (i.e. ADR)
• Untreated indication
PROCEDURE FOR A MEDICATION-ORDER
REVIEW
 Where possible DO NOT review medication
orders in isolation. Instead review them in
conjunction with the patient’s:
 Medical history
 daily progress, treatment plans
 Medication history obtained during admission
interview
 Relevant pathology results
PROCEDURE FOR A MEDICATION-ORDER
REVIEW (CONT)

 Review ALL medication orders, which may

include:
 Routine medication orders on drug chart
 Single dose (‘stat’) orders (e.g. vaccinations)
 Often written on a separate section of the medication
chart
 Variable dose orders (e.g. warfarin, prednisolone)
 Usually written on separate section of the drug chart or
on a separate chart
PROCEDURE FOR A
MEDICATION-ORDER REVIEW
(CONT)
 Review ALL medication orders, which may include:
 Intravenous therapy (e.g. TPN, chemotherapy, fluids)
 Usually written on a separate chart
 Anaesthetic orders,
 Usually written on a separate chart
 Parenteral analgesic orders
(e.g. epidural infusions, syringe drivers,
PCA)
 Usually written on separate chart/s
COMPONENTS OF A MEDICATION
ORDER REVIEW
1. Legibility/Legality/Validity
Consider how the medication orders are
written.
• Are they:
a. Legal or valid?
• Patient identifiers are present
• Order is signed by prescriber
b. legible and unambiguous?
• Administration order? IV, subcut, oral, nasogastric,
maximum dose per 24 hours, time of dose, etc.
c. not abbreviated ?
d. conforming to local requirements?
• e.g. formulary restrictions, antibiotics restrictions
e. written by generic name?
COMPONENTS OF A MEDICATION
ORDER REVIEW (CONT)
2. Patient specific factors
Is the order is appropriate with respect to:
 Allergy/ADR history ?
 Concurrent diseases ?
 Are there any contraindications to prescribed medications?
 Concurrent medications?
 Check for duplications & significant drug interactions
 Pregnancy, lactation?
 Dose and dosing schedule?
 Consider:
 Patient’s age - Renal/liver function
 Body weight - Indication for therapy
COMPONENTS OF A MEDICATION
ORDER REVIEW (CONT)
3. Drug-specific factors
Consider whether the order is appropriate with
respect to:
 dose and dosing schedule (see above)
 route and dosage form
 Ability to swallow tablets? Can be crushed?
 dose-times
 with respect to food and/or other drugs/procedures
 incompatibilities (for parenteral drugs)
 method of administration
 e.g. rate of infusion, co-administration of incompatible drugs
 cost-effectiveness
COMPONENTS OF A MEDICATION ORDER
REVIEW (CONT)
4. Other
 Ensure all medication orders clearly indicate the
date/time at which administration is to
commence
 Check that the duration of therapy has been
specified, and it is appropriate
 Eg. antibiotics
 Ensure that all doses ordered have been
administered by checking the medication
administration section of the chart
 When a medication is ceased, ensure that the
order is cancelled in all sections of the chart
COMPONENTS OF A MEDICATION ORDER
REVIEW (CONT)
4. Other (cont)
 Endorse/annotate medication charts with information
that will facilitate accurate and safe administration of
the medications. For example:
 Allergies/ADRs
 Generic drug names
 Times of administration (with/without food)
 Method of administration (e.g. swallow whole)
 Identify cytotoxic drugs
 Rates of injection/infusion for IV drugs
 Clarify abbreviated orders
 Number of tablets to give
 Storage
COMPONENTS OF A MEDICATION ORDER
REVIEW (CONT)
4. Other (cont)
 Consider what drug monitoring will be required
 Ensure that the new chart matches up with the
old chart when rewritten
 Ensure all necessary medications are ordered (e.g.
pre-medication or prophylactic medication)
COMPONENTS OF A MEDICATION
ORDER REVIEW (CONT)
 4. Other (cont)
 Check medication orders
 interactions, including drug-drug, drug-patient, drug-
disease and drug-nutrient interactions.
 interactions with laboratory tests and environmental
factors, e.g. smoking, alcohol, motor vehicle driving,
contrast for renal patients.
 Cost of medicine therapy to the patient, hospital and
community
COMPONENTS OF A MEDICATION
ORDER REVIEW (CONT)
• 4. Other (cont)
• Check for:
– Availability: government restriction, further supply
outside hospital
– Duplications
– Whether dose conversions required with changes to
route or formulation
– Timing of administration: in regards to food/feeds,
TDM requirements, etc.
– Necessary medicines are available (to order if
necessary)
FOLLOW-UP AFTER A MEDICATION ORDER
REVIEW
 Discuss problems with prescriber/nurse/patient
as soon as possible
 Details of intervention should be documented in
the pharmaceutical care plan and/or patient
notes
 Ensure all medications ordered are available for
patients in a timely manner
 Ongoing clinical review and TDM is essential to
re-evaluate and modify therapeutic goals as
patient’s condition and response to therapy
change.
Metformin in
renal
impairment
Frusemide dose is not
enough in oedema
Frusemide should be
given in the morning
and early afternoon i.e.
08am and 12pm
Trimethoprim for UTI
in female should be 3
days only
Flucloxacillin is
charted for patient
with penicillin
allergy.
CASE STUDY
 JB 83yrs M
 HOPC: Exacerbation of Chronic Obstructive
Pulmonary Disease (COPD)
 PHx: Ischaemic Heart Disease (IHD), Atrial
Fibrilation (AF), Congestive Cardiac Failure
(CCF), COPD, Type 2 Diabetes, Benign Prostatic
Hyperplasia (BPH), gallstone.
 Blood results: Cr=164H, eGFR=33, Na=140,
K=4.4, Hb=116L, Platelets=130L
 Blood Glucose 24.7H
 AFTER RECONCILIATION
Before
Latanoprost 1 drop BE nocte
Seretide 250/25 2 puffs BD
Tiotropium 18microg mane
Dexamethasone 4mg mane
Perindopril 1.25mg mane
Nicorandil 10mg BD
Frusemide 80mg BD
Amiodarone 200mg mane
Bisoprolol 10mg mane
Paracetamol 500mg 2 tabs QID
Gliclazide SR 60mg mane
Lantus 16units mane
Carbimazole 5mg alternate days
Pantoprazole 40mg mane
Allopurinol 100mg mane
Green = Patient was not taking
preadmission
On the interview
Latanoprost 1 drop BE nocte
Seretide 250/25 2 puffs BD
Tiotropium 18microg mane
Dexamethasone 2mg mane
Ramipril 1.25mg mane
Nicorandil 10mg BD
Frusemide 40mg BD
Amiodarone 200mg mane
Bisoprolol 10mg mane
Paracetamol 665mg 2 tabs TDS
Cholecalciferol LIQ 1mL mane
Warfarin (Coumadin) 2mg/2.5mg
alternating daily
GTN spray prn
Pantoprazole 40mg mane
Allopurinol 100mg mane
Salbutamol PRN
 Red =Discrepancies
 Blue = Not charted
AFTER DISCUSSION WITH THE DOCTOR
 Warfarin, Salbutamol, GTN spray are charted
 Dexamethasone dose was deliberately increased
(because of stress)
 Perindopril is changed back to Ramipril

 Frusemide dose was deliberately increased –

Congestive cardiac failure, increased oedema
 Gliclazide was deliberately restarted – BSL
derangement (? Due to dexamethasone)
 Lantus, Carbimazole were ceased.
CURRENT MEDICATION - 1/5/15
Latanoprost 1 drop BE nocte
Magnesium 500mg daily
Seretide 250/25 2 puffs BD
Tiotropium 18microg mane
Spironolactone 12.5mg mane
Dexamethasone 1mg mane
Nicorandil 10mg BD
Frusemide 40mg BD
Amiodarone 100mg mane
Bisoprolol 10mg mane
Paracetamol 665mg 2 tabs TDS
Cholecalciferol LIQ 1mL mane
Warfarin (Coumadin) 2mg/2.5mg alternating daily
Enoxaparin 70mg subcut daily
Gliclazide SR 60mg mane
Mixtard 30/70 7 units subcut mane
Pantoprazole 40mg mane
Allopurinol 100mg mane
Coloxyl and Senna 2 tabs BD
Flucloxacillin 500mg QID
Current medication – 1/5/15
Latanoprost 1 drop BE nocte
Magnesium 500mg daily
Seretide 250/25 2 puffs BD
Tiotropium 18microg mane
Spironolactone 12.5mg mane
Dexamethasone 1mg mane
Nicorandil 10mg BD
Frusemide 40mg BD
Amiodarone 100mg mane
Bisoprolol 10mg mane
Paracetamol 665mg 2 tabs TDS
Cholecalciferol LIQ 1mL mane
Warfarin (Coumadin) 2mg/2.5mg alternating daily
Enoxaparin 70mg subcut daily
Gliclazide SR 60mg mane
Mixtard 30/70 7 units subcut mane
Pantoprazole 40mg mane
Allopurinol 100mg mane
Coloxyl and Senna 2 tabs BD
Flucloxacillin 500mg QID
LAST UPDATE - 1/5/15
 Patient is also on enoxaparin 70mg subcut mane until INR
is therapeutic.
 Spironolactone was started because of the oedema
 After few weeks, Mixtard insulin has been started due to
uncontrolled high BSL.
 Patient has increased erythema on legs, hence antibiotic
was started.
 Amiodarone dose was reduced because patient is in sinus
rhythm.
 Dexamethasone dose was also reduced.
 Ramipril was withheld because low blood pressure and to
be restarted once BP normal
 Coloxyl and Senna was started because of the constipation
(long term stay in the hospital)
Any Questions?