Giving meds early/late

akulahawkRN, ADN, RN, EMT-P · Dec 20, 2014

Birdy2 said:
I know the general rule is 30 min-1 hr, but When I was passing meds the other night a very experienced nurse told me to give 6 o'clock meds at 4. One was a BP med and the other was Nitropase. She said just get it done that way I don't have to go back. Then I asked others what they thought and they said that's too early and I could get in trouble, which is what I was thinking. But I did it because I'm new and that nurse was positive it was fine. I guess I should have used my own judgement. Obviously u wouldnt give antibiotics early or late, but what do you guys think about the others?

First, as others have said, pharmacy is an excellent resource for you. Also, your facility should have a policy for med pass timing. At one hospital that I was at recently, if it was a pain med due Q4 or less, we had a 15 minute window on either side. Any other Q4 med or any antibiotic had a 30 min window on either end. A Q6 or Q8 med (any) had a 1 hour window early or late. Q12 meds had (I think) allowed 2 hours early or late, and I'm pretty darned sure that Q24 could be given 2 hours early or late.

It has been about 6 months, so I'm not as certain of policy as I used to be. School was very insistent upon the 1 hour before/after window... but pain meds had effectively no early window.

Tenebrae, BSN, RN · Dec 25, 2014

In district nursing our only real time specific medication was insulin.

Other meds we were allowed an up to an hour either side. That was more to do with the fact that we could have five-six time specific medications all around the city and cant be in more than one place at a time.

nurseprnRN, BSN, RN · Dec 31, 2014

Never, ever hold a scheduled pain med for fear of "giving too much." Furthermore, if someone is on a scheduled pain med and has been for some time, you can work with the assumption that you can give it in the same way it will treat a BP med or an antibiotic, which is to say, within the time parameter. The patient is used to it, and it's no different than for any other drug.

Look up the concepts of "habituation" and "tolerance" to settle your mind on this.

enkwanta · Feb 8, 2015

One may need to use discretion depending on the type of medication and how this was ordered by the physician. For example should not be a problem or medicines ordered once per day. However, time specific medications should be given on time and follow a schedule like 6, 2, 10.

CamillusRN, BSN · Feb 23, 2015

Birdy2 said:
Well it's my butt if something goes wrong so I think I'll just stick with one hour

Yes, it is your butt on the line. There are several BP meds out there that are very time-specific (i.e., can cause paroxysmal hyper/hypotension when given too far out of a set time frame). My preceptor taught me to question any advice that could even remotely damage my license or reputation. Intentionally giving a med at a time outside what is set by hospital policy without a specific order to do so could land you in some very hot water. Never assume another nurse (regardless of experience) is going to put his/her a$$ on the line for your license, even if you get in trouble b/c you followed their advice! IMHO, doing things as close to by-the-book as possible is your best bet to a long and fruitful career.

Birdy2 · Feb 23, 2015

I'm learning more and more how to make my own decisions based on what I know and have been taught. In most hospitals if you were to give something up to an hour or two before/after its due you would be fired. I have realized that where I work things are just not the same as others. We are so understaffed that often we have no choice but to give things a little off schedule. I still try my best to give things close to when they're due. I pay close attention to when the med was given last, what the recommended time between doses is, how the pt tolerates it, vital signs, Etc. There are still a lot of meds that I'm not familiar with and have to be extra careful when giving. I actually am still a little confused about vanc. I have only given it before surgery and so I haven't ever had to decide when to give/hold it. If someone could explain peak/troughs and what I need to know to safely give this med that would be great.

CamillusRN, BSN · Feb 23, 2015

"I actually am still a little confused about vanc. I have only given it before surgery and so I haven't ever had to decide when to give/hold it. If someone could explain peak/troughs and what I need to know to safely give this med that would be great."

You'll have to check your hospital's policy for trough frequencies (my facility requires a trough to be drawn prior to every third dose (for example, if it's BID, a trough needs to be drawn q 24 hr). It's a good idea to check the trough each time you give it to make sure it's still w/in therapeutic range (correct me if I'm wrong fellow AN's, but that's 15-20 for big bugs, 10-20 for small bugs if remember correctly). If it's above 20 or below 10/15, you'll want to make a phone call to see if the doc wants to increase/decrease the dose. Because vanco is nephrotoxic, you'll def want to be calling doc with any value greater than 20 and start monitoring their renal labs closely. Don't want to have your patient end up on dialysis b/c something didn't get passed along like it should have. And please please please note that you called doc, b/c that might just save your license!

Source: Davis Drug Guide 2015 (every nurse should either own or have access to one - it's saved my butt many a time! Epocrates mobile is also a butt-saver.)

Graduatenurse14 · Feb 23, 2015

Good resources on medication administration!

https://www.ismp.org/guidelines/timely-administration-scheduled-medications-acute

Centers for Medicare & Medicaid Services (CMS) updates its guidance for hospital medication administration requirements in 2014. This pdf is 32 pages and bottom of page 10 starts "Timing of Medication Administration"

https://www.calhospital.org/sites/main/files/file-attachments/survey-and-cert-letter-14-15.pdf

AnnoyedNurse · Dec 28, 2017

wheeliesurfer said:
I think it is better to give an ABX late than to skip a dose unless absolutely necessary. For a BID abx giving it a few hours late and then getting back on schedule would be appropriate. I think a few hours with a TID would be okay as well, but giving a QID abx a few hours late would be pushing it and I would likely skip the dose and get back on track with the next scheduled dose. Even home abx the pharmacist usually says if you forget a dose to take it as soon as you remember, but if you are close to another scheduled dose to skip the missed dose and resume at the next doses time. Use your nursing judgement and call the pharmacist for clarification/recommendation if there is doubt in your mind.

I know this is an old post, but for other new nurses who may be reading this: whenever meds are given earlier or later than facility policy, the doctor always needs to be informed. Otherwise, you can get in trouble for practicing medicine without a license. More than likely, the doctor will just say, "okay." But you still have to let them know. Also, some meds like tacrolimus need to be given on time especially if the levels are being drawn at a certain time. Use your judgement but always let the doctor know to CYA; also as others have mentioned, call pharmacy and ask them to retime the Med and ALWAYS be truthful as to why a Med is being given early or late and provide documentation on which doctor or practitioner you informed.