Joint Commission Uncovers Therapeutic Duplication Non Compliance at Stanford
When two medications are prescribed for the same indication, patient safety is at risk.
During a review of patient medical records at Stanford, a Joint Commission surveyor uncovered cases where two medications were ordered for the same indication without differentiating instructions, thereby giving the nurse a choice of medications for a specific condition or indication. In one case, there was an order for oxycontin 5-15mg every four hours prn moderate pain (4-6) as well as another order for Morphine sulfate 1-4 mg every three hours prn moderate pain (4-6) with no direction for nursing staff as to which agent to administer in case of moderate pain.
The hospital was unable to show evidence of a process or policy to address this therapeutic duplication. As such, Stanford assembled a multidisciplinary taskforce with medical, nursing and pharmacy to develop a policy to reflect expectations and criteria on therapeutic duplication. Listed here are the guidelines for prescribing providers to remedy this potentially dangerous situation.
Therapeutic duplication
Therapeutic duplication is the practice of prescribing multiple medications for the same indication or purpose without a clear distinction of when one agent should be administered over another. For example, prescribing both ibuprofen and acetaminophen for mild pain, or prescribing both ondansetron and prochlorperazine for nausea and vomiting.
Why is it a concern?
Patient safety. Therapeutic duplication may lead to unintended or excessive use of medications, increased errors and adverse drug reactions.
What providers need to know
- Order/select only one medication for each indication. If multiple medications are ordered for the same indication, directions must be provided for unique criteria or sequence.
- If a verbal order is provided, inquire about other medications with the same indication. Discontinue, sequence or clarify the unique criteria to avoid therapeutic duplication.
- Return pages from pharmacists to expedite clarification of orders to avoid delays in care.
The pharmacists’ role
- Pharmacists must clarify unclear orders before they dispense medications
- Refer to the SHC Pharmacist Standard Work, “Duplicate Therapies/Range orders/Dose Titrations guideline”
- Verify orders while considering patient’s overall medication profile. Look for potential issues, including duplicate therapies.
- If duplicate orders are identified, contact the prescriber to clarify indication for intended use, and then either change indications, discontinue one or more items or add qualifiers.
For nurses and MAs
- Ensure that orders for PRN medications provide different instructions if for the same indication (e.g., Tylenol for headache, Ibuprofen for back pain)
- When obtaining a verbal order, ensure other medications with same indication are discontinued, or clarified for different criteria.