1. Time of First Dose for Medication Orders Start Feb 17, 2010

2. Background Feedback from clinicians using eMAR that a new order may start immediately First dose is the pharmacy approval time, which may not be the appropriate time to start an order based on the frequency Goal is to start the 1 st dose of an medication order on an appropriate schedule

3. Pilot First dose will not be tied to the approval time but is based on the frequency of the order and time pharmacist processes the order 8 frequencies to be piloted—Q AM, Q PM, AC, AC and HS, Q AM before breakfast, Q HS, Q PM before supper, BID AC (before breakfast and supper) Starts February Feb 17th

4. Q AM, Standard Medication Administration Time (SMAT) is 8am Order approved between 00:01 and 08:00, due today at 08:00 Order approved between 08:01 and 12:00, due today, now Order approved between 12:01 and 00:00, due tomorrow at 08:00

5. Q PM, SMAT 20:00 Order approved between 00:01 and 20:00, due today at 20:00 Order approved 20:01 to 00:00, order due now Please click here to see time of 1 st dose for the select 8 frequencies— Time of 1st dose for 8 frequencies http://

6. Change Orders Becomes a new order If the next scheduled dose of the old order is in the future, no action needed. 1 st dose of new order will be scheduled. If next dose on THE old order is due/overdue, then: – Must document “not given” on old order – Allows new order to be documented

7. Example Order Change to Lasix 40 mg po Q AM from Lasix 20mg po Q AM Approved at 07:45am and not given yet Lasix 20mg po due at 0800am New 40mg order removes the 20mg dose from the to do list Newly ordered 40mg dose is due at 08:00 *Note due time is the actual due time of 08:00 and does not refer to the 2 hr window of 07:00 to 09:00

8. Same Example Different Approval Time Order Change to Lasix 40 mg po Q AM from Lasix 20mg po Q AM. Approved at 08:15am 20 mg Dose Due at 0800, not given yet 40 mg Dose Due now Must document not given on 20mg dose Administer and document 40mg dose

9. Click on next administration time to see future administrations

10. Summary of Changes Pilot for 8 frequencies starts Feb 17 Based on time of approval and frequency, the system will default the first dose of an order If the order is a change order, then the first dose will be based on the old order: – If there is a dose due for the old order, this must be addressed (i.e. document “not given”) and then give the new order – If there is no dose due for the old order, then no action needed on old order. The 1 st scheduled dose on the new order becomes the next due dose. To customize a schedule from the SMAT, you still need to page the pharmacist.

11. Case study #1 Patient admitted from ED to Wh 10 at 20:00. Medication orders written at 21:00 and approved by the RPh at 22:48 for the following NPH Insulin Human 20 units SC Q AM. With this new function, when would the first dose be due?

12. Answer to case study # 1 System would default the first dose to 08:00 tomorrow and then 0800 every day.

13. Case Study #2 Change order is as follows Change to Warfarin 7.5 mg PO Q PM from Warfarin 5mg PO Q PM. Order written at 13:00 and approved at 14:34. With this new function, when would you expect the 1 st dose to be scheduled?

14. Answer to Case study #2 A change order discontinues the old order and starts the new order. This order would be scheduled for 20:00 tonight.

15. Case study # 3 Change to INSULIN GLARGINE (LANTUS) 20 UNITS SC QAM FROM INSULIN GLARGINE (LANTUS ) 25 UNITS SC QAM Ordered at 09:12 and approved at 10:03. Med was given at 07:43. When would you expect the 1 st dose of the new order?

16. Answer to Case study #3 Since today’s dose was already given on the old order, the 1 st dose for the new order will be scheduled for tomorrow

17. Case study 4 Change to INSULIN GLARGINE (LANTUS) 20 UNITS SC QAM FROM INSULIN GLARGINE (LANTUS ) 25 UNITS SC QAM Ordered at 07:12 and approved at 08:03 Patient has not received Lantus this am What would you expect the nurse to administer and document?

18. Answer to Case study #4 The old order of Lantus 25 units was due at 08:00. The new order of Lantus 20 units is due at 08:03. Both medications appear on the To do list. RN would have to document “not given” on the old order of 25 units as once a dose is due in eMAR it must be addressed (ie not given, etc) RN would administer and document the 20 units