Proper Titration Orders Are Essential for Patient Safety

Medication errors are common and cause patient harm in approximately 5% of hospitalized patients.¹  Titratable continuous infusions are particularly prone to error, and the consequences of these errors tend to be more severe than for other medication errors.²  Lack of titration limits or failure to adhere to limits are the most frequent type of error,³  and the subsequent overdosing most likely contributes to the greater severity of harm from infusion errors. Unpublished data from Joint Commission hospital surveys show that the vast majority of citations related to infusions occur because key components of orders are missing.

To mitigate this risk, The Joint Commission has requirements that organizations have policies in place for continuous infusion orders. These must include the starting dose, the range for dose changes, the range for frequency of changing the infusion rate, the maximum dose, and the clinical goal of the titration (eg, mean...