Medication Administration - Titration Orders

Does The Joint Commission require specific elements for titration orders when such orders are permitted by an organization and what other quality or safety advances should be considered ?

Examples included in this response are for illustrative purposes only.

Titration orders are generally defined as those in which the medication dose is either progressively increased or decreased in response to the patient’s status. Organizations are required to define, by policy, if titration orders are deemed acceptable for use.  The elements of performance found in the Medication Management (MM) chapter at MM.04.01.01 outline the policy requirements.
 
Required elements for medication titration orders
  • 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
  • Objective clinical endpoint (RASS score, CAM score, etc)
For example(*), a titrated medication order would say: 
Start [medication name] drip at 10 mcg/kg/min.  Titrate by 5 mcg/kg/min every 5 minutes until desired patient response and/or numeric target (e.g. RASS =3) is achieved. Maximum rate of 60 mcg/kg/min.
 
Goals when developing requirements for safe administration:
 
• Compliance with manufacturer’s Instructions For Use (IFU) for safe administration
• Consistent administration practices among nurses and other practitioners
• Ensure the patient response is achieved/sustained
• Nursing not placed in a position of making dosing/administration decisions that may conflict with their scope of practice
• Documentation accurately reflects order changes, patient assessments, etc.

The organization’s clinical and pharmacy leadership are encouraged to reach out to their state’s pharmacy and/or nursing boards to determine if any additional requirements need to be considered.

* Examples are for illustrative purposes only:
Last updated on December 12, 2019
Manual: Critical Access Hospital
Chapter: Medication Management MM

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