There's nothing that will send hospitals and it's employees scrambling more than the thought of having The Joint Commission (JCAHO) roll up. As a traveling nurse, I thought I would stay clear from their surveyors as I bounce from hospital to hospital, but I have been surveyed in the last 3 facilities I have worked for.
It is intimidating having the surveyors in your hospital, and when you find out that they are pulling your chart to review it can be scary, I wouldn't want to be the reason the hospital gets cited.
At the last hospital I contracted with, in a progressive care and stepdown unit, it seemed to me that there were a few nurses and physicians that were not familiar with, or had some questions regarding some of JCAHO's guidelines, especially regarding PRN medications.
Per JCAHO's recommendations, 2 PRN medications cannot have the same indication, this is frustrating for nurses when different physicians write orders without checking existing orders. Let's say, patient has an order for hydralazine 20mg IV Q4H, PRN for SBP>170, and another order for labetalol 20mg IV Q6H, PRN for SBP>170, if your patient now has a systolic blood pressure greater than 170, which one do you give?
Overlapping medication indications can land you, as a nurse, in trouble in JCAHO's eyes. If the nurse now chooses between the medications, hydralazine or lebatalol as used in the example, the nurse has now practiced outside of his or hers scope of practice. Per JCAHO, you would have now made a medical decision by choosing to give one over the other, the physician must be the one making that decision.
There must be differentiating specifics in the order, such as one ordered orally and the other IV, and specification such as if unable to take P.O. medication give IV. Nursing judgement in terms of choosing between ordered medications is no longer acceptable for JCAHO. Nurses must contact the physicians and either discontinue one of them, or have them choose which to give (make sure you document what the physicians say).
Same instructions must be followed, if not more strictly, with pain medications. If multiple medications are ordered for pain, it must follow the mild, moderate, or severe pain scale, again, if your patient states they have a pain of 3, you must give the medication ordered for the mild scale of 3. If your patient has pain scaled at 3, and you give hydromorphone ordered for severe pain, you as a nurse have practiced outside of your scope. You're safe if there is only one pain medication and it's ordered for just plain pain, you can give it for whatever scale rating the patient gives.
I have found that many times the physicians would click so fast that they would order, and unintentionally choose whichever scale they see first. Now the patient has, for example, only morphine 2mg IV Q4H, PRN for severe pain (7-10). And you perform your assessment and the patient tells you he has a pain of 4 (0-10), you being the prompt nurse that you are, you document the pain of 4 and go pull medication to administer. You can also get in trouble with JCAHO for that, now you gave a medication ordered for severe pain, when the patient only had moderate pain.
Now, it is acceptable if your patient requests a less potent medication, if they have severe pain, but would like acetaminophen instead, which is ordered for mild pain, but a tip I would give you is to make sure you document, patient requested acetaminophen. This does not apply for patients requesting a higher potency medication.
Also, if you have, let's say morphine Q6H for severe pain and percocet Q4H for moderate pain, and you gave morphine, you cannot administer the Percocet before the 6 hours after the morphine. Unless there are orders written for breakthrough pain. Pain medications are grouped together, regardless of the scale, you must follow the frequency window of the last medication administered.
Also, document, document, document! Get in the habit of documenting, better safe than sorry. I don't mean, "patient sitting in bed drinking milk," (as I have seen), but proper documentation of vital signs, pain assessments, etc., to justify the reasons you are administering the PRNs.
The Dude Nurse
Klaus Campos, BSN-RN