SHM Converge Scientific Abstract ePoster Gallery-Decreasing Duplicate PRN Medication Orders for Hospitalized Patients

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This quality improvement project at UC San Diego Health aimed to reduce duplicate PRN (“as-needed”) medication orders for hospitalized patients when orders lacked clear administration instructions. Such duplications are common for indications like pain, constipation, nausea/vomiting, insomnia, and can confuse nurses and violate Joint Commission and CMS guidelines.<br /><br />In 2017, the team identified duplicate PRN orders as a patient safety concern at their 804-bed academic medical center with about 30,000 annual hospitalizations. They implemented a multi-component intervention that included passive clinical decision support, clinician performance feedback, focused education for hospitalists and pharmacists, a best-practice PRN ordering guide, updates to pain and constipation order sets, and monthly reporting through the electronic health record.<br /><br />The project used both raw observed duplicate PRN order rates and a generalized linear autoregressive moving average negative binomial model to evaluate impact while accounting for temporal autocorrelation. The intervention produced a 32.7% reduction in inappropriate PRN therapeutic duplication (95% CI 22.2%–41.8%, p<0.001), and the improvement was sustained over time.<br /><br />The authors conclude that clearer PRN ordering practices can reduce nursing confusion and may lower the risk of adverse drug events. The work has since been expanded to the other four University of California health systems, with shared data methods to support benchmarking and broader improvement efforts.

Asset Subtitle

Maryann T. Ally

Meta Tag

Author List Anne Goldenberg, Jejo D. Koola, Maryann T. Ally, Sally Rafie, Sherry Zhang

Category Innovations

Concept PRN Medication Order

Concept Duplicate Order

Concept Patient Safety

Concept Administration Instruction

Concept Quality Improvement

Distinguished Finalist

Presenter Organization UC San Diego Health

Presenting Author Maryann T. Ally

Track Quality Improvement

Keywords

quality improvement

PRN medication orders

duplicate orders

patient safety

hospitalized patients

clinical decision support

electronic health record

therapeutic duplication

nursing confusion

adverse drug events

PRN Medication Order

Duplicate Order

Patient Safety

Administration Instruction

Quality Improvement