Journal Information
Vol. 36. Issue. 6.November - December 2016
Pages 583-722
Vol. 36. Issue. 6.November - December 2016
Pages 583-722
Letter to the Editor
DOI: 10.1016/j.nefroe.2017.01.004
Open Access
Blanket orders, an unadvisable practise, yet more and more frequent
Blanket orders, práctica desaconsejada pero cada vez más frecuente
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Anunciación González Lópeza,
Corresponding author
gonzaleza@senefro.org

Corresponding author.
, Álvaro Nava Rebolloa, Beatriz Andrés Martína, Ángel Chocarro Martínezb, Francisco Herrera Gómeza, Henar Santana Zapateroa, Julia Diego Martína, Cipriano Escaja Mugaa, Hugo Díaz Molinaa, Jesús Grande Villoriaa
a Servicio de Nefrología, Hospital Virgen de la Concha, Zamora, Spain
b Servicio de Medicina Interna, Hospital Virgen de la Concha, Zamora, Spain
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Dear Editor,

One concern in relation to drug safety is to reconcile the patient's treatment when changing to another healthcare area. There are reports showing that hospital admissions and transfers to different hospital services or hospital discharges are a cause of error in the treatment medication.

The process of conciliation of the treatment at discharge includes a double supervision. Both, the list of drugs that the patient was taking prior to admission and the drugs prescribed during admission must be conciled to obtain a single list. Generic orders or instructions, such as “resume usual medication”, “continue the usual treatment” or “maintain the same treatment”, known as blanket orders,1,2 are not acceptable.

We have assessed the magnitude of blanket orders in our department, how it has been evolving and associated variables. To that effect, we performed a retrospective analysis of hospital discharges and outpatient reports issued at our hospital's Department of Nephrology from 2006 to 2014. The following variables were collected: date of the report, author, days of admission, age and gender of the patient, presence of multiple pathologies (4 or more diseases), renal replacement therapy (dialysis), use of and the type of blanket order. Our hospital does not have computerised medical records, clinical reports are the only tool available to clinicians to report therapeutic changes.

During the period of evaluation, 2358 clinical reports were issued at our department. After excluding deceased patients (n=61), the number of reports analysed for this study dropped to 2297. Of these, 1190 were hospital discharges (50.5%). Fifty-five per cent (55%) of the patients were male, 68.3% had multiple pathologies and 26% were on dialysis. Blanket orders were used in 50.2% of the cases (1153), with a greater frequency in hospitalised patients than in outpatients (53.1% vs. 47.1%; p=0.004). The types of blanket order found were: “continue the usual treatment” in 65% (751); “as indicated at the time of discharge” in 27.4% (316); “rest of medication as prescribed by another specialist” in 4.16% (48); and other blanket orders in 3.2% (37). The percentages of blanket orders increased over the years (37.5% in 2006 compared with 57.8% in 2014, p=0.0001), but were not influenced by the month issued, nor by the patients’ age or gender. On the contrary, blanket orders were more frequent in patients with multiple pathologies (55.3 vs. 38.1%, p=0.000), in patients on dialysis (64.8 vs. 44.9%, p=0.000) and in patients admitted for a short periods of time (mean±SD) (6.98±6.29 vs. 10.25±8.23 days; p=0.0001).

Blanket orders are used in almost half of the clinical reports and the data indicate that, far from diminishing, this practice is progressively more frequent. It is not surprising that blanket orders are more common in patients with brief hospital stays and multiple pathologies, in whom therapeutic conciliation is more complex and requires greater effort. Although medical records are not computerised, we do have a follow-up programme for patients on dialysis, which would explain the existence of a high percentage of blanket orders in these patients (possibly by giving them a copy of the software without transcribing such treatment in the discharge report).

The use of blanket orders is a practice that should be eliminated. In fact, they are explicitly prohibited by the JCAHO's Medication Management Standard MM 3.20.3 The existence of this type of order immediately shows that the conciliation of treatment was not done. In 2006, the JCAHO added the requirement of giving to patients the reconciled medication list at discharge, written in appropriate and understandable language.4

We hope that in the future new computer tools will help to improve this type of care; however, awareness of this issue by all professionals will continue to be essential.

Conflicts of interest

The authors declare that there are no conflicts of interest.

References
[1]
O. Delgado Sánchez, L. Anoz Jiménez, A. Serrano Fabia, J. Nicolás Pico.
Conciliación de la medicación.
Med Clin (Barc), 129 (2007), pp. 343-347
[3]
D.S. Rich.
New JCAHO medication management standards for 2004.
Am J Health Syst Pharm, 61 (2004), pp. 1349-1358

Please cite this article as: González López A, Nava Rebollo Á, Andrés Martín B, Chocarro Martínez Á, Herrera Gómez F, Santana Zapatero H, et al. Blanket orders, práctica desaconsejada pero cada vez más frecuente. Nefrología. 2016;36:718–719.

Copyright © 2016. Sociedad Española de Nefrología
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