Did I make the wrong call?

[FolksBtrippin, BSN, RN]

I normally work outpatient, but I took an agency position at a hospital this week to help out with staffing during COVID 19 crisis.

Its a very hard job and I had to pass meds for 19 patients yesterday. Paper charting, which I am not used to.

One patient complained that I only had half her normal dose of a psych med. I double checked the chart and she was correct. I said I would ask the charge about getting her the other half, as it was not in my cart. She was angry and accused me of stealing the med or giving it to another patient. Not a controlled substance.

I let her take the half dose and asked the charge nurse how to get the other pill.

Turns out the pill was not available anywhere. Charge nurse called all over.

I documented the partial dose and left it at that. I know this med well and did not think this was a very big deal. She's on the biggest dose I've ever seen, but it is a med that requires more and more over time to get the effect.

The incoming LPN made a big deal out of this and said I should not have given the partial dose, that I should not have given it at all. Then she said I should have gotten a one time order for the half dose. I told her that charge did not think that was necessary. Then she asked me if there was anything else I did that was reportable.

Like... what?

I just told her that it's on me, report whatever she wants. I documented what happened and I'm willing to take the consequences.

I've been sent there for a COVID 19 outbreak with staff both getting sick and also calling out due to fear.

I guess no good deed goes unpunished.

Anyway, I'm an agency nurse and I really doubt anything bad will happen to me.

But I want to know if what I did was very out of line, and what you would have done in my situation.

Also, today is my last day there. I start a new full time gig in the community on Monday. Thank God. I absolutely hate the hospital specifically because of *** like this.

[pixierose, BSN, RN]

Good heavens, no. As soon as she said, “if there was anything else (you) did that was reportable” she lost my attention. Aye yi yi.
You’re helping them out, responded correctly by verifying with the patient and her chart and going to the charge nurse. Why would you get in trouble? Sounds like the LPN was stressed. Sure, some of those psych meds are heavy duty (clozaril for one), but if it isn’t anywhere in the building, what can you do?

If it was a unit I was familiar with I would have contacted pharmacy but I wouldn’t kick yourself over it.

Thanks for helping out - I get emails from my state for help at SNFs but I’m barely getting through my own job.

[Davey Do]

8 hours ago, FolksBtrippin said:

One patient complained that I only had half her normal dose of a psych med. I double checked the chart and she was correct.

With or without knowing the specific psych med, FolksBtrippin, I'd say you did the right thing.

Better to get a little psych med down the patient than none at all.

I had, for example, a patient who would ask me to split their 300mg Seroquel in half and take it, "because 300mg is too much". I merely documented the situation. And as this patient was no behavior problem, in fact quite amicable, the psychiatrist after a few days reduced the dose to 150mg.

Another situation occurred where the psychiatrist had written an order for Zyprexa sol tab 2.5mg. Pharmacy did not carry that dose, with 5mg being the smallest, so the psychiatrist ordered a 1/2 tab. Pharmacy wouldn't fill the order because the drug company recommended not splitting the sol tab.

But still, it's like I said, "Better to get a little psych med down the patient than none at all".

[amoLucia]

Like pixierose said, TY for helping out.

My only question - was the MD called re the situation? I couldn't tell.

The whole thing to me would be a med error/discrepancy report. At the MOST!

Sounded like a systems error on the pharmacy part.

Sheesh! In these C19 times, such much ado about sweating the small stuff!

(I know I combined 2 old sayings!)

[amoLucia]

Hey, DD! You know I was specifically thinking of you when I combined those 2 old adages.

[KatieMI, BSN, MSN, RN]

"Unusually" high/low doses are common in Psychiatry. On the other hand, "half dose" was prescribed and we do not have to believe everything patient says about doses of meds. There are meds which do not belong to usual lists of "controlled substances" and yet abused frequently (like Seroquel and Trazodone) and increased doses can be reported by patients for many reasons - from honest mistake to the fear of worsening symptoms while under stress.

It could make sense to check home meds if they were available, and call provider who prescribed that med if that was possible. But, if you have 19 patients to care for, that can safely go to the back burner.

Re. "reportable"... please. I guess it was one of those policy-kissers who is permanently busy "reporting" various stuff to whoever while ignoring patients who need care.

I would make a little call to your (now former) agency and let them now how you were treated while there and express concern about safety of other agency nurses in that particular unit. Then that LPN will get her chances to start doing her real job as a nurse instead of nit-picking.

[amoLucia]

1 minute ago, KatieMI said:

... Re. "reportable"... please. I guess it was one of those policy-kissers who is permanently busy "reporting" various stuff to whoever while ignoring patients who need care.

I would make a little call to your (now former) agency and let them now how you were treated while there and express concern about safety of other agency nurses in that particular unit. Then that LPN will get her chances to start doung her real job as a nurse instead of nit-picking.

YES.

[KatieMI, BSN, MSN, RN]

42 minutes ago, Davey Do said:

With or without knowing the specific psych med, FolksBtrippin, I'd say you did the right thing.

Better to get a little psych med down the patient than none at all.

I had, for example, a patient who would ask me to split their 300mg Seroquel in half and take it, "because 300mg is too much". I merely documented the situation. And as this patient was no behavior problem, in fact quite amicable, the psychiatrist after a few days reduced the dose to 150mg.

Another situation occurred where the psychiatrist had written an order for Zyprexa sol tab 2.5mg. Pharmacy did not carry that dose, with 5mg being the smallest, so the psychiatrist ordered a 1/2 tab. Pharmacy wouldn't fill the order because the drug company recommended not splitting the sol tab.

But still, it's like I said, "Better to get a little psych med down the patient than none at all".

In SNFs and even some hospitals apparently there are some schmolicies prohibiting splitting any pills at all.

I lost count of how many times some little old lady or gentleman was carefully titrated to correct doses of b-blockers, steroids, coumadin and pretty much everything else and sent out on clearly written regiment only to be dragged back within 24 to 48 h with severe side effects or overdose. In all cases without exclusion, the story was: we cannot give half a pill as per policy, so we just double it as per policy and thought it would be all right, and we did not call provider because it was as per policy.

[Davey Do]

29 minutes ago, KatieMI said:

"Unusually" high/low doses are common in Psychiatry.

This is true, and was more so in the pre atypical dopamine antagonists and SSRI days, Katie!

Back in the early 90's, when I worked at Anomaly State Hospital, I was pulled to the forensic unit now and again. Migod! the doses of those old antipsychotics were incredibly high!

29 minutes ago, KatieMI said:

There are meds which do not belong to usual lists of "controlled substances" and yet abused frequently (like Seroquel and Trazodone) and increased doses can be reported by patients for many reasons - from honest mistake to the fear of worsening symptoms while under stress.

Interesting... I've not had many patients exaggerate their doses of non controlled substances all that much, Katie.

Trazodone 50mg was a typical prescribed PRN for insomnia and I heard a lot of patients say how much better they slept after being prescribed Seroquel.

Again:"Interesting".

[FolksBtrippin, BSN, RN]

1 minute ago, KatieMI said:

10 minutes ago, KatieMI said:

"Unusually" high/low doses are common in Psychiatry. On the other hand, "half dose" was prescribed and we do not have to believe everything patient says about doses of meds. There are meds which do not belong to usual lists of "controlled substances" and yet abused frequently (like Seroquel and Trazodone) and increased doses can be reported by patients for many reasons - from honest mistake to the fear of worsening symptoms while under stress.

It could make sense to check home meds if they were available, and call provider who prescribed that med if that was possible. But, if you have 19 patients to care for, that can safely go to the back burner.

Re. "reportable"... please. I guess it was one of those policy-kissers who is permanently busy "reporting" various stuff to whoever while ignoring patients who need care.

I would make a little call to your (now former) agency and let them now how you were treated while there and express concern about safety of other agency nurses in that particular unit. Then that LPN will get her chances to start doung her real job as a nurse instead of nit-picking.

To be clear she was prescribed 2 pills, and only got 1 because pharmacy never sent the other one.

Also, charge nurse said she called the pharmacy and also the doc, and did not get a callback. Presumably, this was not a priority for them with the current situation.

Thanks for your support. I will consider reporting it to my agency. This wasn't the only problem I had here. I decided to call out today. I like helping, but I'm not going to help people who want to throw me under the proverbial bus, even if no such bus is coming.

[Davey Do]

9 minutes ago, KatieMI said:

In SNFs and even some hospitals apparently there are some schmolicies prohibiting splitting any pills at all.

I'm really not sure what the "schmolicy" (heh!) was where I use to work, Katie, but I believed it was within my nursing judgement to give less of a psychotropic than what was prescribed. I would merely document the amount administered on the eMAR, progress note, and inform the psychiatrist.

Patients sometimes did ask for more than what was prescribed and I'd reply, "No can do!"

[Davey Do]

4 minutes ago, FolksBtrippin said:

I'm not going to help people who want to throw me under the proverbial bus, even if no such bus is coming.

FolksBtrippin, it's called "The Chicken Little Bus"!