BURAIDAH C ENTRAL H OSPITAL

Department: NURSING SERVICE Policy Index: PP-BCH-NR/GNR-036-DPP-E Title: PHYSICIANS ORDERS / REVIEW BY NIGHT SHIFT Effective Date : Applies to: 01-01-1432 H All Nursing Staff New

B. C. H.

DPP

Replace Number : XXXXX Number of Pages : 3 Review Date : 01-12-1433 H

1. PURPOSE:

1.1 To follow-up review of physicians orders by the night shift to prevent and / or correct errors
in transcription.

2. DEFINITION :
2.1 A collection of data that serves as a written proof that the patient had been endorsed by ward staff and received by operating room staff.

3. POLICY:
3.1 During the night shift, each nurse will review the physicians orders for the previous twenty four (24) hours for assigned patients and to ensure that the orders were transcribed correctly. 3.2. Check medications for : 3.2.1. Correct dosage, route, and time for patient. 3.2.2. Drug does not adversely interact with other drugs or treatments. 3.2.3 Patient/procedures are not contraindicated according to patients diagnosis or condition. 3.2.4 Treatment / procedures are not redundant or will not interfere with other treatments, tests or procedures. 3.3 The nurse will initial and date the Physicians order sheet in red ink to verify the review and correction of the orders. 3.4 Complete OVR for identified errors. Follow Occurrence Variance IPP.

4. PROCEDURES : 4.1 The night shift staff nurse will :

4.1.1 Gather all assigned patients medical records.

RATIONALE :

Prepared by: Ghada Falah Al - Harby Staff Nurse

Approved by : Ahmad Abdulla Al - Omar Hospital Director

Page Number : 1/3

Approval Stamp

Form Index: BCH-QM-009-E

4.1.2 Review the Physicians order for the previous 24 hours. 4.1.3 Check the patient medication adminis tration form against the Doctors order at the progress note and Kardex. 4.1.4 Check medications for 7 Rights.: 4.1.4.1 Correct dosage, route, fre quency, medication, time, patient and right documentation. 4.1.4.2 Possible drug interaction with other drug or treatment. 4.1.4.3 Patient procedures / treatment are carried out properly and documented / not redundant. 4.1.4.4.The nurse will initial and date the physicians in black ink. 4.1.4.5 Complete Incident Report Form for identified error. 4.1.4.6 Inform the Head Nurse of any unusual findings. 4.1.4.4 To verify the review and correction of the order. 4.1.4.5 To identify the cause / analysis of the incident. 4.1.4.1 Ensures administration of drugs to proper patient / prevents medication errors. 4.1.4.2 Drug interaction may either increase or decrease the effects of the medi cation.

5. FORMS AND EQUIPMENTS : 5.1 5.2 5.3 5.4 5.5

Patients Medical Record. Medication Record Form. Kardex. Nursing Care Plan. Black Pen. 5.6 Occurrence Variance Report (OVR) (as needed).

6. REFERENCES : 6.1 Ministry of Health Policy and Procedure Manual.

7. APPENDIX :

7.1 N/A

Policy Number: PP-BCH-NR/GNR-036-DPP-E

Title: PHYSICIANS ORDERS / REVIEW BY NIGHT SHIFT

Page Number: 2/3

Approval Stamp

Form Index: BCH-QM-009-E

8. APPROVAL :

Name Prepared by: Ghada Falah Al-Harby 1.Abdulla Obeid Al-Harby Reviewed by: 2.Ehab El Husseiny Ibrahim 3.Manae Al-Belaihy Approved by: Ahmad Abdulla Al-Omar

Position Staff Nurse Nursing Director QM Director Medical Director Hospital Director

Signature

Date
22-11-1431 H 24-11-1431 H 29-11-1431 H 29-11-1431 H 01-12-1431 H

Policy Number: PP-BCH-NR/GNR-036-DPP-E

Title: PHYSICIANS ORDERS / REVIEW BY NIGHT SHIFT

Page Number: 3/3

Approval Stamp

Form Index: BCH-QM-009-E

Policy Number: PP-BCH-NR/GNR-036-DPP-E

Title: PHYSICIANS ORDERS / REVIEW BY NIGHT SHIFT

Page Number: 4/3

Approval Stamp

Form Index: BCH-QM-009-E