Am I freak for charting meds as I pull them?

pixie120 · Aug 1, 2011

Pour chart and pass or pour pass and chart. Either way is correct as long as you are consistent. I've always popped, initialed, and handed out the meds. If they refuse I go back an circle. Never rely on memory. And suppose you were called away? All those blank spots...how would I know what meds the residents had or didn't have?

Honestly, my head is now spinning after reading all the posts on the supposed possible ways to pass the pills. No wonder there is so many med errors and overtime...how about do it correctly, sign out everything as you go, don't try to reinvent the wheel... MAR's all have flags for new med, med or move thepaper to the side for the noon meds, always double check your MAR at end of shift (takes 5 min, look thru for any holes) and you are good to go! This is the tried and true way. It is amazing to me that nurses who have the exact same med pass day after day, never get any faster...how is that possible? and..to quote another post..the meds are not being reordered.

WITHOUT fail, when I have been pulled to the floor, there are NEVER all the meds in the cart, and WITHOUT fail,, all the meds are signed out as if the med was in the cart to give...WITHOUT fail, I find gaping holes in the MARS and have to send 2-3 pages of reorder stickers to the pharmacy. THIS is why the med pass takes so long, and additonally, the MAR only has onemed name and the bingo card has the other name, or the med is in the fridge, but the regular nurse never thought to WRITE that on the MAR, for the poor slobs that would follow. If we do it right, every time, every day, we all benefit. It's no a new way to pass meds, it's the right way. You may not be able to pre-pour, but you can certainly put your house meds in the top drawer and fill your meds that way, keep your cart organized and the med pass goes much quicker also. It takes a village......

Izzy11, NP · Aug 4, 2011

It is amazing to me that nurses who have the exact same med pass day after day, never get any faster...how is that possible?
....
If we do it right, every time, every day, we all benefit.

I'm still pretty new, so forgive me I'm missing something. To do it "right", you need to look at the MAR for the med name and dose, then find the card with the med, verify the resident's name and the dose on the card, pop the pill, sign the MAR, and go to the next med. How much faster can that be done?

The nurses I trained with both said they are able to go a lot faster because they have all their meds memorized so they don't need to look at the MAR and they don't verify the doses, besides not signing the MAR as they go. They also don't seem to indicate when meds are refused because one resident decided to stop using a nasal spray and I was the only one writing that she refused it.

But I ask this in all sincerity, how do you get significantly faster if you don't take shortcuts and do everything by the book?

pixie120 · Aug 4, 2011

I'm still pretty new, so forgive me I'm missing something. To do it "right", you need to look at the MAR for the med name and dose, then find the card with the med, verify the resident's name and the dose on the card, pop the pill, sign the MAR, and go to the next med. How much faster can that be done?
The nurses I trained with both said they are able to go a lot faster because they have all their meds memorized so they don't need to look at the MAR and they don't verify the doses, besides not signing the MAR as they go. They also don't seem to indicate when meds are refused because one resident decided to stop using a nasal spray and I was the only one writing that she refused it.
But I ask this in all sincerity, how do you get significantly faster if you don't take shortcuts and do everything by the book?

Ok, I have to jump in. The goal of med administration is "Safe administration". The safest, smartest, fastest way is become proficient at scanning your MAR's as you pop out the pills, and learn your meds (both names), learn and memorize mg for each med (some meds only have 2 or 3 types of mg), and know your MD orders and your patient. DOn't allow interruptions, manage your unit/your staff, your residents. Train your residents to have YOU come to them and then make sure you are giving meds timely. IE: You take over a shift at 2 pm, you are done with report/count narcs at 2:30, you give your prn pain meds/assess your residents, then blood sugars/4 pm meds/insulins, dinner, chart, treatments, do 8 pm meds, done. Combine all your 4 and 8 pm's by accurately reflecting on the MAR what time you are giving these (write a T.O. clarification order and clarify ok with MD and family and resident). Don't try to outthink the MAR, FOLLOW the MAR. It is against the law, your scope of practice and your nurse judgement and critical thinking to "memorize" the MAR. Period. The nurses that pass meds the fastest will tell you:

1. They know their patient inside and out, quickly

2 They do every shift assessment head to toe, quickly

3 They are on time, start as early as legally allowed

4 are not gossiping and complaining with the previous staff or their staff

5. The C.N.A's will help you line these folks up, won't take them off the floor and will keep the residents entertained until you are done with them, IF you are a leader and engage and help your CNA.

You are not alone in this med pass, it is a team effort. I passed (not an exaggeration) meds to 40 residents in 2 hours without fail for 1 full year, because I learned my mednames, I always put the other name on the MAR for the next nurse, and I wrote the location of the med (fridge, top drawer, house supply big bottle) on the MAR, for the next nurse. These are not secrets, if you act as a team member, keep your cart organized and ALWAYS without fail RE-ORDER the meds, follow up on MD orders and MAR is as clean and organized as possible (orders that are d/c'd are yellowed out, new order handwritten etc and recapped properly) you won't struggle. Floor nurses often refuse to do any of this, and they often refuse to participate in recaps, reordering meds, keeping the e-kit supplied by faxing pharm and getting unnecessary meds dc'd in a timely fashion. If the resident doesn't watn to take the med, tell the MD! Make what is really happening, reflected in the MAR! It is NOT a game to outwit the MAR, and have poor patient outcomes and pretend/circle/say the resident refused. This is BAD, BAD nursing. Don't ever borrow meds, ever! Call the pharmacy and get the med re-ordered. Tell them to satellite it. If unable, call the MD, get temp order to cover either not giving it or a sub med from your e-kit.

Your job as a nurse is to do the critical thinking. Med techs in assisted living truly do more accurate med assist with less med errors because they follow the 5 (6) rights of med administration to a T. They recap better and faster, and they write all in the charts/careplans. It has amazed me that nurses are worse at passing meds than untrained, unlicensed med techs. I for one did not go to school (twice, once for LPN and then RN) to stand there at the med cart with my face buried in the MAR, ignoring my phone, the md, the resident and the c.n.a. so that I can pass meds poorly from memorization. Meds is only one tiny tiny part of nursing, why do some many nurses "just" want to focus on that? The truth is many, many meds are simply unnecessary in LTC residents. There is no reasno for a 90 year woman to be on Estrogen, cream or other wise, nor is it necessary or benficial for her to take 16 vitamins to "prevent" osteoporosis. She DOES need her antidepressant, her pain meds and her constipation meds, and she needs a nurse to assess her every shift and make sure she has some type of quality of life, OR a referral to hospice, immediately.

The nurses on the floor that try to hand every single duty to "someone else" the RCM theDNS, why in the world would you want your RCM and the DNS to look at the labs of your patient? If something were to happen, you go to court or in front of the nursing commission and then say "Well , your honor, the reason I gave that coumadin is because it was on the MAR to give. I didn't know she had a critically high PT/INR cuz it isn't my job to look at the labs, it was the RCM's job." Seriously? Do you think the judge or the BON even would supoena the RCM or the DNS? If you aren't sure, you need to speak to a nurse who HAS been in front of the board and see what restrictions they will put on YOUR license for YOUR failure to act. No nurse can give away her duty to act, or fail to act. SO....do you still want to memorize the MAR for the sake of meeting an arbitrary time line of meds due? You can change the times, you can get those meds dc'd and you can be a good patient advocate, start today. DON"T listen to bad nursing, and you should tell your DNS what her/his "training nurses" are telling new orientees, I am sure they will reassign orientees to nurses that will train them correctly. (I had a nurse "borrow" meds right in front of the state surveyor, without a care in the world, Apparently she has been doing this for years and years. We assumed she needed education, but all together, she made 6 med errors in front of the surveyor). IF a nurse is going to focus on only med pass, can't that nurse at least commit no med errors? A med error for time is far less critical than all the other potential med errors, and trust me, it won't kill the patient (hopefully).

xtxrn, ASN, RN · Aug 11, 2011

I just started working in a LTC facility and it's my first job out of school. It's taking me a long time to do the morning med pass, although I'm getting better at it. The nurse who oriented me said she saves time by signing out the midday meds at the same time she does the morning meds. Another nurse I worked with said he doesn't sign any meds out until the end of the shift because if you do it as you pull them then you have gaps, and you save a lot of time that way. And both of them pull the meds by memory and don't really look at the MAR.
Am I freak for actually signing out each med as I pull them?

I have never worked in a LTC/SNF where this was ok. You have to sign them out when you give them. Period. You can get your butt in a big sling with the state, and also if something happens and you have an emergency, nobody will know what meds have been given and what hasn't.... also, if you sign out a med, only to find it's not there, and have to reorder, you've got that to explain... med administration is no place for short cuts... they will bite you in the butt at some time. Don't leave them until the end of the shift, either- do it as you give them.... You will find it hard to get in trouble that way (it's really not that much slower- you get a rhythm and it just becomes routine. :)

You're not a freak- but setting yourself up :eek:

xtxrn, ASN, RN · Aug 11, 2011

I'm still pretty new, so forgive me I'm missing something. To do it "right", you need to look at the MAR for the med name and dose, then find the card with the med, verify the resident's name and the dose on the card, pop the pill, sign the MAR, and go to the next med. How much faster can that be done?
The nurses I trained with both said they are able to go a lot faster because they have all their meds memorized so they don't need to look at the MAR and they don't verify the doses, besides not signing the MAR as they go. They also don't seem to indicate when meds are refused because one resident decided to stop using a nasal spray and I was the only one writing that she refused it.
But I ask this in all sincerity, how do you get significantly faster if you don't take shortcuts and do everything by the book?

You can't . The same steps have to be taken (find resident, get med, check MAR, give med, sign MAR.... it all has to be done). what you save is sitting before the DON or state (or worse) and explaining why you don't go by the book :) It really is that important :)

CoffeeRTC, BSN, RN · Aug 11, 2011

AMEN, Pixie!!!

mazy · Aug 11, 2011

I'm still pretty new, so forgive me I'm missing something. To do it "right", you need to look at the MAR for the med name and dose, then find the card with the med, verify the resident's name and the dose on the card, pop the pill, sign the MAR, and go to the next med. How much faster can that be done?
The nurses I trained with both said they are able to go a lot faster because they have all their meds memorized so they don't need to look at the MAR and they don't verify the doses, besides not signing the MAR as they go. They also don't seem to indicate when meds are refused because one resident decided to stop using a nasal spray and I was the only one writing that she refused it.
But I ask this in all sincerity, how do you get significantly faster if you don't take shortcuts and do everything by the book?

I usually sit down and go through the MAR at beginning of shift to note any new meds or changes. While I do that I flag all the "off-time" meds -- the ones that I give out of the time frame of the main med pass. I work evenings so I flag and meds given in the PM so I don't forget that. When I worked days I would flag all the lunch-time meds. Gives me a chance to do a quick review of the MAR also.

I have found that those extra 10 minutes of preparation can save me a lot of time in the end because there are no surprises.

Never, ever sign off a med that you haven't pulled. I pull all my med cards, lay them out in front of me and look at each one as I pop them. When I finish with a card I put it at the very back of the patient section, one after another, so if I have any doubts I can look back into the drawer and see exactly what cards I have pulled. But I always keep in mind that that is also not fail-proof. It is so easy to make a mistake when you are operating on autopilot (by memory) or really stressed out.

I never rely on memory, I treat each med pass as if it is the first time I've done it. I've been taught pull, sign, give, but you can also pull, dot, give, sign.

Also circle and document refusal of meds so that if the doc comes in and wants to know how the patient is doing you can show them the page with all that documentation and med changes can be made accordingly.

You do get faster with practice.

JenniferSews · Aug 14, 2011

I usually sit down and go through the MAR at beginning of shift to note any new meds or changes. While I do that I flag all the "off-time" meds -- the ones that I give out of the time frame of the main med pass. I work evenings so I flag and meds given in the PM so I don't forget that. When I worked days I would flag all the lunch-time meds. Gives me a chance to do a quick review of the MAR also.
I have found that those extra 10 minutes of preparation can save me a lot of time in the end because there are no surprises.

I have tried this system, and it does work for a number of my coworkers. But for me I and am still 1+ years later still so paranoid about missing a med at an off time that I found myself going through the entire mar at the off times anyway. So the time I spent at 0800 (crazy overloaded med pass of course) trying to figure out my 1200 med pass was a total waste. But then again it works for some.

I never figured out the time savings in signing off 1200 meds at 0800 unless you don't actually give the 1200 meds. You still have to go back through and find all the 1200 meds. Plus as a friend found out the hard way sometimes your patient is fine at 0800 but at 1100 you send them to the hospital. It doesn't look very good that you send a MAR with the 1200 and 1400 meds signed off at 1100. Maybe you can make copies without the signed portion visible but is that really the most important thing to be thinking about when a full core patient is having 10/10 chest pain and losing consciousness?

As for signing off at the end of the shift, how do you KNOW you gave a med if you didn't sign? How do you keep track!? That sounds crazy.

Personally I have no fail safe system yet. But after over a year I go in and try to do the best every day. Sometimes that is all you can do!

mazy · Aug 14, 2011

I never figured out the time savings in signing off 1200 meds at 0800 unless you don't actually give the 1200 meds. You still have to go back through and find all the 1200 meds. Plus as a friend found out the hard way sometimes your patient is fine at 0800 but at 1100 you send them to the hospital. It doesn't look very good that you send a MAR with the 1200 and 1400 meds signed off at 1100. Maybe you can make copies without the signed portion visible but is that really the most important thing to be thinking about when a full core patient is having 10/10 chest pain and losing consciousness?
As for signing off at the end of the shift, how do you KNOW you gave a med if you didn't sign? How do you keep track!? That sounds crazy.
Erm. I hope you didn't think I meant to sign the 1200 meds off when you do the 0800 pass! Don't sign them off until you give them! Just flag them so that you know you have to remember to go back and give them. After a few weeks of going back and forth on the MAR you do usually get the hang of it.
But everyone has a system that works for them, it's just a question of time and practice.

Izzy11, NP · Aug 18, 2011

I never figured out the time savings in signing off 1200 meds at 0800 unless you don't actually give the 1200 meds. You still have to go back through and find all the 1200 meds.

The nurse who does this was one who had (or thought she had) memorized all the meds, so she doesn't even open the MAR for the midday meds. She just pulls them and gives them without looking at the MAR at all. Her time saving is in not looking up each patient in the MAR.

PollyWolly · Aug 18, 2011

I sign for each med as I pull it. IF, and it is rare, a patient refuses the meds, I then circle each med and waste it. That does not happen often. After you get to know your patients, or in looking at the MAR you can see they frequently refuse, you can ask them if they will take them before you pour them. But I have to sign as I pull them or I don't remember if I pulled it or not, for goodness sakes when you give 30-40 people meds on your shift you better write it down while you have the chance. At the end of the shift I take the 5 minutes to scan through all the pages for any 'holes' and deal with them before I leave.

Fngrpntsnotasin · Aug 18, 2011

I check the MAR, check the res pulse and give eye drops then pull the meds and give then sign( for each individual res). I usually start at 730a and get done at 930a. Not always though. I try to pull reorder stickers as i go but I don't always catch everything...I'm not perfect but I do the absolute best I can, and even though I check and double check i am sure i have left a few holes in theMARs over the years. My advise is to avoid using short cuts if you can (given whatever situation you are in) because when you get in the habit and you are faced with a survey you may have a hard time remembering what is the correct way. Good luck with your new job, you will more than likely gain respect from the other nurses!