Has anyone been successful with curbing unintentional therapeutic duplications with PRN orders? I know this has been a long-standing issue with TJC. I perused prior discussion on this topic from 2013-2016, and hoping to see if there was something new we could learn from.

I will share some of the approaches we had taken in the past. We focused on cleaning up all our ordersets by adding qualifier comments to specify sequence of administration, we have a policy language allowing pharmacist to d/c exact duplicate orders, we have policy guidance specifying the Route sequence for PRN orders with same indication (PO first, then IV, then IM/SubQ, then rectal, etc.). We have also been educating pharmacists regarding this, and auditing the process with compliance above 90%. However, the remaining 10% of duplicate PRN orders has been out of our reach, and it seems to be an issue almost at every TJC survey.

Our issues mostly stem from "one off" PRN orders placed outside of ordersets, and, at times, conflicts when several ordersets are used together. We are wondering if, for those "one off orders", if it would be plausible to develop policy guidance for nursing staff to specify administration sequence for each PRN indication. For example: for N/V, unless specified otherwise by provider, RN to give ondansetron as first line, metoclopramide as second line, prochlorperaizine as third, as applicable. This obviously would depend on formulary options and prescribing pattens for the facility. However, the concern with this approach is these instructions are outside of the EMR, and should really be within the order itself in the ideal case.

I look forward to hearing any suggestions regarding this persistent issue.

Thank you,
Daniel