As needed.....for what?
In the world of inpatient pharmacy, on a daily basis, I'm constantly going through hundreds of orders. A small percentage of the orders I go through every day include the as needed orders. However, there are problems with these orders. These "prn" orders are ordered for an indication, normally, yet, a lot of times, this indication is missing. These orders fall into the classes of antiemetics,wheezing, pain, constipation, sleep, and so on.
Sure, some orders are just known what they're used for, like docusate prn. Yet, sometimes these orders may have multiple indications that could be referred to as needed. When it comes up on the order verification screen, we do not know, in these cases, exactly what indication it was referred to, and have to page the individual who wrote the order and hope for an indication.
Even still further on, these prn orders are not only missing an indication. Sometimes it's parameters. A lot of times range orders are put in, but there's no specific parameter and for what dose is to be given. Take for example, hydralazine 5-20mg prn. When should we give 5mg versus 10mg, etc? Is the nurse just suppose to guess? At that point, we, as pharmacists, page the physician so nurses are not to conduct out of their scope of practice. This happens with pain medications as well. Oxycodone IR and oxycodone ER are both ordered "prn, for pain". But for what pain? Thus, we page to have a pain score put in, and so on.
So how can we solve this?
According to JCAHO's Medication Management standard 3.20, it states that medications are to be "written clearly and transcribed accurately." Back around five years ago, OHSU actually instituted a hard stop on prn orders, if no indication was written. The institution actually had physicians re-write the orders, and as a result, the number of prn orders without indication actually decreased substantially. Yet, in terms of workflow this was a problem. Orders were getting interrupted, and the time it would take for verification increased as well.
Is it a CPOE problem? I attended a Ohio CE this past Saturday, and one of the speaker's went up and spoke about CPOE. I admit, I'm young, I have no idea what it was like without CE, minus a few of the hospitals I had rotation in, where they used paper orders. He was talking about how there used to be typewriters and how there was no alert screen that would pop up with possible interactions when verifying orders. But always with great technology, comes minor problems. Is it a problem that physicians can verify these orders as "prn" without actually putting in an indication, mostly because the CPOE system allows them to? Do we need to alter our CPOE systems (as done with previous problems) to prevent this issue of us paging about indications?
Until then, I will keep paging about prn indications.....