Big Trouble

  1. Hello Nurses,
    This might be long so bare with me!! I am quite distraught at the moment and need your help. I am a relatively new nurse that works in the Medical ICU. Working in the ICU as a new grad has been a huge learning curve but exciting.
    When it comes to the ICU you administer a lot of medications specifically pain medications. I was recently pulled into my managers office with concerns of my documentation with one specific IV pain med. The most prevalent pain med we give. The problem was that some how some way it had come up in my documentation that I had scanned the pain med as if I had given it in our e-chart (Prism), then later on it saying I pulled that med from the Med station making a time stamp. So Me documenting at 0400 that I gave the med, and then at 0430 it showing I took it from the med station.
    My manager has put me on leave because this has come up in my charting almost 5 times on different patients. I get very busy and caught up in my pt care but she wants an explanation of why I did this. The problem is I honestly don't know why I would scan a med before pulling it.
    If there is anyone out there that would have a reasonable / any explanation I really need your help!! I love my job and my pts and I would hate myself if I lost it over this.
    Thank you for all the help!
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  2. 39 Comments

  3. by   Jolie
    Please bear with me, because I have not worked in a hospital in 20 years, so my knowledge of medication dispensing machines and scanning devices is theoretical at best.

    Do you not enter the Pyxis, creating a time stamp, when you pull the med prior to administration? Then, do you not go to the patient room, identify the patient, and scan both the patient's wristband and the medication at the same time?

    I don't understand how it is possible to scan a med that you have not yet removed from the Pyxis.
  4. by   heron
    Perhaps the clocks in the various gadgets are off. Has your manager checked with your IT folks?
  5. by   Sour Lemon
    Quote from heron
    Perhaps the clocks in the various gadgets are off. Has your manager checked with your IT folks?

    That would be my best guess, but in that case, the same thing would be happening to everyone.
  6. by   Wuzzie
    Pardon my ignorance but how is it possible to scan the medication if you have not pulled it from the Pyxis? We don't scan in our clinic so I'm not sure what the process is.
  7. by   Scottishtape
    I agree that I'm at a loss as to how you can scan a med prior to taking it out of the dispenser.

    If the clocks were off though, I would think this would be a consistent issue with everyone who used the machine, not just one nurse on 5 seperate occasions.

    I'm confuzzled on this one.
  8. by   meanmaryjean
    Have you designed some type of workaround? This makes no sense.

    "The problem is I honestly don't know why I would scan a med before pulling it. "

    No, the problem is HOW you could have done it.
    Last edit by meanmaryjean on May 24
  9. by   Meriwhen
    I'm not saying you did or didn't do it--I wasn't there so all I can go by on is what you post. But 5 times is 4 times too many to be an accidental oversight. Especially when the medication in question is a pain medication, likely a controlled substance and a common target for diversion.

    And if the times were off between the EMR and the Pyxis, wouldn't everyone else be dinged as well? You wouldn't be the only one being suspended. But apparently it's just you.

    I'm not sure how your scanning process works. In my facility, I have to pull the medication out of the Pyxis first because when I scan the medication into the EMR, I scan the actual barcode or QR code on the medication itself. There's no way I could scan a medication from the Pyxis into the EMR without the actual medication in hand.

    Of course, I could skip the scanner and manually enter the medication administration into the EMR...and sometimes I have to do that when acuity warrants it (i.e., I have to give emergency IMs to a patient who certainly isn't going to let me scan anything). But it would be flagged as a manual entry and not a scanned one. Then they could compare the EMR and Pyxis time to see when (if) I actually pulled the medication out. But even then, the pull time would be before the manual entry time, unless I misentered (intentionally or accidentally) the manual entry time.

    As far as I know, most acute care hospitals work the same way as mine. Perhaps yours doesn't, though I don't think it's likely.

    So what EXACTLY are you doing?

    • Are you actually pulling the medication before scanning? But if that were the case, the pull time would come before the scanning time.
    • Are you pulling one dose from a floor stock, scanning and administering it, then pulling the next dose from the Pyxis? That certainly would cause a time discrepancy.
    • Or are you scanning/entering the medication into the EMR first for some reason: patient acuity, to avoid a late medication administration (common new grad worry), using the scanner is too annoying, to make thing easier for you, diverting the med, or whatever other reason, and then pulling the med afterwards? That's a bad habit to get into, because you risk thinking you gave the medication and actually forget to give it. And don't even get me started on the evils of diverting.

    Sit down and really think about HOW you are doing things and WHY you're doing it that way. Be honest with yourself. Then talk with your manager about how can fix things. It doesn't guarantee you'll keep your job, but if you get terminated, you'll have learned a lesson for the next job.

    And yes, you are/will be suspected of diverting. Understandable when it's a pain medication involved. Be prepared for that...and don't think that a clean UDS is an automatic "get out of jail free" card. Facilities know that people often divert not for their own use, but to supply/sell to others. And five discrepancies isn't actually reassuring for the hospital to see...it does cast considerable doubt on you and your actions.

    If you are actually diverting, then you definitely need to talk to a lawyer as you could be facing criminal charges.

    I'm sorry if that all came off as harsh. But your manager has a very valid reason for putting you on leave while investigating this. Discrepancies with controlled substances are not taken lightly by either the hospital or the DEA. What you're dealing with is very serious. So it's really important for you to figure out where you're going wrong and correct it.

    Best of luck.
    Last edit by Meriwhen on May 24
  10. by   ~Mi Vida Loca~RN
    So as others have said an error with time stamping would be consistent to that system for everyone or that computer to everyone.

    The only other ways I can see this as a possibility is if you are overriding the med, scanning to give and then pulling the med normally. I have worked on various systems and the ones I have worked on if you override the med it will still show the med still available. However, if nothing shady was going on this wouldn't be the case because 1) there would be no reason to go pull the med again 2) the medication machine (not sure what you use, a lot are Pyxis and Omnicell) would show the medication override with the time stamp prior to the scan, and then again the regular pull after, and management would have that.

    Or if you had a vial from waste. So let's say patient had 1mg Dilaudid ordered at 1400. You have 2 mg vials only. So you gave the 1mg and instead of wasting the other kept the vile. Patient now has 1mg Dilaudid due at 1500 so you pull out same vial and give the other 1mg now leaving you with an order for more Dilaudid in the med machine and the ability to pull out a new 2mg vial not thinking about the fact your times are going to be off and that you have no valid reason to pull out the second vial.

    Or same scenario but there is no waste because the order is 2mg and you give but again hang on to vial and then scan to give again although there would be nothing to give. Then pull out.

    The problem here is none of these scenarios look favorable upon you. Especially because of it happening so frequently and although you may give a lot of pain medication in the ICU, don't you typically have 1-2 patients? So it's not like an ER where you might have 5 patients and between all of them giving multiple doses of pain medications every 45 mins.

    I can't tell if you genuinely made a mistake because multiple mistakes were made multiple times and no real valid explanation so far. Or if maybe you genuinely used poor standard of practice and didn't follow protocols and somehow got overwhelmed and did nothing shady but are too naive to see how this looks.

    Or you have in fact done something shady and you're here asking in hopes of something plausible you can go back with to help get you out of this situation.

    I imagine your department will be conducting an in-depth investigation as well and go over patient charts and your med pull hx and such, probably drug screen you if they haven't yet.

    If you're willing I would like to hear the outcome of this case.

    As the PP stated, if you have been caught doing something you shouldn't have, contact a lawyer. Also self reflect and learn from this and get help.

    If you have not done anything intentionally hopefully it all gets resolved.
    Last edit by ~Mi Vida Loca~RN on May 24
  11. by   meanmaryjean
    Quote from ~Mi Vida Loca~RN
    So as others have said an error with time stamping would be consistent to that system for everyone or that computer to everyone.

    The only other ways I can see this as a possibility is if you are overriding the med, scanning to give and then pulling the med normally. I have worked on various systems and the ones I have worked on if you override the med it will still show the med still available. However, if nothing shady was going on this wouldn't be the case because 1) there would be no reason to go pull the med again 2) the medication machine (not sure what you use, a lot are Pyxis and Omnicell) would show the medication override with the time stamp prior to the scan, and then again the regular pull after, and management would have that.

    Or if you had a vial from waste. So let's say patient had 1mg Dilaudid ordered at 1400. You have 2 mg vials only. So you gave the 1mg and instead of wasting the other kept the vile. Patient now has 1mg Dilaudid due at 1500 so you pull out same vial and give the other 1mg now leaving you with an order for more Dilaudid in the med machine and the ability to pull out a new 2mg vial not thinking about the fact your times are going to be off and that you have no valid reason to pull out the second vial.

    Or same scenario but there is no waste because the order is 2mg and you give but again hang on to vial and then scan to give again although there would be nothing to give. Then pull out.

    The problem here is none of these scenarios look favorable upon you. Especially because of it happening so frequently and although you may give a lot of pain medication in the ICU, don't you typically have 1-2 patients? So it's not like an ER where you might have 5 patients and between all of them giving multiple doses of pain medications every 45 mins.

    I can't tell if you genuinely made a mistake because multiple mistakes were made multiple times and no real valid explanation so far. Or if maybe you genuinely used poor standard of practice and didn't follow protocols and somehow got overwhelmed and did nothing shady but are too naive to see how this looks.

    Or you have in fact done something shady and you're here asking in hopes of something plausible you can go back with to help get you out of this situation.

    I imagine your department will be conducting an in-depth investigation as well and go over patient charts and your med pull hx and such, probably drug screen you if they haven't yet.

    If you're willing I would like to hear the outcome of this case.

    As the PP stated, if you have been caught doing something you shouldn't have, contact a lawyer. Also self reflect and learn from this and get help.

    If you have not done anything intentionally hopefully it all gets resolved.
    This is the most concerning thing to consider. OP: Weigh back in please.
  12. by   JKL33
    My first take was - face value. My second and third takes were: Novice/face value. For the sake of the OP I hope I'm right, I really hope that, although very serious, this is a matter of some kind of glitch, documentation error, or medications that were not handled according to policy, etc.

    I had another concerning thought that I'll put forth for the OP's consideration - has your rate of 'getting up to speed' in the ICU been slower than what your employer would like? What kind of feedback have you received as far as your overall performance? How are you fitting into the ICU milieu?

    I ask because, taking this situation at face value, the OP has no actual knowledge of how his documentation and practice compares to that of his peers other than what he has been told. He also has no idea if there is an ongoing or intermittent glitch that could make this possible, nor does he know if others' documentation occasionally also reflects the glitch, but it is not pursued as it is a known issue. He has no knowledge whether work-arounds or other poor medication handling is widespread in his department or not. In short, he has no IDEA whether or not he is being singled out. OP, I hope you have been given the opportunity to review each case.

    ETA: He also has no idea whether any of his documentation of non-controlled substances reflect this problem or not, IOW is it something he may be doing in a certain situation but that actually isn't specific to the controlled substances.
    Last edit by JKL33 on May 25
  13. by   ~Mi Vida Loca~RN
    Yea on this scenario I am not as quick to jump right into shadiness, too many factors going on. I truly can't tell if it's maybe fallout with precepting a new grad maybe trying to cut corners from feeling overwhelmed, or diversion. I would imagine an in depth investigation will get to the bottom of things if it's not diverting. That's why I am hoping they will comeback and update the situation no matter what the case may be.
  14. by   MunoRN
    I've seen a similar situation where a manager got all bent out of shape because everyone was charting their medications as given in the EMR before the pyxis said the meds had been removed, I asked her to come look at what time the pyxis thought it was right now, which turned out to be 3 hours off.

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