Paracetamol pro re nata orders: an audit

Paracetamol is used widely in hospital practice, but little is known of the details concerning prescribing practices. This study compared the prescribing habits of physicians with regard to paracetamol, pro re nata (PRN), with the nursing interpretation of the order and with evidence-based practice.

The charts of 313 children were reviewed. An audit of 100 children, in whom paracetamol PRN had been prescribed, noted whether an indication for its use was written by the physician. The physician was asked what he/she intended the prescription to mean. The nurses who had signed for administration were asked what their indications were for giving the paracetamol. The hospital guidelines on the prescribing of paracetamol were compared to the clinical practices of the doctors and nurses.

Seventy-four percent of all the charts had an order for paracetamol. An audit of 100 children revealed that only one physician had provided written indications for administration of paracetamol. There were frequent miscommunications between physicians and nurses about the intention of the order for paracetamol. Nurses tended to administer paracetamol at lower temperatures than doctors had intended. In other cases, what the physician had intended as the indication for paracetamol was quite different from what the nurse understood. There were also considerable variations in interpretations within their craft groups.

What was observed in this study was idiosyncratic ordering and administration of paracetamol. It is unlikely that this problem is unique to a single hospital. The current situation needs to be addressed as a system issue, with the challenge being to develop more objective indications for the use of paracetamol, and to ensure the medical staff are more explicit in what their orders mean.