medication mismanagement?

Nurses Medications

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Hello All,

This is my very first post! I visit this site often, but have never posted. My situation is this: I worked on a Med/Surg floor at a small hospital. I was assigned to a wound patient that needed a dressing change and orders to pre-medicate before dressing change. His order was for (2) 5/325 hydrocodone. The omni was out of 5/325's so I gave him (1) 10/650 instead. I was fired for medication mismanagement. I have since talked to a few pharmacists that have said this is a perfectly appropriate substitution. Any thought?

No medication substitution is occurring. Same med, same route, same form. The JC has no problems with medication orders being read as the total dose. Our medication reconcillation process involves re-ordering home meds as inpatient meds, these are often written based on how they are dispensed, such as "1/2 tab 50mg metoprolol". The MD signs the order when it is still in this form, however it can be given as a whole 25mg pill, this process was implemented by a group that included a JC surveyor. Basically, the "2 tab" part is just a factor by which the dose is multiplied. They can write it as "2 times x dose", "1/2 y dose" or "pie divided by the square root of the speed of light minus z dose", it doesn't matter to the JC so long as the final dose is what was ordered.

But the order needs to reflect that, hence the error.

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But the order needs to reflect that, hence the error.

No, the order needs to reflect the amount of medication given. 10 of hydrocodone and 650 of tylenol. A facility may have a stupid rule saying that the order needs to be in the exact manner it is given, but 650/10 of a medication is 650/10 of the medication. Even Joint Commission, with it's own special kind of stupidity, is smart enough to realize that. (We won't get into facilities that blame their stupid rules on TJC when they have nothing to do with TJC.)

It's EXACTLY like giving 1/2 ml of 4 mg/ml morphine instead of 1ml of 2mg/ml morphine. EXACTLY.

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Yes, there's a world of difference between what a facility might choose as a policy and what actually constitutes a med error.

Facilities can elect to implement any dumb policy they want. And they often do. Anything can be a facility policy error. The facility can say it's an "error" to write 'lasix' in the MAR instead of 'furosemide' as the doctor wrote in the order. They can say this is an error because "it's not exactly as the doctor wrote". I've seen this happen. And, technically, they're within their rights to write those up. But, bring something like this before the BON, and it will rightfully be laughed at and dismissed.

A facility can define it's policy any way it wants. Any awful, dumb way. But a med error has a specific definition. Either something is a med error or it isn't. The OP did not commit a med error. This can not affect her license in any way.

And really, it's stupid for whoever's writing/typing the MAR to write number of tabs in the first place. Just write the dose. Don't write "Tylenol 325mg two tabs", just write "Tylenol 650mg". That's all you need to write. And then all this silliness would be avoided.

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And, it the OP's employer is truly calling this a med error, and presenting it to the BON as such, I would consider suing them for libel.

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No, the order needs to reflect the amount of medication given. 10 of hydrocodone and 650 of tylenol. A facility may have a stupid rule saying that the order needs to be in the exact manner it is given, but 650/10 of a medication is 650/10 of the medication. Even Joint Commission, with it's own special kind of stupidity, is smart enough to realize that. (We won't get into facilities that blame their stupid rules on TJC when they have nothing to do with TJC.)

It's EXACTLY like giving 1/2 ml of 4 mg/ml morphine instead of 1ml of 2mg/ml morphine. EXACTLY.

And we can debate this until the cows come home, but I have never, ever in my many years seen an order reflecting "give 1ml of morphine". If the order in question said "give 10/650 of percocet" then it in fact would have been done correctly.

I might add that I have become so type A about all of this due to my absolutely type A pharmacist, who doesn't stray even a minute from things have got to match. I think I have developed OCD from the whole thing.

So personally as much as I don't like anyone losing jobs over foolishness, I can see where this is coming from. Cause I live it at work daily. Some are stricter than others. But the bottom line to this debate is that of course the pharmacy needs to be sure that the medication is available, and if not, a policy needs to be followed when and if it is not. And the entire thing could have been avoided if it was available, or when it was not, to notify pharmacy and have them either make available the correct medication, or they call the MD for a substitute.

Ya, facilities have odd policies. Some odder than others. However, at least in my facility, we can not substitute or stray from an order without getting an EXACT order. Hence why it is not allowed in my facility to write "2 tabs" or "1 tab" or "1/2 tab" because at any given time, any or all of these options could be available.

And on a completely opposite vein, we are not allowed to over-ride for narcotics during regular hours pharmacy is in house. RRT's and codes are taken from the code cart. Otherwise, to start over-riding for narcs is a huge no-no. And requires a witness--which for a number of nurses they just put their finger on the scan and go......so out of curiousity, wonder who did the over-ride with the OP nurse, and what happend to that person? Seems as if they would be in just as much hot water as the OP. If not more so, as in fact, the witness to this could have at any time said "that is not what the order says, let's ask pharmacy about it". This was pre-medication for a wound dressing change that had not commenced. Not someone who was in acute pain at the moment. So this would have been feasible.

So another lesson in this could be that no one should be witnessing an over-ride that is not pharmacy approved that strays from the original order. (nor witnessing a waste that you don't see wasted--but that is a story for another thread). As well as many pp have stated, it also probably did not scan properly, so I am not sure how the OP could prove that she did give the med to begin with--again without changing the order to scan. Which then one would have to discontinue the original order. Which may not be able to be done by the RN. And then a new nurse comes the next time the wound needs to be dressed, and is confused about the orders, and gives 2 10/650's..... and so it goes.

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Specializes in Critical Care.

To get back the OP's question for a moment, if you're on probation for diversion that typically involves being prohibited from overriding any profile meds, this likely had nothing to do with the way the med was given, it may have been that you were not allowed to utilize the override option.

As for the way it's written, the "2 tabs" is superfluous, and happens due to habit since MD's are supposed to write prescriptions for patients self-use in this manner; "take x number of tablets x times per day", the dosage on many labels isn't even really intended to be easily read by the patients. As Nurses though, we go by the dose, "tabs" is not a dose, it's a helpful explanation to a patient based on a set dosage unit, calculating to get the same dosage unit using other available dosages is not outside the Nurse's scope and does not require an MD order.

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Narcotics are a pretty sticky subject lately with more federal scrutiny and tighter controls. Probably better to contact the physician and get an order for what was available. At the LTC facility I work for we have to have authorization numbers for any class II , classIII or classIV medications pulled out and the pharmacy will only give that authorization after contacting the physician. In the case of class IV meds since I work night shift the pharmacy will not call the MD so... I need to call the doctor and have him/her, call the pharmacy to give authorization to pull med from the E-Kit and then the pharmacy sends me the authorization number..... and then I can finally take care of the residents needs.

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Specializes in RN, BSN, CHDN.

It just doesn't make any sense to me that somebody would be fired for this! They must have been waiting for something to fire you!

In 24 years I have seen all different doses of the same meds given to make up for the prescribed dose-something must have changed

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Did you first visit another floor/unit to see if their Omni/Pyxis machines had Norco 5/325mg pills on hand? Unfortunately, each facility has its own policies, some of which do not make a great deal of sense in the real world.

At some previous workplaces that were far more regulated, I would have had to call the doctor, explain to him/her that we're out of Norco 5/325, and obtain an order that specifically reads "May administer Norco 10/650mg until Norco 5/325mg becomes available."

Again, this situation is unfortunate. However, some facilities are anal about DEA rules that govern the administration of controlled medications. Two 5/325mg pills is the same as one 10/650mg pill, but you still must cover your butt when it comes to narcs. Good luck!

I thought too, that it would at least cover your butt to call the prescriber (who I'm sure would be irritated at the nature of the call.) But then I thought, she's in a time crunch, needing to pre medicate, and who knows when the doc would get around to calling back. What a sad, ridiculous situation. It makes me even more nervous to get back out there applying for jobs, worried I could get fired or disciplined do easily. Sigh

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