Changing route of admin

[Nlink]

Recently a nurse (RN) where I work chose to admin a prn bucally instead of via g-tube. The order stated via g-tube. This client has a high risk of aspiration. I did not find out about this until after it had already happened and was working in a different building at the time. Can an RN change the route of medication without an order? Would this not be considered a medication error? Is this something I should encourage the other nurse who called me upset about the situation to persue in regards to reporting a med error/talking to management? She did chart that she opposed this decision, she is an RPN, and the the RN chose to do regardless of her objection. It is possible that this resulted in harm to the client, he was sent to hospital later on that day however I have not worked since and do not know why he was transferred.

[KelRN215, BSN, RN]

I don't really think there is enough information here for me to judge. If a medication is ordered via G-tube, what would the rationale be for not giving it via G-tube?

I will say that I VERY frequently get orders that say PO when the child is a chronically NPO G-tube dependent patient who gets all of their meds via G-tube. Do I give the meds PO in this instance? Of course not. Do the doctors change the orders? Ours don't. I also occasionally get medication orders that list the route as "NG tube" when the patient, in fact, has a G-tube or "NJ tube" when the NJ has been pulled back to an NG. There are also instances when a patient has a G-tube and the provider writing the orders assumes they get all of their medications via G-tube but there's a situation like the tube is about to be removed and the family isn't using it anymore. If that's the case, we'll give it PO no problem.

If the patient has a G-tube because of aspiration risk and is supposed to be NPO, then I would say it is probably an error to administer a med PO.

[Nlink]

Client has a long-term G-tube and all of the orders state via G-tube none PO. Almost all of our clients are tube fed, when we have an order that says PO we get it changed right away so that our NPO clients are not given it orally in error. We rarely have an PO by accident since almost all of our clients are g-tube and NPO and have the same physician.

Her rationale for administering buccally instead of G-tube was that the dose was less than 1ml and would sit in the tube. She said she did not want to flush with water because there was no flush scheduled for that time. Personally I have never not flushed a tube after administering a prn med regardless if there is no flush at the time. Since the med would obviously sit there making it ineffective and the medication could damage the tube. I just deduct the amount from the next flush and give less at that time.

[loriangel14, RN]

Why does this have anything to do with you? OK so she changed the route.If the poop hits the fan it will be her getting heck not you.You are not responsible for her practices.I have seen nurses use nursing judgement and change routes when appropriate.

Now I agree that not wanting to give an unscheduled flush is a lame one but whatever.It's not your problem.

[Nlink]

I wanted to be better informed if I am put in the same postition as the other RPN. I did not know if RNs had the authority to change routes of administration. I want to be able able to advocate for my clients appropriately. I never indicated that this was something that I would personally be disciplined for. I simply asked whether or not this was an error.

[loriangel14, RN]

And what position was that? It had nothing to do with the other RPN either.

[Nlink]

Have you never disagreed with a decision a coworker has made? If you see someone doing something "wrong" you just turn a blind eye and say "not my problem"?! She was directly involved with his care. If you see someone doing something that could potentially harm a client I would hope you would take the time to advocate on your clients behalf.

[loriangel14, RN]

Hmmmm sure if it was likely to cause grave harm or death.I don't think this would be in that category.Sure I have disagreed with a coworkers decision but that's why we have our own licenses that we work under.You can't go around telling everyone how to do their job.

[Nlink]

Like I said high risk for aspiration. Which could cause grave harm...

[agldragonRN]

this is considered medication error. why not just call the doctor and get the order changed?

i had a patient once who had a g-tube and an npo order but when she was actively dying, we got an order to administer morphine sublingually.

op, i think you are advocating for your patient and not trying to find fault with your coworker. i give you kudos for that.

[loriangel14, RN]

Buccal means absorbed through the mucous membranes,not swallowing.Agree to disagree? I would still mind my own business.

[Nlink]

Thank you aldragonRN.

Client is not paliative so I can't see a Dr. changing the order to buccal/subling with the potential for aspiration. Perhaps order should be changed to include an H20 flush though.