Medication administration confusion???

Nurses General Nursing

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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?

Specializes in Emergency, Telemetry, Transplant.
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.

I'm asking this because I don't know, not because I'm trying to be argumentative: is this for free standing dialysis clinics, or does the gowning, change gowning, etc. apply to inpatient, hospital dialysis as well?

Specializes in Critical Care.
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?

Pharmacists certainly play an important role in the medication review process and they should be utilized whenever the clinical situation allows, but they aren't a required part of the process between a physician writing an order and the nurse interpreting the order and giving the med.

Specializes in Med/Surg, Academics.
Pharmacists certainly play an important role in the medication review process and they should be utilized whenever the clinical situation allows, but they aren't a required part of the process between a physician writing an order and the nurse interpreting the order and giving the med.

Ok, now I get that you are saying pharmacists are not LEGALLY REQUIRED to be a part of the inpatient medication process.

I would not feel comfortable. This violates the 5 rights. How do you know it's the right medication, and dose if you didn't witness her draw it up?

Specializes in Pediatric Critical Care.
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?

But the original scenario isn't bypassing pharmacy...

1) The physician ordered a med.

2) Pharmacy checked the order, put it on the patient's MAR.

3) Then the charge nurse got the med out of whatever drug vending machine they use and put it into a syringe.

4) Then the patient's nurse gave the med.

Pharmacy is right there in step #2.

Specializes in Pediatric Critical Care.
I would not feel comfortable. This violates the 5 rights. How do you know it's the right medication, and dose if you didn't witness her draw it up?

How do you know the medicine in the vial was even the correct medication at all, by that logic?

Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.
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.

I'm pretty sure LV/PNs can't give IV push meds...at least in my state. I'm a former LVN.

Specializes in Home Health (PDN), Camp Nursing.

Ok. So I'm gonna com in and ad a little here.

1. Actually there is no pharmacy involved in the process at all in the dialysis units I worked in. The physician writes for the protocol, labs are taken, the medications are adjusted weekly per the protocol. The order is updated in the charting/computer the label is printed and the drug is given from stock. (Think mini fridge, not pixis)

2. Don't loose site of the fact that this is a dialysis clinic, so it is a wildly different practice area than many of you are envisioning.

3. The ability to push IV meds for LPNs is dependent by state, just because you don't do it doesn't mean it's done.

4. Unless you get your gas spectrometer out you are fully trusting the pharmacy label to tell you what drug is in whatever you're giving, I don't think extending that trust to another nurse so long as the correct information is provided is wrong, it logics out just fine for me. Is it ideal...no, but the real world often isn't.

5. Because of the setting the odds of a Catastrophic med error is shockingly low. That's why the system is ok here and probably not on your units. Don't forget the setting.

This is from Frederick Karsten R. Ph. Director of the Drug and Narcotics Agency State of Georgia. 480-28-.08 Practitioner's Assistants.

Nothing in these rules shall prohibit any person from assisting any duly licensed practitioner in the measuring of quantities of medication and the typing of labels therefore, but excluding the dispensing, compounding, or mixing of drugs, provided that such practitioner shall be physically present and personally supervising the actions of such person in doing such measuring and typing, and provided, further, that no prescription shall be given to the person requesting the same unless the contents and the label thereof shall have been verified by a licensed practitioner. No practitioner shall be assisted by more than one such person at any one time.

Authority O.C.G.A. Secs. 26-4-4, 26-4-27, 26-4-28, 26-4-37, 26-4-60, 26-4-85, 26-4-130.

For purpose of these Rules and Regulations, the following definitions apply:

(a) Drugs. Drugs shall mean drugs as defined in O.C.G.A. Section 26-4-5.

(b) Practitioner or Dispensing Practitioner. Practitioner or dispensing practitioner means a person licensed as a dentist, physician, podiatrist or veterinarian under Chapters 11, 34,

35 or 50, respectively of Title 43 of the Official Code of Georgia Annotated. So if I'm reading this correctly, at least in Georgia, the RN cannot draw up meds for someone else to give unless a practitioner is watching . I personally do not give meds that I myself didn't draw up, or witness being drawn up, that is what I was taught in nursing school, and I stand by that. I have seen two different concentrations of the same med delivered to a clinic where I worked ( there was a back order on the concentration we normally used), and the bottles looked the same. Check with your BON. Don't take the administration's word for it. I once applied for a job at a small rural hospital (in Central Illinois) that did NOT have a physician,PA,or even a NP in the building after 8 pm. Administration actually told me that because they were a rural hospital, the rules were different for them......Sure they were....not according to the State of Illinois,and the BON!

'

Specializes in Home Health (PDN), Camp Nursing.

So my understanding of the term dispensing is packaging a medication for direct use by the patent, not another nurse. Even assuming I am wrong I believe this refers to the use of pharmacy techs, thus why there can

Be only one at a time and the complete lack of the terms RN or Nurse.

Disclaimer my knowledge of Georgia law is not great as I don't or practice there. My statements are based on PA law as I understand it.

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.

There were so many replies to the post, I just glanced over yours. Glad I went back and re-read it. It seems to at least make sense. I hope the original poster saw it.

This is from Frederick Karsten R. Ph. Director of the Drug and Narcotics Agency State of Georgia. 480-28-.08 Practitioner's Assistants.

Nothing in these rules shall prohibit any person from assisting any duly licensed practitioner in the measuring of quantities of medication and the typing of labels therefore, but excluding the dispensing, compounding, or mixing of drugs, provided that such practitioner shall be physically present and personally supervising the actions of such person in doing such measuring and typing, and provided, further, that no prescription shall be given to the person requesting the same unless the contents and the label thereof shall have been verified by a licensed practitioner. No practitioner shall be assisted by more than one such person at any one time.

Authority O.C.G.A. Secs. 26-4-4, 26-4-27, 26-4-28, 26-4-37, 26-4-60, 26-4-85, 26-4-130.

For purpose of these Rules and Regulations, the following definitions apply:

(a) Drugs. Drugs shall mean drugs as defined in O.C.G.A. Section 26-4-5.

(b) Practitioner or Dispensing Practitioner. Practitioner or dispensing practitioner means a person licensed as a dentist, physician, podiatrist or veterinarian under Chapters 11, 34,

35 or 50, respectively of Title 43 of the Official Code of Georgia Annotated. So if I'm reading this correctly, at least in Georgia, the RN cannot draw up meds for someone else to give unless a practitioner is watching . I personally do not give meds that I myself didn't draw up, or witness being drawn up, that is what I was taught in nursing school, and I stand by that. I have seen two different concentrations of the same med delivered to a clinic where I worked ( there was a back order on the concentration we normally used), and the bottles looked the same. Check with your BON. Don't take the administration's word for it. I once applied for a job at a small rural hospital (in Central Illinois) that did NOT have a physician,PA,or even a NP in the building after 8 pm. Administration actually told me that because they were a rural hospital, the rules were different for them......Sure they were....not according to the State of Illinois,and the BON!

'

No one in the OP scenario is acting as a "practitioner's assistant" but rather as a practitioner in their own right, performing duties they themselves are duly licensed to do.

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