Use Protocols and Order Sets for at Least 75 Percent of Medications

​Protocols and standing order sets help clinicians quickly select appropriate doses, routes, and other parameters when ordering medications. Thus these tools may also reduce the risk of errors that can lead to adverse drug events, and they can serve as guidelines for care when the therapy is initiated by nurses or pharmacists. An organization should strive to develop protocols and standing order sets for at least 75 percent of the medications commonly prescribed.



  • Involve physicians in the development and approval process for all protocols and order sets.
  • Have only one protocol or order set for each medication whenever possible.
  • Avoid creating a system in which physicians frequently customize their own protocols and order sets.
  • Consider whether nursing or pharmacy personnel can initiate and manage the protocols and order sets.


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