Giving meds late o.k.?

[MikeyJ]

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 instructor was incredibly slow when passing meds with us. For whatever reason she requires that she be with us whenever we give any kind of med's (even PO) and as a result some of us have to wait till 9:30 or 10:00 to give 8:00 a.m. med's. We were always taught that you have an hour window before and after the scheduled time to give the med's. Our clinical instructor has us write down that we gave them at 08:00, even if we gave them at 10:00.

Last week the charge nurse became aware of one student who was still holding her 0800 med's. By this time it was 0945 and the charge nurse took the med's and said she could no longer give them. Our clinical instructor was angry with the charge nurse and said, "yes I understand it is late, but these med's are not scheduled again until tomorrow morning.. so we might as well give them now."

[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

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

[nursemike, ASN, RN]

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!

[nursemike, ASN, RN]

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.

[kanzi monkey]

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.

Wow. Thanks Nursemike. I appreciate the support--and I also can see how my legs and feet ARE starting to learn, to compensate for my brain sometimes. :)

Cheers and peace,

-Kan

[Elvish, BSN, DNP, RN, NP]

To the OP: Your teacher was wrong to have you document that you have the med at 0800 if you didn't give it til 1000. That is falsifying and that can get you in big trouble.

In the real world there may be any # of reasons why your pt's meds aren't given on time (or at all), esp in a hospital:

1) Your patient is not on the floor (gone to smoke/buy drugs, for a procedure, for dialysis, etc).

2) The med is not up from the pharmacy. This is something you cannot control, though you can call & ask what the dealio is.

3) Pt is NPO.

4) Some part of pt's assessment does not warrant giving the med -- ex. who in the world is going to give HCTZ with a BP of 90/50??

5) You are concerned about pt's ability to swallow, esp if this is a change in condition.

6) You forgot.

7) You are attending to another patient whose immediate needs outweigh all others. (Code blue or hemorrhage, anyone?)

8) Pt declines or asks to take med later. This is especially true on my floor where we have lots of antepartums on Colace, Iron, & PNVs. If they don't want to take their stuff at exactly 0900 or 2100, who am I to care? That is their right. I'm pickier about other meds, but those? Come on.

Some of these reasons are more valid than others, and of course you document everything you can. But it happens. The best thing you can do is document when you gave it, what the reason was (if there is a good one -- not smart to document "RN forgot"). And be sure to let the next shift know. Sometimes they can split the difference on the next dose to make it up, sometimes you will need to change the schedule altogether. Just depends.

I would not, however, under any circumstances, document that I gave a med at a different time than when I actually gave it.

[CoffeeRTC, BSN, RN]

:uhoh21:

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.

Just to touch on the med passes in LTC. It is a systems problem. Am and the Pm med passes are awefull. Why do they need 10+ horse sized pills? What happened to the Beers list? Why can't they split the times or change it so that half of your assignment are at 8am and the others at 9am? That way you can start the one half at 7am and keep moving till the others are due to be satrted at 8 am and keep passing til 10am. Of course you will be able to start the 11ams then:trout:

Another place instituted a "do not bother the nurse when she is passing meds rule" yeah...that really worked well. not always. My biggest beef is getting someone to answer the phones during the med pass. Their solution was to put phones in the middle of the hallways. Oye....there are solutions tho and I make all efforts to get my meds done in a timely fashion. Its not like I'm sitting around or something

[Elvish, BSN, DNP, RN, NP]

Another thing for the OP:

Part of nursing is prioritizing, as I'm sure you are learning and will continue to learn (I know I am still learning). Let's say you have the following meds to give at the same time, each group for a different patient. Assume they are all breathing and relatively stable.

1) Combivir, Diflucan, Dapsone

2) Colace, Multivitamin, Zoloft.

3) Insulin (stable diabetic), Lipitor, Norvasc.

Ideally you are going to give all these meds at the right time, right? Right. Of course you are going to make the effort all the time. But IF -- key word there -- if you can't give them all on time, which patient is the one who most needs their meds given within in the magic window? Those are the types of priorities you are going to have to constantly be making as a nurse. This is why NCLEX will have all sorts of 'pick the answer that is most right' questions. They want to know you know how to prioritize.

For the record, I would give the meds in order of 1, 3, 2.

[Faeriewand, ASN, RN]

In the perfect clinical environment, we would start an hour early. However, every floor we do our clinicals on, the nurses are notorious of doing morning report until 7:30. And the RN's have to pull the meds for us... the clinical instructor is not able to pull the med's. Thus by the time the nurses finish morning report and finish chatting with each other, it is already 8:00 by the time they pull the meds. That gives the clinical instructor an hour to pass all of the meds.

Oh that's interesting. We pull our own meds and the instructor checks them with us. Makes a big difference.

[kwagner_51]

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 would come on shift at 7 PM and start passing meds immediately after my 10 min. report. The med pass was scheduled for 9 PM. I would get finished at 11 PM on a good night. I had 28 pts; most received 9 meds each. I had 3 G-Tubes and 8 IDDM with hs accuchecks.

After med pass, I would get vitals, assessments, etc.and do all charting. I was required to restock the med cart, call in Rx orders, etc. At 0330 I would pre-set my meds for the 6AM pass and get finished with set up at 5 Am.

I quit this job in January d/t the fact that I was Charge nurse for the ENTIRE building! My last night I had 56 pts, because the person on the next hall, was a QMA and couldn't do G-tubes, give insulin, or do the G-tube feedings!!

I never got out on time.