Long post from new orientee with questions

[Graduatenurse14]

I've worked three 12-hour shifts on Orientation! So far so good!! But...

I have some concerns about med passes here (it's a large teaching hospital affiliated with universities in other cities in the state.)

I did all of my clinicals and worked as a nursing assistant in another hospital- a large teaching hospital system affiliated with a big university in the city. This hospital system was a Top 10 of US News and World Report, international sites, big research going on, etc. Most of their facilities are Magnet, patient-outcomes are better, the amount of RN's who have a BSN/MSN/DNP is very large, and the amount of RN's who publish is large. Essentially, where I worked as a nursing assistant and did my clinicals is a superior healthcare system to the one I am employed so I am apt to go by their practices which I will compare and contrast below.

As good as they are clinically and well-respected internationally, is also as shabbily as they treat their employees so that's why I didn't want to work for them again this time as an RN.

My basic question is this: Since none of them are policy-related and mostly preference, I want to do what learned as a student at clinicals and saw working as a nursing assistant as I saw tons of students nurses/preceptees/orientees while working get taught, reminded and drilled about some of the things that I'm concerned with.

1.) My Preceptor said I don't have to swab the vials as they are sterile. On clinicals, I've seen the dirt on the swab myself and found on here a 2010 position paper from the Association for Professionals in Infection Control and Epidemiology, saying to swab (scrub) the top of the vials and the CDC in 2011 says to scrub the top of the vials.

http://www.apic.org/Resource_/TinyMceFileManager/Position_Statements/AJIC_Safe_Injection0310.pdf

http://www.cdc.gov/injectionsafety/providers/provider_faqs_med-prep.html

Question: I want to scrub my vials. How do I do this without offending my Preceptor in her clinical practice? Do I print the article and website? Or do I just say, "I'm more comfortable scrubbing." I really do not want to make a big deal out of this but I think it's important. I really need some guidance on this one!

2.) The next ones so scare me and is so unsafe that I'm actually more comfortable not doing it how she does (and everyone else too) and explaining why.

-I'm used to using on clinicals/seeing while working, the COWs with individual patient drawers stocked by pharmacy. Pyxis used for opioids and such.

-The EMAR was brought up on your COW so it's up to date to the second as you pull your meds out of the patient's drawers. Cerner was used where I did clinicals and worked and it asked for pain rating, location of injection, blood pressure, apical pulse, etc. right at the bedside and I used VeriScan with Sunrise while precepting at a third independent hospital. At both places the Patient ID band and meds were scanned at the bedside. Of course, all of this info seamlessly went into their chart.

-At the hospital I've only been at 3 days, all of the meds are kept in the Pyxis and taken out per patient med pass, there is no bedside scanning of meds/ID bracelets, very few use a COW at the bedside though they are available and all RN's write down all of their patient's meds/times on a piece of blank paper at the start of shift even though they could print each patient's med list and times which seems very inefficient at best and unsafe at worst if not checking new orders or the EMAR before med pass.

- The inefficiency of everything stored in the Pyxis drives me crazy but I can't do anything about that. It was drilled into me at clinicals and I saw it drilled into tons of students nurses/preceptees/orientees while working as a nursing assistant to not to go by the printed med list you printed off at 6:30 am or if you wrote them down by hand, since it could literally change in seconds if the MD changed/discontinued a med and to refresh and check your EMAR before administering anything!!

-Since there is no scanning of anything you have to go back into the EMAR and "sign off" your meds that you gave and the time and apparently, it's not required to be done immediately following the med pass. For example, we gave a patient a PRN opioid and didn't sign it off for hours. Yes, they all write down when everything is given but if you forget to sign something off or lose your paper or it's been super crazy and you literally can't remember when an opioid was given and didn't write it down, that's so dangerous for the patient and your license!! I am so freaked out!

-I want to take a COW and chart as I go, print each patient's med list rather than write them all out, check the EMAR prior to pulling them from the Pyxis then again at the bedside, give my meds then immediately sign them off at the bedside. They have a computer by each Pyxis but not at very good viewing angles so it will be cumbersome and there is usually a few people waiting. Maybe that's why I haven't seen anyone else do it but go off their handwritten med list.

I'm a second-career RN on my first job in a new-to-me hospital and don't want to seem like I know it all but in these situations, I feel confident that what I was taught on clinicals and saw taught to so many other SN's/RN's is truly "best practice" as opposed to what I've seen where I now work.

Thoughts?? Advice?? I'm looking for normal, healthy, constructive feedback regarding safe nursing practice not people automatically assuming that I'm just another unteachable new nurse who already clearly knows everything since I am willing to try safer nursing practice.

[BuckyBadgerRN, ASN, RN]

Thank you, NightCrow!!! No, I don't think that she would mind my way of charting and med passing to help to keep things straight as a new grad, however, she did make a comment about the COW slowing us down.

She's not used to traveling with one on the unit with one so I can see why she said that but interestingly it was when when were in a patient's room and were asked something that she needed to look up and I asked if she wanted me to get my COW and then said no, it slows us down. We had to walk back to a computer at the nurses' station which was all the way down the hall to find the information and walk back to tell the patient. Pretty inefficient if you ask me.

Maybe when I'm with her, I won't scrub the vial but when on my own I'll scrub. I'm very conflicted as I have anecdotal (I saw the dirt) and research-based evidence that scrubbing the vial is correct (at this time anyway.)

I'd still scrub EVERY time, who cares what she thinks? You KNOW that it's the right thing to do. If she calls you out on it in a review, you have tons of research to show that you're right and she is wrong.

[Graduatenurse14]

Thanks BuckyBadgerRN, RN!!! I do have the evidence behind me so that helps!!!

[VANurse2010]

I think you'd be fine to simply tell your preceptor that you're still getting the hang of being a nurse and you really can't be sure you didn't touch the top of the vial when you flipped the cap off, so you're just going to scrub and be safe. That way you're not taking on the whole unit.

I work ICU in a university hospital. A BIG university hospital. We only get a handful of antibiotics prepared by pharmacy. Everything else we do ourselves. We reconstitute antibiotics that aren't stable at least 24 hours once mixed (like meropenem) as well as other drugs; we mix almost all of our infusions, unless they come prepackaged by the manufacturer. Our pharmacy is closed from 2230 until 0700 every day. If we need something that isn't in our Pyxis we have a global locator function on it that will tell us what other units might have it; otherwise we get it from the night cupboard, and if that fails, the on-call pharmacist comes in. It's far from ideal.

Not to be insulting, but having the pharmacy close at a big university hospital seems kind of ghetto to me. I worked at a small community hospital in BFE, Virginia, and our pharmacy was always open.

[NotReady4PrimeTime, RN]

No insult taken. I've been saying much the same for years. I came from a much smaller hospital in a much-less affluent area where the ICUs all had satellite pharmacies 24/7. Quite the culture shock.

[Graduatenurse14]

****UPDATE****

I worked yesterday but not on the unit as we had more orientation classes. I found out from two educators that we are to swab vials every time and sign off meds as soon after administering them as possible. One even mentioned taking the COW into the room, using the EMAR while you administer and sign them off right there. I feel so much better!!!

Regarding the pulling of multiple patient's meds from the Pyxis at one time, placing in plastic bags and putting them in a COW that has locking drawers, it is preferred that we don't but no policy. I think that the most difficult part would be taking up too much time as the Pyxis while others are waiting.

Not surprisingly, they also mentioned that they have a very high amount of med errors at this hospital and the assigned working group wanted the educators to ask the orientees (about 15-20 in number) what we thought could be done about it. Almost all of us said scanning the patient and the meds is a big one that we know can help to prevent errors (I realize nothing is 100% foolproof, though) Many of us did clinicals and/or worked previously as nurses at hospitals that scanned so we really had something to compare non-scanning to. All of the us had used Cerner or Epic previously and now are using Sunrise there and none of us like it for anything- especially the EMAR.

This system (8 hospitals) is getting EPIC over the next year and we were told that scanners are still on the table! As in they might not get them!!! UGH!!!!! I know it costs millions of dollars but they have a lot of med errors and they are trying to be on par with and/or compete with three internationally known university-affiliated hospital systems in a tri- state area who all scan and have for awhile now. This system went from the brink of bankruptcy to being infused with millions and millions of dollars d/t a "partnership" with an insurance company and really upping everything. I feel that if there are so many medication errors, that the use of the latest, safest technology is a no brainer. The evidence is overwhelming that scanning decreases med errors. Nothing will ever eliminate them though.

One strategy to reduce medication administration errors is barcoded medication administration (BCMA). Many institutions have adopted this technology as a computerized support system for nurses who are responsible for administering medications. Barcode technology has been an indispensable advancement for patient safety as it permits clinical staff to identify individual patients and their prescribed medications with increasing accuracy. BCMAs help confirm the five rights of medication administration: right patient, drug, dose, route, and time. BCMA technology involves placing a unique identifier (barcode) on each unit-dose of medication and the patient armband so that each can be read by an optical scanner. The nurse can safely administer the medication if the two barcodes match the drugs ordered and listed on the patient profile. Patient identification is confirmed with a barcode scan of the armband. Medication identification is confirmed with a barcode scan of the medication. But if the two scans do not match, then there is an alert that cautions the nurse about giving the medication. A recently published study by Eric Poon and his colleagues at Brigham and Women's Hospital demonstrated a 41.4% relative reduction in medication administration errors using this type of system (Poon et al., 2010). Several other authors report significant reductions in medication errors from barcoding technology (Franklin et al., 2007; Neuenschwander et al., 2003; Patterson et al., 2002).

http://psqh.com/design-for-reliability-barcoded-medication-administration

[KelRN215, BSN, RN]

Being a preceptor is not easy. Everyone has different ways of doing things and different learning styles and, to be honest, having an orientee DOES slow you down. It's not easy to slow down when you're used to hitting the ground running and not stopping until you high tail it out of there the minute you give report. That said, I think you can tell your preceptor that you are trying to develop your own groove and that you think it will be better- for you- if you do xyz.

Personally, I can't see printing MARs every shift. That's a huge waste of paper to me and I would cringe watching someone else do it. You can still check the MAR prior to every med pass. I didn't write down all the meds I had to give when I worked in the hospital, I just wrote "meds" with an empty box at the hour they were do to remind myself to check the MAR to give meds. When I worked in the hospital we did scan meds, but only for the last year or so that I was there. Our MARs were on paper when I started whereas the rest of our charting was in the computer. After that, we moved to eMAR but no scanning for a while. And we didn't have COWs in patient rooms, so we'd give meds and then sign them off. I know the research shows that scanning decreases med errors but our system was so flawed that I never saw how that could be- for example, to scan morphine, you could only scan the whole vial (2 mg, 5 mg, 10 mg depending on what we had in stock) and since it was pediatrics, the dose we'd be giving would be something like 0.7 mg. You scan, it would say "5 mg is not the ordered dose" and then you change it to 0.7 mg by entering the dose by hand. The scanner does nothing to ensure that what you are giving is actually 0.7 mg, you could be scanning the vial, pushing saline and pocketing the whole vial of morphine for all the scanner knows. Actually, that was one of the reasons scanning made me nervous- instead of withdrawing the ordered dose of med and wasting the vial in the med room you now had to carry a nearly full vial with 4.3 mg of morphine in it to scan. And then there was the problem that the pharmacy would randomly assign a vial size (say a 5 mg vial) to the patient. Then the pyxis runs out of 5 mg vials and you have to pull a 2 mg vial. You scan that and it tells you that there is no order for this medication. Then you say "whatever" and just check the box to say you gave morphine. I'm so glad my current job doesn't involve med scanning.

Since there is no scanning of anything you have to go back into the EMAR and "sign off" your meds that you gave and the time and apparently, it's not required to be done immediately following the med pass. For example, we gave a patient a PRN opioid and didn't sign it off for hours. Yes, they all write down when everything is given but if you forget to sign something off or lose your paper or it's been super crazy and you literally can't remember when an opioid was given and didn't write it down, that's so dangerous for the patient and your license!! I am so freaked out!

I really don't think anyone is losing their license over going back to sign off the morphine they gave an hour later and changing the time to reflect what time it was actually given. We did it all the time when I worked in the hospital. The Pyxis tells you what time you pulled the med. I know this seems like a huge deal to you because you're new and had experiences with scanning when you did clinicals but nurses have been giving meds since long before there were computers...

Your unit's orientation must be wicked hard!

Your use of the word wicked as an adjective makes me think you must be from my neck of the woods...

[annie.rn]

Actually, that was one of the reasons scanning made me nervous- instead of withdrawing the ordered dose of med and wasting the vial in the med room you now had to carry a nearly full vial with 4.3 mg of morphine in it to scan.

And then there was the problem that the pharmacy would randomly assign a vial size (say a 5 mg vial) to the patient. Then the pyxis runs out of 5 mg vials and you have to pull a 2 mg vial. You scan that and it tells you that there is no order for it.

I hope I am not coming off as a know-it-all but the "perfect world" way you are supposed to do this is to withdraw the entire volume from the vile, waste what you are not going to use and then bring the empty vial and the syringe w/ the ordered dose to the bedside where you can then scan the vial. I say "perfect world" b/c it is often difficult to do this. For example, if the unit is busy and you can't find a witness right away or if you have dose ranges and you aren't sure yet what dose you are going to give.

As for the second issue.... I hate this! We get dinged big time if we don't scan a med (esp. narcotics) so we have to call pharmacy and wait for them to refill the appropriate dose vial. Patients LOVE having to wait for

that process to unfold. Not!

[KelRN215, BSN, RN]

I hope I am not coming off as a know-it-all but the "perfect world" way you are supposed to do this is to withdraw the entire volume from the vile, waste what you are not going to use and then bring the empty vial and the syringe w/ the ordered dose to the bedside where you can then scan the vial. I say "perfect world" b/c it is often difficult to do this. For example, if the unit is busy and you can't find a witness right away or if you have dose ranges and you aren't sure yet what dose you are going to give.

As for the second issue.... I hate this! We get dinged big time if we don't scan a med (esp. narcotics) so we have to call pharmacy and wait for them to refill the appropriate dose vial. Patients LOVE having to wait for

that process to unfold. Not!

Yes that is what we were told when we brought up this issue too... but then there's the matter of they discourage you from wasting meds down the sink nowadays. I don't know what people there do now, I left the hospital almost 3 years ago. No med scanners in home care = happy nurse. I can read orders and vials. And I can honestly say that the only med error I ever made while working in the hospital came AFTER scanners were introduced.

[Loo17]

Appreciate the knowledge your preceptor brings. Kindly say when you are the one signing off the meds you would prefer to use the cow and chart in real time. If you want to swab a vial swab a vial. If someone says something say you are anal and it makes you feel better jokingly. I would not bring in the article or say anything negative about any of these things. Single use vials have a cap on them that you flick off and it is supposed to be sterile underneath. The coloring on the rubber stopper can rub off looking like dirt on an alcohol swab. Regardless as long as you don't make others feel like their practice is substandard and yours is better I don't think most people will care. There will always be those that complain regardless. Just smile be polite and listen to others. Be open to their ideas. If you decide to do things differently than the way they suggest and its within facility policy just do so politely. Everyone works differently and as long as you aren't putting patients safety at risk or taking significantly more time to do something, it shouldn't matter. Congrats on the new job.

[Graduatenurse14]

@KelRN215, BSN, RN,

My sister lived in Boston for awhile and I picked up "wicked" as an adjective from her!

I agree with whether you scan or not, there is no way to know if any med is really given other than it's action in the body being evidence. I believe that with technology and in the not so distant future, we will be able to know that immediately upon administration. Not sure how though, that's above my pay grade!!

I really don't think anyone is losing their license over going back to sign off the morphine they gave an hour later and changing the time to reflect what time it was actually given. We did it all the time when I worked in the hospital. The Pyxis tells you what time you pulled the med.

I'm used to Cerner (where I did my clinicals and worked there as an aid so witnessed it countless times) and also used Sunrise with VeriScan (where I precepted) and the times you scanned the patient's ID bracelet and the meds at the bedside to administer went into the chart immediately so there were no issues about times things were given if all was done correctly and the med truly was given as the next step and not diverted or thrown away by accident with all the wrappers if not paying attention.

The hospital where I worked would post weekly "scanning scores" for each unit which wasn't truly a reflection of the unit's RN's scanning adherence for the very reasons you stated. I don't ever remember seeing a score for pharmacy!! Not cool!

@Loo17,

Thanks!!

Just smile be polite and listen to others. Be open to their ideas. If you decide to do things differently than the way they suggest and its within facility policy just do so politely.

I think that this is the key to everything in life! I will do my very best to approach things in this way!