Giving meds late o.k.? - page 3

Is it typically acceptable to give a medication after more than an hour has lapsed from the scheduled time? I ask this because last week during my clinicals (I am a nursing student) our clinical... Read More

  1. by   SuesquatchRN
    Quote from suzanne4
    Sorry, but a med pass in a nursing home should not take more than two hours, and that time falls within the scope of med administration if started one hour before meds due until one hour after. Anything else and you are liable for it, and can be brought on issues by the Board of Nursing for your state. What a DON tells someone to do, does not make it legal for you to follow, she is not the BON that can take a license.
    It wasn't possible for me or those with whom I worked in LTC. It simply wasn't, if one did it safely and properly.
  2. by   PatricksRNMommy
    There were 10 students in my clinical group in fundamentals and med pass was a disaster. We would have 10 students first waiting in line (with 4-5 nurses trying to take care of their OTHER patients) at the accudose to pull meds. THEN we had to wait for our instructor, who drilled us on each med we were giving: class, action, side effects, adverse reactions, contraindications, etc. Then she went with us for med pass. It was definitely a long process. We were lucky if we got our 9 am meds passed before lunch. My instructor was usually OK with us passing meds with the patient's primary nurse though. Maybe you could ask her if it would be OK to ahve the primary nurse accompany you to pass them.
  3. by   VivaLasViejas
    I've done time as a nursing-home nurse too, and I will be the first to admit that getting med passes done on time was one of the biggest challenges I faced. But the fact is, you HAVE to get those meds out in the time frame allotted, or be able to explain why you didn't. This means that if you give an 0900 med at 1100, you must document the reason on the back of the MAR (and for gosh sake, take care not to administer the next dose at noon, even if it's due then).

    We all know things happen in real life that make it difficult, if not impossible, to give all meds on time every single time; residents fall, choke on their food, have MIs, and die. However, chronic failure to complete med passes on time usually means either a systems problem or an individual problem, and in my experience it's most often an individual problem. But even when it IS a systems problem, a nurse still has the obligation to try to fix it---it's not OK to just say "I can't do this" and leave it at that.
  4. by   santhony44
    It sounds as if the way we did it when I was a student (yes, back in the day!) actually worked better.

    We took turns being the medication nurse. The student giving meds did not have a patient assignment, but rather gave meds to a hall or group of patients. We were expected to know about the meds our patients were getting, whether we were giving them or not. When it was your turn to be med nurse, you were expected to know all of them! The instructor could help other students in between med passes but didn't have to chase around with every student to give meds.

    It seemed to work well.
  5. by   wooh
    It is your responsibility to get the meds administered within the appropriate timeframe that they were ordered in.
    If they were ordered "Q day" then as long as they're given once a day, they're being given in the timeframe that they were ordered in. And I would argue that I know better than a pharmacist that has never seen my patient what time of day is best to give them. I currently work peds. I'm not going to wake a sleeping baby to give prevacid at 0859 just because a pharmacist thinks they need to be given within an hour of 0800. Doing something just because the pharmacist picked a random time to call "QD" on the MAR is just as mindless as doing something just because the doctor ordered it, whether it makes sense or not. One facility has TID at 08,14,20 and one down the street has 10,16,22. I can't believe that giving the same med at 1000 in the first facility (as long as I adjust other times that day) is dangerous because it's past the magical hour, but it's the "proper" time to give it in the second facility. If the BON wants to take my license because I gave a qday med once a day, then it's my time to get out of nursing.
  6. by   woody62
    Quote from wooh
    If they were ordered "Q day" then as long as they're given once a day, they're being given in the timeframe that they were ordered in. And I would argue that I know better than a pharmacist that has never seen my patient what time of day is best to give them. I currently work peds. I'm not going to wake a sleeping baby to give prevacid at 0859 just because a pharmacist thinks they need to be given within an hour of 0800. Doing something just because the pharmacist picked a random time to call "QD" on the MAR is just as mindless as doing something just because the doctor ordered it, whether it makes sense or not. One facility has TID at 08,14,20 and one down the street has 10,16,22. I can't believe that giving the same med at 1000 in the first facility (as long as I adjust other times that day) is dangerous because it's past the magical hour, but it's the "proper" time to give it in the second facility. If the BON wants to take my license because I gave a qday med once a day, then it's my time to get out of nursing.
    I hate to point this out to you, medications, even one given once a day, is given within a specific time frame. You are aware of the half lives of various medications, aren't you. Medications are absorbed and excreted at a specific rate. It may not be important to you but it is important to the patient's well being.

    Woody
  7. by   wooh
    Quote from woody62
    I hate to point this out to you, medications, even one given once a day, is given within a specific time frame. You are aware of the half lives of various medications, aren't you. Medications are absorbed and excreted at a specific rate. It may not be important to you but it is important to the patient's well being.

    Woody
    If it needs to be given within a specific timeframe, it needs to be ordered "q 24 hour" (antibiotics for example.) The average qday med, being given at 0901 instead of between 0700 and 0900 isn't going to make such a big difference that I need to disturb my patients' sleep or ignore a pressing need in another room to give my meds "on time." My point is that I have just as much respect for nursing judgement than arbitrary times set by a pharmacist that hasn't laid eyes on the patient.
  8. by   wooh
    I think what bothers me most (and has nothing to do with the OP) is that we spend so much time worrying about little rules like giving meds within an hour of the ordered time, rather than worrying about why it's a rule, and whether it applies to our patient and is actually best for them.
  9. by   Jo Dirt
    Quote from suzanne4
    Sorry, but a med pass in a nursing home should not take more than two hours, and that time falls within the scope of med administration if started one hour before meds due until one hour after. Anything else and you are liable for it, and can be brought on issues by the Board of Nursing for your state. What a DON tells someone to do, does not make it legal for you to follow, she is not the BON that can take a license.
    Med passes shouldn't take more than two hours but where I worked you were lucky to get them passed out at all, especially taking into account all the disruptions the nurses dealt with: difficult patients, unexpected occurences, phone calls, and there was even a special inservice where the nurse's were singled out because of complaints they were not giving PRN pain meds in a timely enough manner when the aides or whomever instructed the nurse to give them. This often meant stopping med pass, locking up the cart, usually to go way down to the other end of the hall, and if we were technically doing as we should this meant pulling out the charts and starting on the paperwork which was even more time consuming. Oh yea, and we were to answer call lights, too. Call lights were to be answered within a minute or two, which would mean locking up the cart yet again and going down the hall and depending on what they wanted this could take a minute or ten minutes. Not to mention the way the MARS were set up if it was done just as the MARS said, even using the hour before or hour after window, we would have been passing out meds around the clock. It was especially bad because we had certain doctors who loved to prescribe pills in excess. Everytime we would orient a new nurse she was appalled at the amount of medications we were to give.

    I've worked 7a-3p and 3p-11p and 11p-7a and 3-11 was the worst shift to pass meds on.

    Anyway...

    I'm no longer in LTC and I'll be scrapping junk cars to make a living before I go work in another nursing home. I've been followed by the inspectors with their clip boards, I've even met them on a surprise visit when a disgruntled, terminated employee wanted to create a little excitement for the facility. They (inspectors) were nice actually, and usually understanding. In spite of the dings the facility always fared pretty good. I can see a purpose for the inspectors, but it seemed like each one decided things should be done differently and some of the so-called standards were not reasonable and it looks to me like if things keep going the way of more and more expectations and standards most nursing homes will eventually be regulated right out of business.

    But I can see how it would be perfectly reasonable to expect meds could be given on time in a hospital.
  10. by   Kelly_the_Great
    Quote from wooh
    I think what bothers me most (and has nothing to do with the OP) is that we spend so much time worrying about little rules like giving meds within an hour of the ordered time, rather than worrying about why it's a rule, and whether it applies to our patient and is actually best for them.
    THANK YOU, Wooh!

    See, this is a nurse that has an appreciation of the concept of a nurse having autonomous control over his/her own practice!

    And, Woody62, I'm quite sure that Wooh is

    Quote from woody62
    aware of the half lives of various medications...Medications are absorbed and excreted at a specific rate
    .

    In fact, I would go so far as to say that most nurses are aware of those issues, considering pharmacolgy is a heavily emphasized portion of NCLEX and that most spend the biggest majority of their days as staff nurses in dealing with medication administration and its effects on their patients.

    And Wooh is right. If it needs to be given at specifically 0800 or an hour thereof, then it would be written q 0800 NOT q day.

    Furthermore, guess what...it's not the pharmacist's position to make that determination either but rather the prescriber's.

    The point is, nurses have the knowledge to make accurate judgments regarding time of administration if not otherwise specified and if we were truly practicing our profession autonomously we would be doing so!

    ETA: I'm gonna go check out Wooh's other posts b/c I think she/he ROCKS!
    Last edit by Kelly_the_Great on Oct 2, '07
  11. by   kanzi monkey
    I have been thinking about this thread since I read it the other morning before work. I thought "hey, I'm REALLY gonna get my meds out on time today cause I DON'T want to be making med errors!"

    Did I succeed? No. I never do. And I always try. Crikey, I had to pee--etc.--for >3 hours that morning. I think going to the bathroom would probably not have made a difference, but I was so committed to doing my job properly, and everything SEEMED so urgent (and with due respect to our professional obligation, it was...). Oh, and while I AM in an acute setting, I ONLY have 4 pts.

    But, here's the deal. I want to know a lot of information about my pts before I give them their meds. Period. Especially labs and vitals. If I've had the pt before, I get a quick report, do a quick lab/vital check, contact the doc if something doesn't make sense, and I feel comfortable prioritizing their care. If I HAVEN'T met the pt, I want to see what their lab/vital trends are. Just because you've HAD a pt who has baseline SBP <100 does NOT mean that's ok for your pt TODAY. If they were admitted that way, but was not addressed in report or in the plan by the doc, or documented ANYWHERE, or recalled by the pt--this is something I want to get cleared up, or in the process of clearing up before ANYONE gets their colace. If they have an abnormal lab, or pending lab after an abnormal one, I want to address that before I give a med that might have an adverse effect (ie, CRE and many antibiotics or potassium, etc).

    Now, first I want to check WHICH med are due, and which route they're given. If it's a med I'm not familiar with, I look it up--quickly, in the computer--for what it's used for, MOA, and admin. guidelines. Usually if it's not a med I'm familiar with it's something that should be given as close to ontime as possible (lot's of anti-seizure, anti-parkinsonian, or immunosuppressant drugs with narrow therapeutic windows). If it's a cardiac/BP/diabetes/antibiotic med, I prioritize these--they will require closer assessment prior to giving--does pt have good IV access? What are the vitals and BG? Is the pt nauseas or experiencing any s/s of adverse side effects of said med? Basically I ask--will this med hurt them? And--is this med administerable (ie, available on the floor, pt can swallow, IV intact, etc). Pain assessment falls into this category too--how has it been controlled, what are they taking, what's their last dose, how's it effecting them, etc. Not all pts have conditions or meds in the moring that require this much assessment. If all they have is a usual combo of vitamins and stool softners, their meds are prioritized last. Multi vits--while certainly important--are rarely given on time.

    I work in a large teaching hospital that is quite well-regarded--but, "business as usual"= SNAFU on 9/10 days. A line is clotted. A med isn't there. A heart rate is sky-rocketing. A patient is newly confused. A pt. woke up and realized that today is the worst day of his life--and I have to assess and negotiate strong emotions/personalities as part of my nursing care. Ignoring a crying pt--even if he is not causing chaos--can be the worst mistake you'll ever make.

    Basically, I spend my med admin. time trying to not adversely effect my pt's VS, keeping them tackling that infection and not spawning new resistant bugs, maintaining electrolyte balances (or not furthering their havoc), and establishing a trusting relationship with people I am just meeting who, quite frequently, ARE having the worst day of their lives. This requires a lot of interdisciplinary coordination on most days, patience and stoicism masking impatience and panic, and usually more time than my allotted med admin. window allows.

    I have now 6 months experience as an RN. For those of you a little less green--any comments about/suggestions for my method? Oh, I'm also trying to get my full assessments and documentation done during this time. And I usually am responsible for 1-3 of my pts AM care.

    I leave feeling guilty for the care I couldn't give. I don't think I should feel this way--but I'm not sure if I should feel proud for the work that I DO accomplish, or completely incompetent for the work that I don't. And honestly, till I read this thread, giving a med outside the time window was the least of my worries--as long, of course, as the med does not have a narrow therapeutic window and is not known to have adverse effects if given only approximately on time.

    -Kan
  12. by   nursemike
    Quote from Bala Shark
    In the real world, nurses in nuring homes have to pass out medications to about 50 patients..And that is one nurse doing that..Say, you have 50 patients and all of them have 9 am medications..Sorry to say but it would be impossible to do..Some pateints will recieve their meds late if they are the last ones to recieve the medication..Some would be very late...

    You can go by NCLEX and their own rules about 30 minutes to 1 hour after or before in passing medication, but in the real world, it is quite different on what is acceptable..
    I think it's 1/2 hr before or after in my state's nurse practice act, but even with 5-6 pts in a hospital setting, how do you give a 10:00 med that doesn't come up from the pharmacy until 12:00? Our P&P is to give it if it's less than halfway to the next dose, but chart it at the actual time given. IV ABT's are then usually rescheduled to maintain the correct interval.

    I do look at my meds to prioritize. If one of my pts gets pepcid and colace at 2200 (bid) and another gets coreg at 2200 (bid), I'll leave the pepcid for last and probably do the coreg first. I don't usually do extra charting for a QHS xanax given at 2300 instead of 2200, either.
    Heck, 2300 probably is their QHS!
  13. by   nursemike
    Quote from kanzi monkey

    I leave feeling guilty for the care I couldn't give. I don't think I should feel this way--but I'm not sure if I should feel proud for the work that I DO accomplish, or completely incompetent for the work that I don't. And honestly, till I read this thread, giving a med outside the time window was the least of my worries--as long, of course, as the med does not have a narrow therapeutic window and is not known to have adverse effects if given only approximately on time.

    -Kan
    I should always read the whole thread before I post. You explained this much better than I did. Clearly, your rationales are far more valid than "just didn't get around to it."

    As someone a little less green, I'm sure I'm in agreement with most experienced nurses that you don't have anything to feel guilty about. Sounds like you're a fantastic nurse.

    I often joke that these days I'm running my butt off getting stuff done that a year ago I didn't even know I was supposed to do. Sad part is, I'm sure I'll be able to say the same thing next year! Still, it is kind of exciting how time management skills improve simply by repetition and a sense of urgency. I rarely have the time or energy to stop and think about how I can do things more efficiently, but if my brain lets me down, my legs and feet will soon teach me to make sure I have all my supplies before starting a dressing change or IV.

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