Can you give a lesser dose than prescribed without an order?

klone, MSN, RN · May 28, 2018

The dear doctor should know better. He or she should just write the right order, and take into account that it is pretty hard to give 2/3 of certain meds - like those that don't come in doses that are truly calculable, also what Pharmacy has available.

You have no argument from me there.

psu_213, BSN, RN · May 29, 2018

You're wrong. They most certainly do get involved with "scope of practice" issues as they pertain to orders, how they're written, and how they're carried out. I'm not saying that they would get involved with disciplinary action for individual nurses, but the facility could certainly get cited.

My last hospital got "dinged" during TJC visit because the pt had orders: "Percocet 1 tab PRN for pain 3-6" and "Percocet 2 tabs PRN for pain 7-10." The nurse charted a pain score of 8 and then gave 1 tab. The surveyor said this was practicing medicine without a license. It was on our report that it was done, but the surveyor did not pursue it further with the nurse in question ended up not getting in trouble for it.

Yes, there was frequencies with the orders so that was not an issue...they just weren't important to this situation.

MunoRN, RN · May 30, 2018

My last hospital got "dinged" during TJC visit because the pt had orders: "Percocet 1 tab PRN for pain 3-6" and "Percocet 2 tabs PRN for pain 7-10." The nurse charted a pain score of 8 and then gave 1 tab. The surveyor said this was practicing medicine without a license. It was on our report that it was done, but the surveyor did not pursue it further with the nurse in question ended up not getting in trouble for it.
Yes, there was frequencies with the orders so that was not an issue...they just weren't important to this situation.

While JC surveyors often share their views on different things, they don't actually have any say as to what crosses the line into "practicing medicine". The JC is an accreditation service that hospitals can chose to utilize for CMS accreditation. Licensure issues are not controlled by either CMS or the JC, those are up to State medical and nursing licensing boards.

The only specific nursing board position I've heard on this topic is that they don't consider giving less than the low end of a range as "practicing medicine" if it is not clearly in opposition to the prescribers expectation and if it is based on proper nursing judgement.

dudette10, MSN, RN · May 30, 2018

Officially, yes. Unless the order has the applicable wording from the post above:

Oh, what a load of ****. (Not at you klone...at the whole 'nurses are idiots' way that the accreditors are acting.)

And, as you indicated at your workplace, this is just a matter of 'tightening up order sets.' Does it really change anything about our practice, except cost the facility money for the HIIM group to change the way the orders read?

klone, MSN, RN · May 30, 2018

Oh, what a load of ****. (Not at you klone...at the whole 'nurses are idiots' way that the accreditors are acting.)
And, as you indicated at your workplace, this is just a matter of 'tightening up order sets.' Does it really change anything about our practice, except cost the facility money for the HIIM group to change the way the orders read?

Nope, which is reason #342 Why Klone Has a Strong Dislike For Joint Commission

So much busywork and jumping through hoops. Gotta play the game.

psu_213, BSN, RN · May 30, 2018

While JC surveyors often share their views on different things, they don't actually have any say as to what crosses the line into "practicing medicine".

They may not, and it may have been an overreaction by my hospital (shocker!), but this comment by the surveyor lead to 6 weeks of my staying late to complete pain med (and pain score) audits. Maybe it didn't have to be, but it was written into our plan of correction (or whatever the correct term for it is...I may not know the ins and outs of TJC--I just know that they have caused me angst over the years).

jodispamodi · Jun 2, 2018

If the order does not have a range, such as give 1 to 2 tablets per patient request you cannot give it, that would put you in the realm of prescribing the med and unless you have prescriptive authority, even if the patient requests it. If you are not licensed to prescribe meds-Don't simple as that. The patient is a lay person, you are not. Protect yourself!

Daisy Joyce · Jun 2, 2018

My last hospital got "dinged" during TJC visit because the pt had orders: "Percocet 1 tab PRN for pain 3-6" and "Percocet 2 tabs PRN for pain 7-10." The nurse charted a pain score of 8 and then gave 1 tab. The surveyor said this was practicing medicine without a license. It was on our report that it was done, but the surveyor did not pursue it further with the nurse in question ended up not getting in trouble for it.

This happened to me a couple months ago, but I wasn't dinged for it.

The alert and oriented resident rated her pain as high, and was eligible for the higher dose, but wanted and requested the lower dose.

So I wrote her stated "number" on the MAR, the dose she actually received, and "per resident request".

Then, in the narrative note I explained further . And passed on the interaction in report.

I never got any negative feedback from this.

Jory, MSN, APRN, CNM · Jun 7, 2018

We are not talking about holding a medication. We are talking about changing the medication dosage. You can't just choose to do that without an order. See what I copied above directly from TJC.
I'm sorry I was not clear when I wrote "TJC would come down on you in a hot second" - what I meant was that they would cite the facility, not an individual nurse. An individual nurse's actions can certainly result in a "finding" for a facility. But the most likely scenario is that if one nurse is doing it a certain way, then multiple nurses are as well.

I'm sorry, but you are still incorrect. If the order called for 10 mg and the patient only wanted to take 5 mg, you already HAVE an order for 10 mg. Notify physician, document refusal, but you do NOT need a new order. If you don't need a new order for refusal of a dose, you don't need a new order for refusal of a partial dose.

When you are holding a medication due to REFUSAL when it is DUE to be given and is needed for the therapeutic goal...that is absolutely no different than refusing a partial dose. Why in the world would you think that it is?

Now, if the order was for 10 mg and the patient wanted to take 15mg? THAT, you need a new order for because it's up, above, and beyond what the physician wrote for.

You are confusing the nurse making a unilateral decision with the patient making a choice. They are not the same thing.

klone, MSN, RN · Jun 7, 2018

Jory, you can have this one by attrition, because I've grown bored of debating the issue. Believe what you wish. I'm not confused about anything. I live and breathe TJC regulations. It's part of my job.

Guest219794 · Jun 7, 2018

Wow-

My ER gets so little oversight.

Most of us would think nothing of giving a partial dose of a narcotic, and call it nursing judgement. We get no kick back from the docs. I suppose I could cover myself in a note, and document it a VORB order, but it just wouldn't occur to me.

But, there is no way I am making a patient in pain wait for a doc to cancel one order, and place another in a busy ER. Unfair to the patient, and a poor use of a limited resource; time.

Not saying that is right, just what we do where I work.

BTW- some of the recent posts remind me of a situation I had last night. Had a stoic patient with bouts of pain that had him grimacing, wincing, and so diaphoretic I had to use an ACE to secure his IV. He rated the pain as a three. I did not find this out till later, as I did not initially ask him. Shockingly, our charts are rarely audited, and a PTs pain rating rarely effects what we do.

I noticed later, that my order was for MS 5mg for pain 4-6. Odder, the floor order, which I used prior to transfer was for MS 3 mg for pain 7-10. I warned the patient that he would be losing me as a nurse, and might get a good nurse who follows protocols and rules.And that if he needed medicine, he would probably have to say his pain was 7/10.

That being said, I would not give a patient a partial dose of most meds, particularly scheduled, home meds. Unless the PT convinced me that it was his normal dose. In which case I would give the normal home dose, document why, and might even do a VORB note. Since a PTs home meds in the ER are based on lists obtained by nurses, this is obviously a safe practice, and maybe documenting a VORB even makes it legal.