One of our clinical scholars has been collecting data to assess the effectiveness of reconciling medication orders as patients are discharged from the University of North Carolina Hospitals. When the student and I were reviewing the records of our first 50 patients, I was surprised by the number of medication orders for "as needed" medications that were not continued (no prescriptions written) after discharge.
As a young pharmacist, I can remember processing orders for new admissions to a surgery floor. All had a laxative, a stool softener, a sleep medication, an anxiety medication, and skin lotion as PRN orders. I was told that these routine orders were written "so we can minimize delays in administering medications and make patients as comfortable as possible in an unfamiliar environment." On the surface, it makes sense, but, as my student and I reviewed patients' orders for the reconciliation project, I began to see the phenomenon through different eyes.
It is clear to me that prescribers write these orders in part for the patients' convenience, but largely so that they will not get a page for an order. When an unanticipated order is needed, it is rare for a prescriber to literally see the patient before prescribing an "as needed" medication as described above. What physicians do not realize, and what I had lost sight of, is the tremendous work each order causes, the inventory expansion that results, and the risk involved in processing the order. Each order that is entered or reentered creates an opportunity for errors.
All automated storage cabinets undoubtedly have more drugs than they probably need to. Having the orders live and available probably encourages drug use when a well-intentioned nurse asks, "Do you want something that will help you go to sleep?" Opportunities increase for drug administration errors in direct proportion to order volume increases.
Finally, perhaps the ease with which a PRN medication is administered without physician notification leads to missing a valuable symptom that should be considered. My guess is that few physicians focus on the medication administration record to determine PRN use.
As I thought more about this inefficient and wasteful practice, I wondered why we as pharmacists are not authorized to write orders for such medications when a patient asks for them. Without question, we have been educated on the use of these drugs more effectively than any other provider, and many of them are OTC drugs that patients themselves select when they are at home. We are qualified, are available, and will probably be more focused on why the patient needed the medication and would report it on the next rounding opportunity. It seems that the next logical step in the evolution of pharmacy practice is for us to assume responsibility for these types of medications.
I think I will forward these thoughts to the chairman of our Pharmacy and Therapeutics Committee as my first sounding board to have these drugs added to the therapeutic interchange list we currently have privileges to rewrite. What do you think?
Mr. McAllister is director of pharmacy at University of North Carolina (UNC) Hospitals and Clinics and associate dean for clinical affairs at UNC School of Pharmacy, Chapel Hill.
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