A Quality Improvement Project Using a Patient-Centered Approach to Reduce PRN Medications Among Patients with Serious Mental Illness

Pro re nata (PRN) or “as needed” medications are embedded in psychiatric practice providing a useful tool in symptom management of physical and psychiatric conditions in healthcare settings. In practice, long lists of scheduled and PRN medications are commonplace, and “automatic” bot refills via electronic prescribing add to medication reconciliation concerns and unintended safety consequences for patients. The lack of systematic protocols for PRN use, and the need for judicious review for the continuation or discontinuation of PRN medications guided this quality improvement (QI) project at an adult residential facility for persons with severe mental illness (SMI). Utilizing a Plan-Do-Study-Act (PDSA) method, a protocol was developed with stakeholder input to enumerate all PRN medications for each resident, and decide with the patient’s input whether a particular medication was needed or not at scheduled treatment team reviews. PRN audit tools were built to capture the frequency and rationale for use of PRN medications. Automatic PRN refills generated electronically were cross-checked before refills were ordered. In this initial SMI cohort of 24 patients receiving a mean of 3.58 PRN medications per person, 100% of antipsychotic drugs and 58% of laxatives were discontinued without adverse consequences, whereas only 12.5% of respiratory inhalers were discontinued. The most common reasons for discontinuation were “no longer indicated” or “patient request”, and rarely due to drug-drug interactions. The survey results of the healthcare team indicated high satisfaction with PRN deprescription and shared decision-making efforts. Future QI will focus on patient education materials and quantitative measures.