Clipboard Conundrum


Our hospital created new order sets to be compliant with all of the new JCAHO patient safety mandates.

One of the JCAHO requirements is that pain medications must be administered according to a patient’s rated pain scale. If a patient complains of pain of “3” they get one medication whereas if they complain of pain of “7” they may need another medication.
So the order for pain medications on the order set reads “Administer [chosen pain medication][chosen dosage]intramuscularly/intravenously every ___ hours for pain rated as _______.”
While writing admission orders for a patient, I just decided to write “administer morphine 5mg intravenously every 4 hours for pain rated as 2.17 or greater.”
The patient went upstairs to the floor. I forgot about her amongst the multiple other admits throughout the evening.

The following morning as my shift was ending, I get a visit from the president of the medical staff.
“You know that patient you sent upstairs last night … Mrs. Smith?”
Those are words that usually mean something bad happened.
“Yeah …” I said hesitantly.
“Well there was a big problem with her orders.”
“Like …?”
“What’s with the pain rating of ‘2.17’? The secretary didn’t know how to enter it into the system. She called the nurse. The nurse didn’t know how to interpret it. She called the nursing supervisor. The supervisor had never seen someone enter a pain scale like that, so she called me – the attending – at 4 AM to clarify your order.”
“You’re kidding me.”
“No. But I kind of laughed, though. I’m actually surprised that no one has done that before. I just wanted you to know that you had the whole medical floor up in arms with that order.”
“Great. Sorry about that.”

Next time I’m going to write for medications when a patient rates their pain as “π” or above.
Then again, the symbol for “pi” looks too much like a Roman numeral “II” which could cause people to get pain medication when they rate their pain as a 2 instead of when they rate their pain as a 3.1415 or higher. That could result in patients getting pain medication for a rating 1.1415 points sooner than they actually need that pain medication and could compromise patient safety.
I will therefore write out the word “pi” when making this entry.
Then again, a sloppily written “pi” could look like the number “61” which could make it so that some patient has to complain of pain of 61 or greater in order to receive pain medication. That could leave patients in pain and could compromise patient safety.
Or the “pi” could look like a “pl” which might be mistaken for a shorthand form of “please” so that a patient could be given pain medications for any pain rating in which they say “please.” That could result in overmedication and could compromise patient safety.

I think I see another patient safety mandate on the horizon.



  1. This post is hysterical! 2.17? Isn’t that like a hangnail? I do have to say, though, your new hospital protocol might favor a lot of seekers who come in with a pain scale of ten…bad, bad dental pain again! LOL

    Happy New Years to you and yours. Great post.

  2. on a scale of 1 to 10 I rate this post as a 10.361. Hilarious. Working with the old folks, I’m a maverick. When you’re 99.9999 y/o the pain scale is ridiculous. I still just go with a lot or a little. When a patient thinks he’s at the bank and you’re the teller, trying to figure out a number on pain is low on the totem pole. And frustating for everyone involved.
    Happy New Year, wc.

  3. I had a patient that once described pain as 5.5, 4.0, 6.75 etc. She just wanted to be accurate, I guess. I do like the pi idea. How many numbers after the point will your system accept? 🙂

  4. Hey WC
    You missed the part of the JCAHO directive where you get Nurse K to hand the order to the patient and have the patient fill in the part “Administer [chosen pain medication] [chosen dosage] intramuscularly/intravenously every ___ hours for pain rated as _______.”

    Silly WC. You thought you had to fill that in…

  5. I absolutely refuse to use the pain scale execpt with cardiac patients. I call it pain “mild”, “moderate” or “severe” and that is it. Either that or I just order a pain med for “PRN pain”. Luckily no one has complained.

  6. Hilarious WC!! 🙂

    I used that method of reporting pain to the ED nurse this summer just to tease a bit but she just said we I couldn’t do that and its 1-2, 3-4, 5-6 pain, etc. I think I said a 5.something. I told her I was joking. And I did that because I think it’s funny how some med people get all squirrelly if a patient says 20 or whatever. 🙂

    Love the 3.1415 and the Pi/61.

  7. What about e (2.71828…)?

    Pain > 0 and = e and = (e ^ 3)/4 and = (e ^ 2) and 10, call funeral director for patient to test-fit casket

    It’s very simple to type that into a computer, and MS Excel can do the calculations in no time.

    Seriously, the 0-10 scale as frequently used is only useful in a small minority of patients in the ED and likely a similar proportion of patients in the hospital as inpatients. It is useless for the patient with daily back pain visits who is allergic to everything but that medication that starts with a “D”, “di”-something, given rapidly by IV bolus with a chaser of Benadryl. Oh, and a few Xanny bars to go, please, because they are having a panic attack from all these ED visit bills and the pharmacies are all closed at this time of night around a holiday weekend when their family doctor is on vacation and won’t be back for 2 weeks.

    Board Certification in Emergency Medicine does NOT equal legalized drug dealer, and accreditation of hospitals should be inversely related to the amount of CDS-listed medications prescribed for the recreational use of the patient.

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