Recently during our presentation at a conference there were several questions asked about the requirements for titration orders. The questions arose when we were discussing that MM 06.01.01 EP 3 is a TJC Hospital Accreditation Program. Element of Performance #3 includes several expectations for the pre-administration review of medications. These items include matching the medication order and the product label, visual inspection of the medication for signs of product degradation or loss of integrity, but most importantly it contains the following two expectations:
- Verification that the medication is being administered at the proper time, in the prescribed dose, and by the correct route occurs.
- Discussion of any unresolved concerns about the medication occurs with supervisory staff or the prescriber.
When we look specifically at titration orders, these are orders in which the medication dose is either incrementally increased or decreased in response to the patient's status. A different standard in The Joint Commission Hospital Accreditation Manual requires the organization to define, in their policies and procedures if titration orders are, and sets forth the following elements as being required to be considered a complete order :
- Medication name
- Medication route
- Initial or starting rate of infusion (dose/min)
- Incremental units the rate can be increased or decreased
- Frequency for incremental doses (how often dose(rate) can be increased or decreased
- Maximum rate (dose) of infusion
- An objective clinical endpoint such as RASS score, CAM score, blood pressure parameters as examples.
Medical Record documentation needs to evidence the increase or decrease of the dose in addition to the measurement of the objective clinical endpoint measured that triggered the increase or decrease in dosage.
Titratable medication orders that are missing any of the above elements must be clarified with the prescriber by either nursing or pharmacy to ensure the safe execution of orders and delivery of care, while ensuring that nursing is not placed in a position of making decisions that would place their practice outside of their authorized scope of practice. Clarification of order must, of course, be documented in the medical record.
Please contact us for questions or more information at 704-573-4535 or info@courtemanche-assocs.com.
Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 30 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.
