Clinical Safety

No. CQ-3.009
Policies and Procedures
[INSERT
HOSPITAL Title: Page: 1 of 3
LOGO] Origination Date: 01-26-12; 06-07-10
Effective Date: xx-xx-xx
AUTOMATIC Retires Policy Dated: xx-xx-xx
STOP ORDERS Previous Versions Dated: xx-xx-xx
Hospital Governing
Board Approval Date: xx-xx-xx
Medical Staff
Approval Date: xx-xx-xx

I. SCOPE:

This policy applies to _________________________ (Hospital) and its Medical Staff.

II. PURPOSE:

The purposes of this policy are to ensure that there is a means by which all medications are reevaluated
and reviewed on a consistent basis and that this information is shared with the prescriber.

III. POLICY:

The Hospital will ensure safe administration of medications through the stop order process.

IV. PROCEDURE:

A. The following medications will be automatically stopped by the Pharmacy Department

after initial use has begun:

1. Ketorolac after 5 days of use

2. Nesiritide after 2 days of use

3. Alvimopan after 15 doses have been administered

4. Meperidine after 2 days of use

This automatic stop order process is defined as a hard stop.

B. Hard stops may be superseded by a physician order to continue for a specified period of
time past the specified timeframe defined in Section IV.A., above. The Hospitals
Medical Executive Committee may determine alternative specified timeframes.
Medications shall not be prescribed for an indefinite period of time (e.g., continue until
further notice or continue until discharge). All medications must be reviewed and
reordered by the physician every 30 days.

C. Pharmacy will notify the physician and the nursing staff that the identified medication has
reached its safe administration limit. As a result, the medication will not be made
available for administration past the automatic stop order timeframe as defined in Section
IV.A. Medication continuation will occur per physician order only.
 Clinical Safety
No. CQ-3.009
Policies and Procedures
[INSERT
HOSPITAL Title: Page: 2 of 3
LOGO] Origination Date: 01-26-12; 06-07-10
Effective Date: xx-xx-xx
AUTOMATIC Retires Policy Dated: xx-xx-xx
STOP ORDERS Previous Versions Dated: xx-xx-xx
Hospital Governing
Board Approval Date: xx-xx-xx
Medical Staff
Approval Date: xx-xx-xx

D. Identification and communication of hard stop medications will occur 48 hours before the
medication order is about to expire.

1. This identification process is completed by utilizing the pharmacy computer

system.

2. The Pharmacy will be responsible for sending out the notification of an

impending hard stop.

3. The notice will be flagged to the attention of physician and RN.

4. Notification can be (but is not limited to):

a. Sticker

b. Chart flag

c. Progress note

E. Twenty-four hours before a hard stop should occur, the Pharmacy will place a
communication in the chart that the identified hard stop medication will expire.

1. The communication will read per stop order policy, the following medication
order will expire at _________ [include date and time].

2. This communication will be placed in the physician order section of the medical
record.

F. Additional automatic stop order medications may be defined per the Hospitals Medical
Executive Committee. In addition, automatic reorder of all medications shall be
discontinued for

1. patients undergoing surgery

2. patients transferred into or out of a critical care unit

3. patients transferred to a different level of care

 Clinical Safety
No. CQ-3.009
Policies and Procedures
[INSERT
HOSPITAL Title: Page: 3 of 3
LOGO] Origination Date: 01-26-12; 06-07-10
Effective Date: xx-xx-xx
AUTOMATIC Retires Policy Dated: xx-xx-xx
STOP ORDERS Previous Versions Dated: xx-xx-xx
Hospital Governing
Board Approval Date: xx-xx-xx
Medical Staff
Approval Date: xx-xx-xx

G. Auditing and Monitoring

The Hospital shall monitor adherence to this policy and report results to the Pharmacy
and Therapeutics Committee. The Quality Management Department will audit adherence
to this policy as part of the Comprehensive Clinical Audits.

H. Responsible Person

The Hospitals Pharmacy Director is responsible for ensuring that all individuals adhere
to the requirements of this policy, that these procedures are implemented and followed at
the Hospital, and that instances of noncompliance with this policy are reported to the
[insert title of person to whom Pharmacy Director reports or other individual
responsible for high-level oversight of this policy].

I. Enforcement

All Hospital staff and Medical Staff whose responsibilities are affected by this policy are
expected to be familiar with the basic procedures and responsibilities created by this
policy. Failure to comply with this policy will be subject to appropriate performance
management pursuant to all applicable policies and procedures, including the Medical
Staff Bylaws, Rules and Regulations.

V. REFERENCES:

- Medicare Conditions of Participation