11.1: Medication Orders

Learning Objectives

By the end of this section, you will be able to:

• Describe types of medication orders
• Identify components of a medication order

Medication orders are a fundamental aspect of nursing practice, serving as the directives for the safe and effective administration of medications to patients. A thorough understanding of medication orders, including the various types and their components, is crucial for nurses to minimize the risk of medication errors, ensure optimal patient care, and enhance therapeutic outcomes. This section will explore the complexities of medication orders, equipping nurses with the basic knowledge required to accurately interpret, verify, and execute these orders accurately. By mastering this aspect of nursing practice, nurses play a pivotal role in ensuring patient safety and delivering high-quality care.

Types of Medication Orders

A medication order is a prescription ordered within clinical practice. When administering medications, it is important for the nurse to be aware of the various types of medication orders that may be written. Common types of medication orders include routine orders, one-time orders, standing orders, STAT orders (to be completed now), PRN (as needed) orders, and titration orders. Each order type has indications for nursing practice. Identifying the order type helps the nurse to prepare for medication administration by knowing which medications to administer, when to administer them, as well as specific indications for administration.

• A routine order is a medication order that is continuously followed until canceled. For example, “Aspirin 81 mg PO Q Day” is a routine order. For the order to be canceled, the provider would need to discontinue the order.
• A one-time order is an order for a medication to be administered just one time. An example of a one-time order is “Cefazolin (Ancef) 2 g IV × 1 dose before surgery.”
• A standing order is a standardized order that may be implemented under certain circumstances. Standing orders are written to address protocols in which the nurse can intervene in a timely manner without having to wait on the provider to write orders, or there are general guidelines for treating a certain condition. For example, surgical procedures often utilize standing orders that allow the nurse to administer medications for pain, nausea or vomiting, constipation, and venous thrombosis prophylaxis.
• A STAT order is a one-time order that is administered as urgently as possible. An example of a STAT order may be to administer “Lorazepam (Ativan) 1 mg IV STAT” when the patient is having a seizure.
• A PRN order is a medication order to be administered as needed. PRN medications are commonly ordered for symptoms such as pain, nausea or vomiting, itching, sleep, cough, or fever greater than 101°F (38.3°C). An example of a PRN order is “Diphenhydramine (Benadryl) 25 mg PO Q4 hours PRN itching.” It is important to note that a PRN medication may only be administered for the ordered indication. For instance, an order that reads “Acetaminophen 500 mg PO PRN headache” cannot be administered for mild arthritic pain.
• A titration order is an order in which the medication dose is either progressively increased or decreased by the nurse in response to the patient’s status. Titration orders are typically used for patients in critical care as defined by agency policy. An example of a titration order is “Norepinephrine 2–12 mcg/min, start at 2 mcg/min and titrate upward by 1 mcg/min every five minutes with continual blood pressure monitoring until systolic blood pressure > 90 mm Hg.”

Components of a Medication Order

According to the Centers for Medicare and Medicaid Services (2014), all medication orders must contain the following:

• patient’s full name and date of birth
• name of the drug
• drug dose, route, and frequency
• date and time medication order was written
• name and signature of the prescriber

The following additional requirements must also be included when applicable:

• weight of the patient if dose calculation is based on weight (kilograms for children and adults, grams for newborns)
• dose calculation requirements
• exact strength or concentration of medication
• specific quantity or duration to be administered
• specific instructions for use
• reason for use if medication is ordered PRN

An example of a complete medication order is shown in Figure 11.2.

Figure 11.2 A complete medication order includes the patient’s information as well as the date, medication and dosage, and prescriber’s name. (CC BY 4.0; Rice University & OpenStax)

When reviewing a medication order, the nurse must ensure all essential components are included in the prescription before administering the medication. If any component of the medication order is missing, the nurse must contact the prescribing provider to clarify and correct the order.

Drug Name

Drugs are provided with three categories of names: (1) a chemical name, (2) a generic name, and (3) a brand name (Table 11.1). The chemical name provides a detailed description of the drug's molecular structure and chemical composition. This name is often complex and used primarily by chemists and researchers. The generic name, which is the standard name assigned by the United States Adopted Names (USAN) Council, is universally accepted and provides a simpler, more concise designation for the drug (Merck & Co., 2023). It is typically used by healthcare professionals and is preferred in clinical settings to reduce confusion. The brand name, also known as the trade name, is the proprietary name given by the pharmaceutical company that markets the drug. This name is usually easier to remember and is used in advertising and marketing to the public. Although a single drug may have one chemical and generic name, it can be sold under multiple brand names by different manufacturers.

Chemical Name	Generic Name	Brand Name
N-acetyl-para-aminophenol	Acetaminophen	Tylenol
Dihydroxy monocarboxylic acid	Atorvastatin	Lipitor
3-(α-acetonylbenzyl)-4-hydroxycoumarin sodium salt	Warfarin	Coumadin

Table 11.1 Examples of Drug Chemical Names, Generic Names, and Brand Names

The drug name must be clearly specified to prevent errors in medication administration. The name should be written in full and should not be abbreviated in order to avoid confusion with other medications that may have similar abbreviations. Both the generic name and brand name of the drug are often included to ensure clarity, with the generic name being preferred to reduce the risk of errors due to similar-sounding brand names. It is essential for the nurse to be familiar with both names to accurately verify and administer the medication. In cases where the drug name is unclear or misspelled, the nurse must contact the prescribing provider for clarification to ensure patient safety.

Dose

The dosage of the drug refers to how much of a drug a patient should receive. Drug dosages may be written using three systems of measurements: metric system, household, or apothecary. The metric system is the most widely used international system of measurement and is considered to be the most accurate of the three systems of measurement. It is a decimal-based system based on units of ten. The household system utilizes everyday household items, such as measuring cups and tablespoons, to serve as measuring devices. Due to variations in the size of household items, it is considered to be the least accurate system of measurement. The apothecary system utilizes fractions as a part of the whole to measure weights and volumes.

According to the Institute for Safe Medication Practices (ISMP, 2021), household and apothecary measurements should only be used to provide directions for mixing dry ingredients to prepare a topical product. In all other circumstances, the metric system should be used. Common units of measurement for drug doses include the following:

• gram (g)
• kilogram (kg)
• liter (L)
• microgram (mcg)
• milligram (mg)
• milliliter (mL)
• units

Special care should be given to orders that contain a zero. Drug dosages should not be written with trailing zeros. For example, 1 milligram should be written as 1 mg instead of 1.0 mg to reduce the risk of the dosage being mistaken for 10 mg. However, if the dose is less than one unit, a zero must be included before the decimal point, often called a leading zero. For example, half a milligram should be written as 0.5 mg instead of .5 mg to reduce the risk of the dosage being mistaken for 5 mg.

Real RN Stories

Ensuring Correct Dosage

Nurse: Joseph, BSN
Clinical setting: Cardiology unit
Years in practice: One month
Facility location: The inner city of a small metropolitan area in South Carolina

As a newly graduated nurse on the cardiology unit, I was still becoming familiar with the specific medication protocols followed by the cardiologists. One busy afternoon, Dr. White approached me and informed me that Mr. Thompson, a patient with a history of atrial fibrillation, was experiencing an irregular heartbeat. Dr. White had just placed a new order for a stat dose of IV digoxin to stabilize Mr. Thompson’s heart rate and asked me to administer it immediately.

I opened Mr. Thompson’s chart and read the order: "Digoxin 0.25 mg IV STAT." I promptly sent the order to the pharmacy for processing and proceeded with the medication administration by overriding the automated medication dispensing machine to avoid any delay, given the urgency of Mr. Thompson's condition.

As I prepared to retrieve the medication, I noted that Digoxin was available in 0.125 mg vials. Believing the order called for 0.25 mg, I calculated that I needed two vials to meet the required dose. However, as I prepared the medication, I was interrupted by an alert from the dispensing machine, warning that the amount requested was unusually high for this drug.

Feeling uncertain, I decided to consult with my charge nurse before proceeding. We rechecked the chart together and discovered a crucial detail that I had initially overlooked. The actual order read: "Digoxin 0.125 mg IV STAT." The way the order was written, the ".125" had been mistakenly read as ".25" due to poor handwriting and a misalignment on the chart.

Realizing my error, I adjusted the medication dosage to the correct 0.125 mg. Thanks to the alert from the automated system and the verification with my charge nurse, we avoided administering double the intended dose. This incident reminded me of the importance of carefully reviewing and verifying medication orders, especially in emergent situations where overriding the safety mechanisms in the medication dispensing machine may be warranted.

Route

The route of the drug is the method by which the drug should be administered. Commonly used abbreviations for medication routes can be found in Table 11.2.

Abbreviation	Route
AD	Right ear
AS	Left ear
AU	Each ear; both ears
BU or BUC	Buccal
EPI	Epidural
IA	Intra-arterial
IC	Intracardiac
ID	Intradermal
IM	Intramuscular
INH	Respiratory (inhalation)
IT	Intrathecal
IV	Intravenous
IVP	Intravenous push
IVPB	Intravenous piggyback
NAS	Nasal
NG	Nasogastric
NGT	Nasogastric tube
OD	Right eye
OS	Left eye
OU	Each eye; both eyes
PO	Per mouth
PR	Per rectum
SC or SQ	Subcutaneous
SL	Sublingual
TD	Transdermal
TOP	Topical
PV	Per vagina

Table 11.2 Abbreviations for Routes of Administration

A drug may only be administered via the ordered route. In the event the medication cannot be administered via the route ordered, the nurse must notify the provider. The nurse should document the reason for the route change and await further instructions from the provider to ensure patient safety and the effectiveness of the medication. If an alternative route is necessary, it must be clearly specified and approved by the provider before administration.

Frequency

The frequency of the drug refers to how often or how many times per day the medication should be administered. Examples of drug frequency include Q30 minutes (every thirty minutes), Q4 hours (every four hours), Q12 hours (every twelve hours), Q Day (daily), BID (twice daily), TID (three times daily), QID (four times daily), and QHS (at bedtime). If the frequency is denoted in terms of number of times per day, the frequency can be determined by dividing 24 hours per day by the number of times the drug should be administered. For example, a medication ordered twice daily should be administered every twelve hours (24 hours in a day/2 administrations = every 12 hours), and a medication ordered three times daily should be administered every eight hours (24 hours in a day/3 administrations = every 8 hours).

Date, Time, and Signature of Provider

For the medication order to be complete, it must include the date and time the order was written, along with the prescriber’s signature (electronic or handwritten). Best practice is for the provider to enter the order; however, there may be times when the provider is not able to do so, and a verbal order is required (Patient Safety Authority, 2006). When taking a verbal order, the nurse must restate the order back to the provider to ensure the message was received correctly. The nurse must immediately document the verbal order in the patient’s chart, and the provider must review and sign the order according to the agency’s policy. Nurses should be aware that both state and organizational policies will dictate required verbal order components. Be sure to follow the organization's policies.