Medication administration confusion???

[Mike DBD]

Hello everyone! I am a nurse who is newer to dialysis. I have only been working there for a short period of time, but I am concerned about their medication administration to patients. There is a charge nurse (RN) who is responsible for drawing up all of the medications for the clinic. If there is a LPN, or RN who is running a pod of 4 patients they are expected to administer the medication. I have a few concerns with this process. The charge nurse draws with a syringe from a vial, after drawing from the vial she labels the syringe, with the medication and initials. Once this is completed she drops them off for the other nurses to administer. This goes against my fundamental principles of what I have been taught and practice as a nurse, You don't give medications you do not draw up yourself, and then chart them off! How am I supposed to do my rights of medication administration? I didn't see what was drawn up into that syringe.... I have to rely on the charge nurse to draw the correct medication, and then label it correctly. I am looking for advice, because the manager doesn't care about my concerns. I mentioned it to the charge nurse as well and she agrees with me and about the nursing standard of practice, but she says this is how it works, we're in the real world not the ivory tower. How should I approach this? what should be done?

[Alex Egan, LPN, EMT-B]

I see both sides of this. On one hand we trust coworkers. I don't go back and recheck all the normal BPs that a tech got. I trust that the antibiotic that was mixed in the pharmacy was the correct med in the correct diluent. I trust the blood was drawn on the correct patient and the correct patient labels were applied. I treat (or do nothing) based on all these actions by others that I trust.

OTOH, I have worked with nurses who I thought were good nurses--yet I've seen "good" nurses throw fellow staff under the bus even though it was clearly that nurses fault. In other words, even if I generally trusted this nurse, I'm not sure I could trust that nurse enough to push a med that he/she pulled up while away from me.

I've never been a dialysis nurse, so I'm unsure of the exact workflow. Would it be unreasonable to bring the unaccessed vial of medicine to the bedside and pull it up in the presence of that nurse who will be pushing it? Could the charge pull the med from the Pyxis and bring the vial, syringe, needle/access device, etc., and the bedside nurse could then pull it up? I would definitely prefer to do either of these than push a med pulled up by another nurse.

CMS guidelines specifically forbid the drawing up of any medication at chair side.

Thats most likely the reason they want to do it this way, is to comply with the current CMS guidelines around infection control. Medications in dialysis must be prepared in the "clean area" of the clinic. To work in the clean area you must be wearing a different clean gown (different than the one you where on the floor) and wash or sanitize you hands when entering and leaving. So. I enter the clean area, change gowns, wash hands prepare med, remove gown, wash hands, apply "dirty" gown walk over administer med. repeat 36 times a shift. When your doing it as OP discribed you can hand the meds across the clean dirty line and still be in compliance.

[dudette10, MSN, RN]

If there's no reason to do it this way then you're right, it shouldn't be done that way given the additional potential for error.

You're not sure if registered nurses can interpret a physican's order and administer a medication? I feel like I must not be understanding you correctly.

It's certainly a bonus and ideally should be part of the process to have a pharmacist review the order, but a pharmacist is not required for a registered nurse to interpret an order and administer a medication.

I think we are getting stuck on the definition of the word "interpret" so let's skip that part and go directly to a role discussion.

It seems that what you're saying is that, as a matter of course, nurses are fully able to bypass in-patient pharmacy all together and administer any medications a provider orders that he/she also agrees is clinically appropriate.

It leads to the question, then, why have in-patient pharmacists at all?

Do you believe they have no important role in the patient medication process, and that a nurse's education and clinical expertise suffices to ensure patient safety?

[dudette10, MSN, RN]

That actually depends entirely on where one works (unit) combined with policies in effect for that unit. It may not even involve an override...

In healthcare, there is always an exception. However, I'm focused on the act of bypassing pharmacy all together, however that might be done, as a matter of course during inpatient care.

[Have Nurse, ADN, RN]

Seems wrong to me. Is there any logical reason it is done this way? Something to do with LPN's?

Can the LPN's even give the medications (I assume) I V push?

All very confusing to me.

No. In MN the LPN may do Heparin flushes, Saline flushes, hang electrolytes, set up the saline and prep the tubing with saline for blood, cross check with an RN, do the vitals for the transfusion. Once the R.N. has started the blood, may monitor the patient. They can crosscheck TPN, Heparin, Insulin, IV narcotics, but the R.N. hangs them and the R.N. does any I.V. med pushes.

[Have Nurse, ADN, RN]

Agree with this, so long as the medication is properly labelled.

For those of you making the distinction between meds prepared by an RN, and meds prepared in the pharmacy. You are aware that most of these medications are prepared by a pharmacy technician, and the only time it is seen by a pharmacist is when he or she verifies the information on the label with the order.

ETA: I find it sad that some of you have so little trust and confidence in your coworkers that you would refuse to administer a medication prepared by one of them.

I don't really think it is fair to say that. Granted, when one hear horror stories in the news, it makes one take pause. However, to be honest, we are all human and any one us can make a mistake. The fact is it simply isn't a safe practice, and not something that a careful and prudent should do, period.

[Have Nurse, ADN, RN]

I don't know why the disagreement about this is so annoying to me. Let's lay out all the potential for error by taking step-by-step the safety check bypass.

Five rights: right patient, right med, right dose, right route, right time. Transcription error.

If the Charge RN draws up the med, right time cannot be checked. The charge RN labels the syringe, introducing the possibility of transcription error. The administering RN cannot verify right med or right dose and, by extension, right patient.

And the question is why take the risk? There is no benefit to this method.

Amen!

[Leader25, ASN, BSN, RN]

Drawing up and giving meds someone else drew is a minefield,it depends....I have seen many mistakes made by pharmacy or tech that nurses have caught.

Im just saying....

[brownbook]

I have thankfully only come close to drawing up the wrong med, or caught my error immediately afterwards. Any human can make a mistake even doing something very routine they do every day at work.

I just seems if it's found the wrong med was drawn up and given two nurses are going to be in deep dodo, not just one. And the whole why are you giving IVP a med (NOT in an emergency situation) you didn't even draw up seems like a lawyer's dream.

[Mike DBD]

The individual who give the med takes all responsibility, the charge nurse name is no where documented.

[IVRUS, BSN, RN]

Yes, but when a pharmacy tech draws up the medication, he/she will attach the empty vial to the syringe so that the pharmacist who does the final checking can sign off that it truly was the drug ordered. So that there is another check in the system.

[kbrn2002, ADN, RN]

Huh?

The pharmacy check is when the pharmacist signed off on the provider order by reviewing the indication, dosing, interactions, etc. for the med to show up on my patient's med profile. I think we agree on that.

MunoRN said "As nurses, we are licensed to administer medications, which means we can legally skip the "dispense" step and instead directly interpret the physicians order and administer the medication without it being "dispensed"."

She seemed to imply that we can just see the order then go override the Pyxis and pull the med and administer without any consequences. That's just not true.

Now this topic is starting to really confuse me. My facilities pharmacy is 150 miles away. The vast majority of our meds are in a pyxis type machine. When we get a new order from the MD/PA/CNP we fax that order to pharmacy and pull the med from the machine. We are able to pull the med from the e-kit function of the machine and administer it before pharmacy even enters the order in their system. There's no need to overide the Pyxis, we just select the patient name, navigate to the med in the system and pull it. No consequences, that's how it's done. I can't imagine our facility and our pharmacy has us pull a med this way if it's somehow wrong.

The exception to this process is a controlled med. In that case the pharmacy has to have the order entered in their system before the med can be pulled as those meds require a written order from the provider before being dispensed, though a schedule 3 can be dispensed with a verbal order from the provider given directly to pharmacy. That process can take as little as 5-10 minutes to as long as an hour or more for the med to be approved for dispensing from the machine depending on the providers willingness to call the pharmacy with the order in a timely fashion and the pharmacist entering that order as soon as they get it.

[brownbook]

Now this topic is starting to really confuse me.

I agree. I thought the "correct" answer would be more clear cut!