Did I make the wrong call?

[FolksBtrippin]

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.

[Daisy4RN]

I would have given what was available, then charted that you notified the Charge, s/he called the MD but no response. Not much more you could have done than that. I don't blame you for calling out, it hurts when you are under the bus!! Sounds like they don't care about the help so let then do it!

[KatieMI, BSN, MSN, RN]

1 hour ago, Davey Do said:

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, psychiatry is a quite separate world ?

Patients on medical floor more frequently than not know it. Trazodone is not addictive by itself but being combined with IV opioids, apparently, sends some folks directly to the upper sit in the heaven. They know that they are more likely to get the said IV opioids on med/surg floor than in inpatient mental health unit (where they are rightly belong otherwise but they have uncontrolled DM or something or there are no beds available). They know that their chances to get more opioids than already ordered are pretty low. So, they ask for more trazodone arguing that their home dose is 300 mg QHS. Experienced nurses know about this trick as well, and tell patients that the order says 100 mg and that will be that.

Thanks God, we have mandatory home meds check with pharmacy verification for everything which must be done in ER.

[FolksBtrippin, BSN, RN]

Thanks to everyone who posted for your support. It means a lot to me.

[chrisjk]

I remember working thru agency at a snf years ago; I had a patient whose pain med prescribed was Tylenol #4. I mistakenly gave Tylenol #3(patient's pain was relieved with lower dose, I documented appropriately/notified the charge and filled out an incident report)....and thought that was all that was needed. Oh, no; the oncoming nurse(s) told me that I had committed 2 med errors(can't remember now how they came to that conclusion.....maybe because 2 T3's would have equalled the codeine in the #4?). Anyway, the look of glee on their faces I'll never forget as they told me that after 3 med errors I wouldn't be able to return(I didn't anyway as I was starting a new job). So I think alot of this negative vibe was because of OP being a temp; some regular staff are resentful(for whatever reason; the $ maybe?--they don't think of the relief from a heavier workload) so if they can find a reason to emotionally dump they will. It is very sad, especially in the present situation we're all having to deal with.

[Workitinurfava, BSN, RN]

I am staying put and doing just enough. I keep getting asked to pick up extra shifts.. I will not do it. It leads to more possible exposure to the virus. We wear paper mask which basically do nothing as far as protecting us. I will not be putting sw (super woman) on my back. This virus is still not something I fully understand and many places of employment are making nurses work short staffed. I don't want to go to a new unfamiliar place to possibly get taken advantage of. I already am being screwed where I work.

[HarleyvQuinn, MSN, RN, NP]

14 hours ago, Workitinurfava said:

I am staying put and doing just enough. I keep getting asked to pick up extra shifts.. I will not do it. It leads to more possible exposure to the virus. We wear paper mask which basically do nothing as far as protecting us. I will not be putting sw (super woman) on my back. This virus is still not something I fully understand and many places of employment are making nurses work short staffed. I don't want to go to a new unfamiliar place to possibly get taken advantage of. I already am being screwed where I work.

Yeah, don't feel too bad. I've had patients literally bite their pill in half and throw the other half in the trash, in front of me. Had to document that half dose, but what else can you do in that situation? Not fishing it out of the trash, that's for sure (not controlled).

[Lauragfa2000]

On 4/17/2020 at 4:55 PM, 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 doing her real job as a nurse instead of nit-picking.

My new hero! Yes, yes, and yes. I hope I covered everything ?

[Emergent, RN]

The LPN is one of those insecure nitpickers. She felt threatened by a newcomer. She knows her own corner of the world well, but probably is ignorant of the wider world of healthcare.

[ruby_jane, BSN, RN]

On 4/17/2020 at 3:55 PM, 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 doing her real job as a nurse instead of nit-picking.

Double down on the YES.

I am afraid to volunteer for a shift in a hospital because I've been ambulatory care so long. This post is informative.

[BlessYourHeartt]

On 4/17/2020 at 7:45 AM, FolksBtrippin said:

You did the best you could with what you had. The LPN sounds like she has a huge chip on her shoulder for whatever reason. In the future, I would get up with the patient's attending though before giving her the half dose to let him or her know about availability issues, and document the Dr.'s response. I know you were overloaded and just trying to get it done.

[ladycody, BSN, RN]

On 4/17/2020 at 5:01 PM, KatieMI said:

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.

I cannot believe that there is a policy ANYwhere that allows for doubling of a med order without provider involvement. I worked in a prison system that didn't allow pill splitting but there is NO way a med adjustment would ever have been made without an order unless it was a crazy nurse who decided to make some REALLY bad choices. That's prescribing...and can't be done by nurses anywhere without a specific provider-signed protocol that names specific meds allowed to be issued with specific dosing under specific conditions with specific criteria met.

Where the heck is this happening???

(Squirreled but was jaw dropped by this).

As for the OP...I could see a hard liner saying you shouldn't give half a dose...but that wasn't your INTENT either. Your intent was to provide the full dose but you were unable to do so...which makes it a near miss med error on your part (because it was caught and wouldn't have reached the patient....the pt WOULD have gotten a full dose had it been available). Near misses arent even considered by many though they provide valuable learning moments when tracked and looked at for quality improvement. It was instead an active pharmacy error because the med was not available for administration. Bottom line...you are fine. Now get yourself out of any hospital that has you passing meds for 19 patients.

[limey]

Why would a nursing home that has a hall strictly for COVID positive residents, put an Agency Nurse instead of a Staff Nurse in charge of that particular hall, even with proper PPE?  Wouldn't that Agency Nurse be exposing other residents and staff in other LTC facilities?