Ethical advice needed for a new grad...

Nurses New Nurse

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What would YOU do?

Say, hypothetically, that you are a new graduate RN at your first job. During morning med pass at a SNF, you witness another RN entering incorrect times for med administration on multiple patients in order to seem like everyone received their medication within the designated time frame. When you asked this nurse about the times, she states that she "guesses every nurse has to make a judgement call on how to chart."

Would you take it further? Would you ignore it?

I work in acute care. emergent situations arise every shift, sometimes multiple. That means meds are often given late. I don't chart an excuse for them typically. If each pt stands alone, I can't realy chart med given at 10pm instead or 8pm , because I have one pt getting blood, one i had to take to ct and go get, and one whose bm took 30mims to clean, then anotherone who complained of chest pain. almost always will get at least stat labs, ekg, and depending on the resident on call a chest xray, maybe more. all one person sees though is that I gave a 8pm med at 10pm. rarely is anyone underatanding of this. That's why people lie about it. I chart when given for reasons like the bl example from above. This is very overwhelming when any pts have stat meds. Have seem drs chart stuff like, "medication given at 1pm when ordered for 12pm". etc...... this is a welcome to the real world.

We do A.M., Midday, P.M. and HS meds at my facility. This came with the "culture change" and trying to make it a more home like environment. If a doctor prescribes me a med and tells me to take it in the morning I would take it anytime before noon. Really it is near impossible to pass meds to 30 residents within the time frame you describe. No harm comes to the patient because they get their morning med at 10am instead of 8am. Especially if it is something such as a vitamin. Now having said that of course you should prioritize who gets their meds when depending on what they receive. Ex: I would give meds to the resident that is to receive BP meds & pain meds before I would give meds to someone who receives daily senna and vitamins. Nursing is all about prioritizing and using nursing judgement.

This is a good solution, if I worked in a facility were it was impossible to pass the meds to the residents within the time frame, I would strongly advocate for this.

For whatever reason, the pharmacy scheduled 5 IV meds at 0900. That morning, my patient also got orders for magnesium replacement IV, potassium replacement IV (6 little IV bags) and 4 units of blood products.

With electronic charting, my exact times were charted. It didn't look pretty, but I gave everything as efficiently as I could logically and safely manage, and nobody has said anything to me. When the prompt to explain why a med was given late, there is an IV line traffic option.

Specializes in orthopedic/trauma, Informatics, diabetes.

I worked at in a rehab unit at a LTC with 20 beds. O900 meds were given a little after 0800 so I could be done with back half of the hall by 1000. Where I am now we have a computerized system and we 1 hour before and 72 minutes after they are due to be considered "within time due". it can still be rough if something comes up.

Specializes in CICU.
For whatever reason, the pharmacy scheduled 5 IV meds at 0900. That morning, my patient also got orders for magnesium replacement IV, potassium replacement IV (6 little IV bags) and 4 units of blood products.

With electronic charting, my exact times were charted. It didn't look pretty, but I gave everything as efficiently as I could logically and safely manage, and nobody has said anything to me. When the prompt to explain why a med was given late, there is an IV line traffic option.

But, why didn't you just get 8 iv sites?!?!?!? (Please note my sarcasm... =))

Specializes in CICU.

I chart actual times - meds, repositioning, etc. I wouldn't be comfortable with anything else. I work tele and ICU, and many many shifts are chaotic and 0900 meds get finished closer to 1100, etc.

So far, I have never heard anything about it, officially anyway. If I run into logistical issues (several IVPBs and lack of access) I consult one of our pharmacists if I am not sure how to prioritize.

Specializes in Geriatrics, Dialysis.

A large med pass is almost impossible to safely complete in 2 hours. I work with computerized MARS now so times are automatically recorded and nobody has been talked to about late meds, largely because even the administration and state is well aware that the 2 hour time frame is unrealistic. Staggering med times is one solution [ie some people's meds at 07, some at 08 and some at 09] but it is a real pain to do, especially when your computer program automatically enters a time of 0800 when processing orders that are QD or AM; this means every med that is given at a different time needs to entered manually. The problem we ran into is some people would end up with meds at 07, 0730, 08 and 09 because different nurses changed meds to different times. I thought the med pass was bad before, but thinking I was done with somebody to have to go back 1 or 2 or even 3 more times was horrible!

I always chart accurate times. I worked in LTC for only a month and left because I didn't like the staffing and the poor patient care as a result. I didn't like that people saw no problem with inaccurate charting. I chart accurately for the safety of my patient. I don't chart in order to save my license. If it comes to me being afraid of disciplinary action against my license, I'd rather it be for passing meds late than for lying in a legal document.

In my last facility (acute care), we had electronic charting and hospital policy was 30 min before and 30 min after admin times. That was eventually changed to an hour before and after due to the number of medications that were late with only an hour to administer them all. When a medication is given late, you must document why or you can't save the administration at all. There is the option for "Patient Care" indicating you were with another patient, "insufficient IV access", "patient off unit", "given in another department", "given, not charted", "computer downtime", "medication missing", "new order", "MD order".

I always chart accurately because I find it more dangerous for my license to "cover myself" by being dishonest. I think it's unethical and dangerous. I would be very upset, as a patient, to find out that my nurse didn't accurately chart when I was given my medications because she was more worried about her license than my safety. My job is to protect my patients, not myself. I protect myself by charting accurately and most nurses I've worked with would do the same except in long term care. The only way that will change is if people get an accurate picture of what's going on. If, for some reason, it goes to court, they will know that there is no way every medication was given at 8am and that nurses are perjuring themselves.

This is a good solution, if I worked in a facility were it was impossible to pass the meds to the residents within the time frame, I would strongly advocate for this.

Yes it makes it very nice. AM meds can be given between 7am-11am. Midday are given from 12-2. PM are given from 3pm-6pm and HS from 630pm-11pm. We still have paper mars and don't sign a specific time given just the AM, Midday, PM or HS slot.

Specializes in Home Health,Dialysis, MDS, School Nurse.

I guess most everyone is using Emars or some such thing now?? The last two LTCs I worked at were paper MARs and there is no charting what time you gave a med-only that you gave them. Only things you had to put a time in for were PRNs. My current LTC ( I'm no longer on the floor) does the same.

OP, pick and choose your battles. I used to be like you. In fact, I had written my BON to tell them that the medpass was too much for one nurse. I made them aware of one nurse passing meds for 60+residents in a SNF. They did nothing. Administrators didn't care. I changed my attitude and later changed jobs. Trust me, you will NOT win.

Specializes in Emergency, ICU.

This is an interesting question.

First off, I'd like to say that it is completely unrealistic to safely medicate 30 patients in the 2 hour window and NO, this is not the nurse's fault. It is bad staffing. Unsafe staffing actually.

Now, the more important issue is that nurses who document that the meds were given on time are aiding to perpetuate the problem. If all nurses start documenting the actual time they were able to accomplish the task, management would have to deal with the fact that they are understaffing. By not documenting reality, nurses continue to set themselves up for failure.

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