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eDocTalk article

Joint Commission says Legacy physicians must take action on medication orders

September 2016

The Joint Commission surveys for three of our five sites this summer have resulted in a common finding around medication orders and an observed non-standard practice in the interpretation and implementation of prn, range and duplicate medication orders.

The bottom line is that physicians need to write clear and complete medication orders to avoid delays in patient care. We ask physicians to review their personal preference list in EPIC and revise any non-compliant orders saved in your favorites. Unclear or incomplete medication orders will result in a pharmacist needing to contact the prescriber to clarify the order.

Legacy has implemented changes and updated policies to ensure this issue is addressed. Below is some background and a summary of the policy changes. 


The Joint Commission surveys at Legacy Emanuel Medical Center and Randall Children’s Hospital resulted in two medication management findings related to unclear titration orders and duplicate prn therapy, and the surveys at Legacy Mount Hood Medical Center and Legacy Salmon Creek Medical Center also resulted in a finding around duplicate therapy.

These findings require Legacy Health to address medication orders so they are clearly written by our licensed independent practitioners (LIPs) and interpreted by nursing. Legacy had to have an action plan in place by Sept. 1 and then must submit audits showing compliance with our new policy on the writing and interpretation of range orders and the clarification of duplicate prn orders.

The Joint Commission medication management standards require that titration and range orders clearly specify parameters for titration and that orders for duplicate prn therapy clearly specify priority for use. These same findings have been common for other institutions around the country.

To ensure compliance, Legacy has made policy changes to address these practices in our medications orders and medication administration policies.

Policy changes:

  • All titratable infusion orders must include: starting dose, titration increment, titration interval, maximum dose and goal clinical parameter.
  • Range orders are only allowed for: prn orders for opioids, sedatives/anxiolytics, antihypertensives, inhaled medications, PCA and epidural infusions, insulin per supplemental scale, and continuous infusions.
  • Range orders are NOT permitted for scheduled medications or any medication not listed above.
  • Multiple prn orders for the same indication must include admin instructions as to the priority of the specific order for use (i.e. use first). 
  • Some duplicate prn orders for the same medication may be discontinued by the pharmacist without notifying the prescriber. This does not apply to different prn medications ordered for the same indication. Pharmacists will call prescribers to ask for clarification.

We ask for your patience as these are major changes that impact nursing, pharmacy and medical staff. We acknowledge the magnitude of the change to practice, but ultimately the changes should result in improved care of our patients.

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