What is policy for 'range' orders? JCAHO will ask

Unclear drug orders can put you at risk

Are nurses in your ED given "range" orders for pain and other medications, without specific dosages and frequency of administration? This prescribing practice puts patients at risk, says Susan F. Paparella, RN, MSN, director of consulting services for the Huntingdon Valley, PA-based Institute for Safe Medication Practices.

She gives the example of an order for "Tylenol 325 mg-1,000 mg 2-4 hours PRN for headache, fever, or pain." "We refer to these as 'don't bother me orders' because the prescriber is writing a broad order to cover almost anything," she says. "The nurse is left to decide how much, how often, and for what reason."

Range orders results in variation in care since different nurses will choose different doses and frequencies, says Paparella. "Getting a handle on what the patient actually received and measuring its effectiveness is particularly difficult to do," she says. "There is really no reason for a prescriber to give range orders."

Instead, specific orders should be tied directly to a pain scale or other objective measure, says Paparella. She suggests the following example order: "For a pain scale rating less than X, give Drug A one tablet po prn pain every four hours. For a pain scale rating X-Y, give Drug B mg IV prn pain every four hours. For a pain scale rating of Y or greater, give Drug C mg IV prn pain. For pain unrelieved with Drug C, contact the prescriber."

"That way, the order is not open to interpretation," says Paparella. "Anything else borders on being ambiguous." If range dose orders are written in the ED, the nurse should ask the prescriber for clarification, so the order is clearly understood, she adds.

If an order such as "Morphine 2-4 mg every 3-4 hours prn for pain" is written without a policy in place for guidance, this leaves the criteria for medication administration up to nursing judgment, says Gail Williams, RN, CCRN, CEN, clinical nurse specialist for the ED at Shore Health System in Cambridge, MD. "Legally, this could be interpreted as practicing medicine without a license," she says.

If range orders are used in your ED, you need to specify the required elements of that type of order, says Anita Giuntoli, associate director of the standards interpretation group at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). If those required elements are not present in a range order, then the nurse or pharmacist must clarify with the prescriber exactly what is intended for that patient, she adds.

"Allowing for too much discretion for those interpreting the order can potentially put a patient at risk and may have nurses practicing outside of their scope of practice," says Giuntoli. "The range order should be written so specifically that every nurse or clinician working with that patient would be able to interpret and implement that order exactly the same way."

At Shore Health System, the ED's policy states the shortest time interval ordered will be the official time increment, with a system for correlating the patient's numerical report of pain with the nursing assessment to determine medication dosage, says Williams.

At Methodist Hospital in Indianapolis, physicians no longer give range orders, reports Mary J. Ross, RN, BSN, CEN, charge nurse in the Emergency Medicine Trauma Center. "We made this change over a year ago due to a JCAHO recommendation," she says. "Now the practice in the ED is that a nurse and physician assess the patient's response to all medication before and after each dose." Here are the steps that occur:

  • A written order is given for a specific dosage, such as 4 mg of morphine.
  • Before the drug is given, the nurse asks the patient to rate their pain, gives the pain medication, and performs a reassessment in 15-30 minutes.
  • If the patient has had little result, the nurse then takes the patient chart back to the physician and relays the patient's response, so the physician then will write an order for additional medication.

"Sometimes it is a different medication, sometimes it is a repeat of the same dose of medicine, and sometimes it is a larger dose of the same medication," says Ross. "It all depends on the patient's response to the medication that was given."

In some cases, the physician goes to the room to reassess the patient and writes an order for additional medication, adds Ross. In this case, an assessment of the patient's drug response before and after each dose is documented. "After this assessment, the nurse can get another order for additional medication," she explains.

The pain assessment is done before and after medications are given, by asking patients to rate their pain from 1-10. "We also use nonverbal cues to assess pain," Ross says. "We audit the ED charts every month to assess compliance."

Sources

For more information on medication orders and patient safety, contact:

  • Gail McWilliams, RN,MS,CCRN, CEN, Clinical Nurse Specialist-ED/Critical Care/Behavior Health, Shore Health System, 300 Byrn St., Cambridge, MD 21613. Phone: (410) 822-1000, ext. 8019. Fax: (410) 221-6213.
  • Susan F. Paparella, RN, MSN, Director of Consulting Services, Institute for Safe Medication Practices, 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006. Telephone: (215) 947-7797. Fax: (215) 914-1492. E-mail: spaparella@ismp.org.
  • Mary J. Ross, RN, BSN, CEN, Charge Nurse, Emergency Medicine Trauma Center, Methodist Hospital at Clarian Health Partners, 1801 N. Senate Blvd., Indianapolis, IN 46202. Telephone: (317) 962-8355. E-mail: MJRoss@clarian.org.