PRN scale opioids

[Emmers4]

Hi everyone!

Question for you guys! I work on a Tele floor, and many of our PRN pain medications are on a scale- for example, PRN morphine IV 2-4mg q4hrs. Let's say that you give 2mg at noon, I was under the impression that if needed you could do an additional 2mg at 2pm (as long as you stay within that 4mg range, so at 4pm, you couldn't do 4mg, you'd have to do another 2.)

Someone recently told me that you have an hour to give an additional dose. So with our example, you have until 1pm to do additional dose, otherwise you have to wait until the 4hours are up. They said it's too much like dispensing.

Any thoughts? Is this familiar to you guys? Also, an explanation on the dispensing explanation??

Thanks!!

[Guest219794]

I doubt it.

I don't think that there is any particular reason 1 hour is OK, and two hours is not. Unless it is stipulated by hospital policy.

I think that a second 2 mg dose is perfectly safe, well within the intention of the order, absolutely fine with the ordering provider, and a technical violation of the rules.

I don't think there is a difference if the second dose is given at 59 minutes vs 61 minutes.

[JKL33]

You need to review your facility's med administration policies related to this.

Per JC, it's up to the hospital to determine how such an order will be interpreted by nursing staff in that institution. See below:

Medication Administration - Range Orders

Does The Joint Commission prohibit the use of 'range' or 'double-range' orders?

No, there are no Joint Commission standards that prohibit the use of range orders as long as such orders are permitted by the organization's medication management policy (see MM.04.01.01). In addition, range orders may be a component of other order types, such as taper orders and titration orders, unless prohibited by hospital policy.

The glossary of the accreditation manual describes a 'range order' as "Orders in which the dose or dosing interval varies over a prescribed range, depending on the situation or the individual's status."

Example of range orders may be:

Hydromorphone 2mg tablets 1 - 2 tablets PO every 4 hours prn mild pain.

Morphine 2 mg to 4 mg IV every 4 hours prn severe pain.

Example of a double-range order may be:

Hydromorphone 2mg tablets 1 - 2 tablets PO every 4 - 6 hours prn mild pain.

Morphine 2 mg to 4 mg IV every 4 - 6 hours prn severe pain.

Organizations are responsible for determining the implementation process for how range orders are entered into the medical record and that staff are properly trained to ensure consistent implementation. It is also the responsibility of the organization's leadership and medical staff to determine how these orders are interpreted. For example, if an order is written 'Morphine 2mg-4mg every 6 hours' and the patient is given 2mg, must the nurse wait until the 6 hours has passed to give another dose or may they give the remaining 2mg if the pain is not adequately controlled prior to the 6-hour interval ?

Compliance with applicable law/regulation, recommendations from professional organizations (state pharmacy boards, ISMP, etc) and evidence-based resources should be incorporated into applicable policies, procedures, etc.

***

Though I am aware of the act of dispensing, I'm not sure how your source was applying it to this particular situation.

[MunoRN, RN]

The general rule is that the prescriber and the person interpreting the order should have the same understand of how the order is to be interpreted. This common understanding can be through facility policy, deferring to best practice recommendations, or through discussion of expectations. I don't find facility specific policies to be practical, since generally pain management best practices don't change from one facility to another, it's better to use a commonly accepted reference for how prn pain management orders should be utilized, such as: http://www.aspmn.org/documents/rangeorderpublished2014.pdf

I think the nurse you were talking to was confusing "dispensing" with "prescribing" although completing a range dosage at any time during the order timeframe is neither prescribing nor dispensing. "Dispensing" refers to the packaging and labelling of a medication for self-administration by a patient.

[JKL33]

I don't find facility specific policies to be practical, since generally pain management best practices don't change from one facility to another, it's better to use a commonly accepted reference for how prn pain management orders should be utilized, such as: http://www.aspmn.org/documents/rangeorderpublished2014.pdf

Agree with that sentiment! Still, this OP must be aware of institutional policy in order to prevent institutional blow-back (write-ups/discipline, allegations of "med errors" or some ramped up allegation because "controlled substance"). Checking policy and comparing it with accepted standards/professional society recommendations is a good habit to get into and is always better than coworkers' opinions (especially when they don't know what they're talking about/can't explain their rationales).

[NewEnglandRN16]

I would clarify your hospital policy. Our PRN opioids are ordered with 3 separate orders. For example 1mg morphine for pain 1-5 q4h, 2mg morphine for pain 6-10 q4h with a breakthrough pain q2h of 1-2mg morphine. That way if the patient was still uncomfortable the could get the breakthrough relief. I would still use the q4 for the morphine. Hope that makes sense.

[Emmers4]

Thank you guys!! I did check with our hospital policy, and it does stipulate the 1 hour rule that I had mentioned. Thank you for your thoughts!!

[Been there,done that, ASN, RN]

Technically the max dose would be , 4 mg in 4 hours.

In reality... you would get an order for whatever it takes to relieve your patient's pain.

[SICUMURSE1]

agreed with HERNN

[TriciaJ, RN]

I thought the time range was no longer to be used. For example, suppose a med was ordered q 2-4 hrs. This means it's okay to give after 2 hours, so what does the 4 mean? Under what circumstances would you make a patient wait 4 hours if he needed the med after 2 hours? And what if the 4 hours had elapsed? Could you not give it after 5 hours?

At the last hospital I worked in, time ranges were not allowed because they really don't mean anything and muddy the waters.