Ethical advice needed for a new grad...

[AnnaleaRN]

What would YOU do?

Say, hypothetically, that you are a new graduate RN at your first job. During morning med pass at a SNF, you witness another RN entering incorrect times for med administration on multiple patients in order to seem like everyone received their medication within the designated time frame. When you asked this nurse about the times, she states that she "guesses every nurse has to make a judgement call on how to chart."

Would you take it further? Would you ignore it?

[Morainey, BSN, RN]

Part of being a nurse is having the nursing judgement to realize that giving a routine med a couple hours late is not 911-melodrama-everyone-panic time. If being a nurse means blindly and obsessively following rigid orders and schedules at any cost, then they may as well let Joe blow off the street pass meds.

I haven't read all these posts, but I'm sure many have told you by now that "turning in" this nurse or "taking it further" is a horrible idea.

Yessss. I agree. For those huge med passes you just can't give all your meds exactly on time. If I have, let's say, a Coumadin due at 4pm, a Caltrate due at 5pm, and an ATC Tylenol due at 6pm all for the same resident, I don't have time to make three trips in on the hour. It's just not happening.

[kbrn2002, ADN, RN]

As a DON in a 68 bed facility-I feel the generalization of Nursing Home staffing offensive. I have been here 20 years. We continue to be a 5 star facility, and our staffing is ABOVE the industry norm. We have 28 Nurses, 24 of them RNs. We have had surrounding facilities tell us we "over staff" and make it bad for the rest of them. I AM management. I set the staffing. We have 4 nurses on days and evening shift. We have concentrated on DECREASING the number of medications our residents receive, because polypharmacy is the actual issue, not staffing. If I am 97 years old, DO NOT put me on a cholesterol medication, multiple blood pressure medications, antidepressants and multiple vitamins. Please do not color all Nursing Homes with the same pen, we are not the same.

Amen to that! Off topic but you are right, polypharmacy is rampant. For instance I have one lady I pass 17 meds to in the morning, 15 of which are some kind of OTC supplement. How many different vitamins/minerals can one 88 year old lady really need???

[newkidnurse]

tl;dr; I've done a little reading on this and other similar issues related to med admin....

The Institute of Safe Medicine Practices (ISMP) released this document which you all may find pretty interesting: Acute Care Guidelines for Timely Administration of Scheduled Medications. Basically, this set of recommendations came in response to the realization that the 30 Minute Rule was causing way more harm than good (for example, see this article).

Even though my hospital hasn't made any changes to our '30 Minute Rule', the ISMP guidelines has allowed me to feel much better (in my head...) about giving Patient A her scheduled 0800 Colace at 0845 because I decided I needed to prioritize giving Patient B her 0800 IV antibiotics and Patient C her 0800 seizure meds.

[candyimage16]

Thanks so much for the feedback, everyone. I want to clarify a few things and ask a couple more questions. Please humor me:-)

GrnTea- I am certainly willing to put the effort into making a change for the better of the patient's and the unit staff! I really love my job. I'm also not a quitter:-)

I agree with you that not taking meds exactly on time can be perfectly safe and happens all the time at home. However, the unit I am referring to is relatively acute. We are a "sub-acute" rehab. PICC lines, trachs, etc. We hang IV meds, blood, as well as the patient's regular meds. These folks certainly don't need acute care. However, they are still quite sick.

My biggest concern is the fact that it isn't charted accurately. I may very well be being a silly new grad about this. However, if you can't get it in on-time, and it's not unsafe to do so, why put false information on the medical record?(Again, not being flip. I just want to understand.)

I'm not sure how to change my attitude about the situation. Do you mean to be less rigid about charting administration times?

The Commuter

I have no doubt that timely med administration is difficult in any healthcare setting at least some of the time.

For everyone, I guess the question is:

Do experienced nurses, as a whole, feel comfortable charting late med administrations as on time under circumstances that are not going to cause any immediate harm to the patient?

To answer your last question, Heck Yes i feel comfortable charting a 0900 administration time if I gave it anywhere between the +/- one hour scheduled time. Unless it's a pain med/PRN med, then I always chart correct time (+/- 5 min).

[Deidra47]

It has always been you have an hour before and an hour after the "due" time to get your meds. out.

[Spidey's mom, ADN, BSN, RN]

To answer your last question, Heck Yes i feel comfortable charting a 0900 administration time if I gave it anywhere between the +/- one hour scheduled time. Unless it's a pain med/PRN med, then I always chart correct time (+/- 5 min).

It has always been you have an hour before and an hour after the "due" time to get your meds. out.

That isn't the issue. Of course if your policy is that you have an hour (or 30 minutes) before and after scheduled time and you do it then you are ok. Usually in that case the med sheets don't have an exact time that you have to initial though. From what I've seen it is QAM or BID or TID or QHS.

Say, hypothetically, that you are a new graduate RN at your first job. During morning med pass at a SNF, you witness another RN entering incorrect times for med administration on multiple patients in order to seem like everyone received their medication within the designated time frame. When you asked this nurse about the times, she states that she "guesses every nurse has to make a judgement call on how to chart."

Would you take it further? Would you ignore it?

My understanding of the above highlight part is that the nurse was putting in exact numbers (8:00 a.m.) when the med was actually given after that one hour designated time frame.

That is a different question.

[Spidey's mom, ADN, BSN, RN]

tl;dr; I've done a little reading on this and other similar issues related to med admin....

The Institute of Safe Medicine Practices (ISMP) released this document which you all may find pretty interesting: Acute Care Guidelines for Timely Administration of Scheduled Medications. Basically, this set of recommendations came in response to the realization that the 30 Minute Rule was causing way more harm than good (for example, see this article).

Even though my hospital hasn't made any changes to our '30 Minute Rule', the ISMP guidelines has allowed me to feel much better (in my head...) about giving Patient A her scheduled 0800 Colace at 0845 because I decided I needed to prioritize giving Patient B her 0800 IV antibiotics and Patient C her 0800 seizure meds.

Good info, thanks. Personally 30 minutes (30 minutes before and after scheduled time) is all I've ever heard. Not the hour (one hour after and one hour before) that some folks have mentioned.

[TheCommuter, BSN, RN]

Personally 30 minutes (30 minutes before and after scheduled time) is all I've ever heard. Not the hour (one hour after and one hour before) that some folks have mentioned.

In the nursing homes here in Texas, the TX Dept. of Aging and Disability Services (DADS) legally allows medications to be administered one hour before or one hour after the scheduled time. This regulatory agency will cite a medication error for any prescribed drug not taken within one hour before or one hour after the arbitrary time (refusals do not count).

[Spidey's mom, ADN, BSN, RN]

In the nursing homes here in Texas, the TX Dept. of Aging and Disability Services (DADS) legally allows medications to be administered one hour before or one hour after the scheduled time. This regulatory agency will cite a medication error for any prescribed drug not taken within one hour before or one hour after the arbitrary time (refusals do not count).

Thanks. I'm going to check when I go see our hospice patient who is in LTC.

It has been a long time since I've worked LTC . . . . .

[hope3456, ASN, RN]

In the nursing homes here in Texas the TX Dept. of Aging and Disability Services (DADS) legally allows medications to be administered one hour before or one hour after the scheduled time. This regulatory agency will cite a medication error for any prescribed drug not taken within one hour before or one hour after the arbitrary time (refusals do not count).[/quote']

Do they enforce this? What happens when they ARE late? How are your meds scheduled - some at 8am some at 9 AM ect? Do you use scanners?

[TheCommuter, BSN, RN]

Do they enforce this? What happens when they ARE late? How are your meds scheduled - some at 8am some at 9 AM ect? Do you use scanners?

I have never worked at a nursing home that used scanners.

Nothing happens if medications are administered late, unless management or the state surveyor dislikes the nurse for some reason. In that case, they'd make a huge example out of the nurse and possibly refer his/her license number to the state BON for medication errors. Then, the state BON would formally reprimand and/or issue fines and sanctions if the nurse cannot disprove the allegations made against him/her.

[chrisrn24]

We have hour before and hour after. And I've never heard of any consequences from giving them late. I'm sure the EMAR records the times but to my knowledge no one has ever been confronted on giving meds late.