Interpretation and Implementation of Range, Titration, and PRN Orders in Hospice

Mary Lynn McPherson, PharmD, BCPS; Karen S. Kaiser, PhD, RN, AOCN; Cameron Burns, PharmD

Disclosures

Journal of Hospice and Palliative Nursing. 2005;7(5):289-298. 

In This Article

Background

The 2004-2005 JCAHO home care and hospital JCAHO standards require organizations to develop policy addressing various types of medication orders they feel have the potential for ambiguity to those dispensing or administering medications.[4] Specifically, JCAHO lists "range", "titration", and "as needed" (PRN) orders in the "Medication Management" section of the standards (refer to Standard M.M. 3.20). In the manual, range orders are defined as "orders in which the dose or dosing interval varies over a prescribed range, depending on the situation or patient's status." Titration orders are defined as "orders in which the dose is either progressively increased or decreased in response to the patient's status." PRN orders, which are not defined in the standard, are orders of medication that are written to be administered as needed. While range, titration, and PRN orders have been used liberally and routinely for many years by prescribers, the variability in interpretation of these types of orders has led JCAHO to identify these order types as a national patient safety concern. The use of as-needed and range orders for opioid analgesics is supported by the American Pain Society and the American Society for Pain Management Nursing.[5] Since opioid analgesics are one of the five drug classes associated with medication-related sentinel events reported to the joint commission, this issue is of special interest to JCAHO surveyors.[6]

An example of a range order would be "Percocet (oxycodone 5 mg/acetaminophen 325 mg), one to two tablets every 4 to 6 hours, as needed to achieve comfort." Both the dose (one to two tablets) and the frequency (every 4-6 hours) are written as ranges. Implementation of this order may vary widely. First, "to achieve comfort" is a nebulous, subjective endpoint. "Comfort" according to whom—the patient or practitioner? Furthermore, this order could be instituted with the patient being told to take only one tablet every 6 hours, up to two tablets every 4 hours.

Some organizations are under the impression that JCAHO disallows, or discourages, range, titration, and PRN orders. This is incorrect. JCAHO suggests, "the organization specifies the required elements of any of the following types of orders [including as-needed (PRN) orders and range or titration orders] that it deems acceptable for use."[4] In other words, JCAHO asks that the institution identify minimal criteria for these types of orders with the intent that the orders are safe, clear, and understandable. During the survey process, JCAHO surveyors look for compliance to the institution's policy and that the organization's practitioners demonstrate consistent understanding regarding the meaning and interpretation of range, titration, and PRN orders.

Although JCAHO does not mandate an organization have written policies, procedures, or protocols regarding the interpretation of these orders, it acknowledges the benefit of doing so.[7] Furthermore, JCAHO does not dictate how PRN, range, or titration orders should be written or interpreted, and recognizes the importance of assessing an individual patient.[7] According to Dr Darryl S. Rich of JCAHO, the 2004 medication management standards require an organization to address in policy the interpretation of both range and PRN orders, and elements of each that are deemed acceptable.[7] It is also expected that the organization's policy describes an action plan for unclear or illegible orders, and that a documented diagnosis or indication accompanies each prescribed medication, including PRN orders. Obviously, it is prudent for an organization to embrace its own policy in thought (as can be demonstrated by practitioner interviews) and deed (as can be demonstrated by audit data and/or clinical documentation that supports implementation of the organization's policy).

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