QUESTION: We use standing orders for several common procedures, such as arthroscopy, tonsillectomy, and cataract extractions. A new RN at our facility says that this is against Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. She also says that we should not accept medication orders that give a range for the dosage. We have been doing this for a long time and have undergone several ICAHO reviews but never have been questioned about this practice. Using standing orders has worked well for us and has not caused any problems, but we want to comply with JCAHO standards. Can we use standing orders and medication range orders?

ANSWER: Standing orders are acceptable if the health care facility has a written policy that specifies the required elements of the order. The 2004 JCAHO standards require that medication orders be written clearly and transcribed accurately. The health care facility should take steps to reduce the potential for medication errors. Preprinted order forms, commonly referred to as standing orders, must be reviewed and updated “as needed.” (1) The Joint Commission does not specify the frequency for review of standing orders and does not further define what is meant by “as needed.” The facility must determine how and when the review should take place and include this in the written policy.

When used and managed appropriately, preprinted orders may help reduce the opportunity for transcription errors and can be a valuable tool for providing safe and efficient patient care. AORN suggests that standing orders or preprinted order sheets be reviewed by the ordering physician on a routine, defined schedule. Most facilities require an annual or semiannual review. An original copy of the current preprinted order sheet with the surgeon’s signature and date should be kept on file in the OR. To ensure that outdated forms are not used by mistake, a process should be in place for removing outdated order sheets from circulation and making new ones available for use. A verbal or written order to use the standing orders should be documented on each individual patient record and signed by the ordering physician. A copy of the preprinted order form should be placed on the patients’ chart and signed by the ordering physician.

Medication orders that give a dosage range (ie, the dose or dose interval varies within a prescribed range, depending on the patient’s status), titrating orders (ie, the dose is either progressively increased or decreased in response to the patient’s status), tapering orders (ie, the dose is decreased by a particular amount with each dosing interval), as occasion requires orders (ie, PRN), and orders for medications at discharge also are acceptable if the health care facility’s written policy specifies the required elements of the order. Blanket orders to reinstate previous medication orders are not acceptable2

Whether a health care facility is accredited by JCAHO or another agency, communicating medication and other orders in a safe manner is of utmost importance. Every facility should develop physician ordering policies and procedures that reduce the potential for misinterpretation and error.

QUESTION: At our facility, we use an automated endoscope reprocessor to process flexible endoscopes with a high-level disinfectant. The reprocessor is a closed system that automatically recycles the disinfectant, and it is very difficult to check the solution concentration daily. Given that it is a closed system, are we still required to perform a daffy test strip?

ANSWER: The concentration of chemicals used for high-level disinfection should be monitored at least daily or according to the disinfectant manufacturer’s directions. Liquid chemical disinfectants can be diluted by water remaining on surfaces and in lumens of endoscopes and other items, even when an automated reprocessor is used. A test strip or other testing device cleared by the US Food and Drug Administration should be used to test the concentration of the disinfectant. The test must be specific for the liquid chemical disinfectant. (2) If the solution has been diluted as demonstrated by the concentration monitor, the solution should be discarded, even if it has not reached the manufacturer’s recommended reuse time, number of reuses, or expiration date. (3)

The difficulty in performing concentration testing will vary with the design of the reprocessor. Automated reprocessors that operate with reusable liquid chemical disinfectants contain reservoirs that supply the disinfection basin of the unit with the disinfectant during a disinfection cycle and store the disinfectant between cycles. Some automated reprocessors are designed with disinfectant reservoirs that are easy to access for concentration testing. Other reprocessors’ disinfectant reservoirs may be more difficult to access or may be inaccessible. If an automated reprocessor has a design that renders concentration testing in the disinfectant reservoir difficult, users may need to run an abbreviated disinfection cycle that will transfer liquid disinfectant to the disinfection basin so that it can come into contact with a concentration test strip. Under these circumstances, users should contact the manufacturer of their automated reprocessor for recommendations regarding accessing the disinfectant for concentration testing.