Cosigning Conundrum

[KelKelRN]

I'm wondering what people think about my current predicament. I went to nursing school in one area of the country, and am now working in another area of the country. I was taught to consider cosigning as a nursing commandment (thou shalt always get a cosigner for insulin, heparin, narcotic wasting, etc)... I foolishly assumed that these rules were followed everywhere, but now that I'm working as a nurse, I realize that is not the case everywhere. When I went to administer insulin for the first time I asked my preceptor to cosign and was told, "No one does that here", and that though your're supposed to, no one does. After talking with several other people in my new grad class, I've found that this is a hospital wide problem. SO, people don't want to "bother" cosigning for insulin injections, but I'm also frequently doing insulin drips where I'm changing the rate of infusion every hour on multiple patients, and even the charge nurses are telling me you don't need a cosigner for that, which honestly makes no sense to me. I know I'm not going to mistakenly administer the wrong amount, but I am more concerned with the fact that even when you administer the correct amount that bad things can happen (i.e. hypoglycemia)... I'm working in an environment as a new nurse where I thought my preceptor was supposed to have my back..and I'm honestly feeling more that I have to watch my own back double-time due to the flagrant disregard for general nursing standards. I've addressed this issue in my new grad class, but the attitude I get from the nursing educators (most of whom are fairly young) is that it's my responsibility to go to my department educator and inform them of what's going on, but I also feel like they're trying to make a hospital wide problem way before I arrived my responsibility.....when I feel like this is something that needs to be corrected from the top down, and not the bottom up.... What do I do??? Thoughts please!!

[eatmysoxRN, ASN, RN]

While cosigning for high risk medications is a fantastic and safer idea, it is immensely difficult when you have 2 nurses for 16 patients on a busy floor and about half need insulin.

If nursing school didn't prepare me to accurately measure 4 units of regular insulin then I shouldn't be a nurse.

Other drugs we give can be just as dangerous and no one thinks of needing a cosigner. What if you hooked up a ivpb vanc incorrectly and the patient got the whole bag as quickly as it could? (I've seen it happen when it was hooked to the wrong port).

Should we have to have a cosigner state we give iv narcs over an appropriate amount of time?

Instead of requiring cosigners the hospital should lower nurse patient ratios. I think that would have the most positive impact on the amount of med errors.

[MunoRN, RN]

Be careful about considering anything you learned in Nursing School to be a "commandment". There is evidence and recommendations to support double checking IV insulin and heparin, however many facilities no longer require an independent double check for Sub Q doses of either insulin or heparin, there is little if any evidence to support that practice, and it's potentially harmful as it dilutes the importance and focus on truly necessary double checks.

[bugya90, ASN, BSN, LVN, RN]

We only have to co sign on narcotic wasting and that is only because I work at a large hospital and they had issues in the past with narcotic theft. When I worked in nursing home we didn't have the staff to cosign. We had three wings with one nurse per Wong and 50 or more patients several diabetics. There is no way between three nurses on opposite sides of the building and close to 200 patients that we could get a co sign for every single insulin. You need to learn your facility policy and nurse practice act, those are the rules you need to follow.

[Altra, BSN, RN]

There is no "commandment" that 2 nurses must cosign insulin -- it's strictly an institution-specific policy you encountered while in nursing school clinicals.

I believe what your educators are attempting to elicit in you is developing a sense of responsibility for your own practice, and a culture of, yes, bottom up improvements in patient safety as warranted. After a few years in nursing, you may find you feel quite differently about top-down edicts ... .

Good luck to you.

[chrisrn24]

There is no "commandment" that 2 nurses must cosign insulin -- it's strictly an institution-specific policy you encountered while in nursing school clinicals.

I believe what your educators are attempting to elicit in you is developing a sense of responsibility for your own practice, and a culture of, yes, bottom up improvements in patient safety as warranted. After a few years in nursing, you may find you feel quite differently about top-down edicts ... .

Good luck to you.

I would agree.

Some facilities, you don't need a co-signer. If everyone is saying "no you dont need one" then don't worry about it!

[AngelRN27]

I didn't read through the previous comments, but, I was personally never taught that insulin and heparin had to be cosigned for...? Perhaps it is an area-based ideal? I went to nursing school in Miami, FL and graduated from a very reputable program. Really the only type of medication we were warned to get cosigned were more along the lines of narcs/pain meds/benzos... not really insulin and heparin...

Is it THAT common for the rest of you to see nurses being required to cosign for these medications?

[drowningdaily]

What I learned in school, and what is done in my floor is to verify PPINCH drugs.

Pca, Potassium, Insulin (iv), Narcotics (not so much), Chemo ( we don't give) and Heparin (iv drip). Never heard of 2 nurses checking sq hep or insulin.

[NutmeggeRN, BSN]

I would check your policy and procedures manual and/or staff education.

[psu_213, BSN, RN]

At my first job we had to have a cosignature on subQ insulin and certain drips (heparin, dilt, etc.). My next job we had to have a cosignature on the previous meds and on subQ heparin and for coumadin (the latter 2 is, in my mind, the stupidest cosignatures I have ever encountered). Now, it the ED, we don't need a cosignature on anything, including insulin, drips of any sort, etc.

*Of note, for all of my positions...all narcs required witnesses for wastes, although this was done in the pyxis, not an actual signature. Also, all places required the necessary cosignatures when hanging blood products.

Having said all that, what exactly is your predicament? If you are unsure of your dosages of SubQ insulin or of rate changes on a drip, make sure your preceptor looks at all of them, even if there is no actual signature.

Finally, if there is any nursing "commandment" it would be to always follow policy at your facility/unit.

[BrnEyedGirl, BSN, MSN, RN, APRN]

I'm curious where you work that still does paper charting? I was also taught to have a cosigner for high risk meds. Our computer won't let you chart the med without a cosigner period. Our Omnicell won't let us record a narc waste without a cosigner,.no arguing over it, it can't be done.

[anon456, BSN, RN]

Maybe because I work with peds, we have a lot of meds that require co-signs that probably are not required in the adult world. Frankly I am glad we have those guidelines in place, even though it is a pain to sometimes find people to cosign multiple meds per shift. My worst days that way are when I have two patients on morphine/ativan weans, one on TPN/lipids, a patient getting lovenox, and one is getting expressed breastmilk feedings because all those things require cosigns. But it also helps to know that I'm not making errors. :-)