I took a short break from hospital pharmacy and now back in the acute care so have a question that may have been discussed in days gone by.
How should orders for multiple pain medications be handled?
I.E. Dilaudid 2mg ivp every 4 hours as needed for pain. and Hydrocodone/APAP 7/5/500 2 tablets po every 6 hours as needed for pain.
Nursing Services feel comfortable with these orders as written. I of course feel that to much is left to nurse interpretation.
My experience tells me this is a circumstance where JCAHO would interview multiple nurses to see if they can provide a consistent answer as to how they would choose between these two orders.
I completely agree with you and have brought that philosphy to the Hospital I work at. If there is mmore than 1 pain order the clinician has to define the parameter. I.E., vicodin 5/325 1 tab q4hr prn mild pain, 1 vicodin 10/325 q4hr prn moderate pain, Morphine 5mg SC q4hr prn severe pain. Pharmacy rejects any order for clarification if the dosing range is not defined.
We were cited for that exact issue when the JC visited us last year. We have CPOE, so we have built comments into all order sets (e.g., mild, moderate, severe; or "use if Vicodin ineffective".... To cover ourselves when a prn med is ordered outside of an order set, we have a policy that says the RN will follow our published hierarchy of meds. We have a list of meds, based on potency. For example: Vicodin 5/325, then Percocet 5/325, then oxycodone plain, then morphine IV, etc. The RN must follow the list, and be able to speak to it when the JC returns, of course. (The list is only used if the MD order does not give clear instructions.)
