PRN frequency - lockout

PLEASE NOTE:   Posts made to this forum should not be considered as the expressed opinions of, nor should be considered endorsed by, the Medication Safety Officer’s Society (MSOS) or the Institute for Safe Medication Practices (ISMP). 

Make sure your email is up-to-date
In order to continue to receive updates from MSOS, as well as forum posts and other valuable information as a member of MSOS, please be sure to update your email address with us, whenever it changes. If you need assistance doing so, please send an email to

3 posts / 0 new
Last post
Jaime L Gray
Jaime L Gray's picture
Last seen: 3 weeks 1 day ago
Joined: 01/14/2021 - 13:51
PRN frequency - lockout

Hi - we are an Epic Institution. I have identified issues with our PRN orders where there is no lockout period to prevent PRNs from being given as frequently as the Rn wants up to the max # of doses based on frequency ordered. For example: oxycodone 5mg q4h PRN can be administered at 1305 and 1310 without any warning that this is too close together or shorter than the ordered PRN frequency. The only alert the Rn will get is when they have reached 6 doses of oxycodone and they try to administer a 7th dose in 24h.

For institutions that use Epic, what have you done to lockout the time between doses to reflect that of the PRN interval (within certain limits). I have seen some use BPA alerts but they can still be overridden. I was told by our Willow team there isn't anything they can put in place other than the BPA. This is a huge safety concern; and could be at risk for JC citation because we are administering more frequent than the order states. Any insight would be much appreciated. Thanks in advance!