Medication administration confusion??? - page 3

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... Read More

  1. by   dudette10
    Quote from chare
    To those of you saying that you would only give medications drawn by another during an emergency situation, what makes this different? If your concern is that the medication wasn't properly prepared, don't you think that the increased stress and anxiety during an emergency is going to greatly increase the probability that an error will occur?
    I can't believe I have to explain this.

    It's a benefit to harm ratio. All hands on deck for a true emergency where speed may be the difference between life and death. In those situations, we take verbal orders without protesting--even if it's against policy and procedure--or just anticipate what needs to be done and do it.

    In situations where there is no emergency and no real reason to bypass safety checks, the benefit to harm ratio shifts.
  2. by   Have Nurse
    Quote from Double-Helix
    This is exactly what happens when the pharmacy sends a pre-filled medication syringe or bag to an inpatient unit. You didn't see the pharmacist draw up the medication either, but do you go to the nurse manager and refuse to give the medications sent from pharmacy? No. You check the label on the syringe with your order and give the med and sign it out. It's not a violation in practice to give a medication that another trained and licensed professional prepared.
    I would have to disagree with this post, with kindness. The Pharmacist is a specialist in Pharmacology. While the nurse has had Pharmacology in training, it isn't the same the extensiveness as what the Pharmacist is required to do.

    I would bring this unsafe practice to the Medical Director and the Board of Nursing. It wouldn't be the first time an organization was making serious mistakes.

    You have a license to protect. If they insist that the Charge RN draw up the meds, then she needs to be the one to sign off and give them, not you.
  3. by   Have Nurse
    Quote from LilyRN99
    I agree with smf. I was taught never to give a med prepared by another nurse.
    Absolutely right.
  4. by   dudette10
    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.
  5. by   Julius Seizure
    Quote from dudette10
    Can you provide a link to where you got this information? The way you have described the word "dispense" hinges on who (RN or patient) will actually be administering the medication, licensed or not and not all the checks that pharmacists do.

    I'm not a pharmacist, so I'm not sure if it would be appropriate for me to interpret a physician's order. I have not been trained in med interactions or all the lab values that need to be reviewed or all the indications for a med before being ok with a medication order.
    Have you never gone to the Pyxis/Omnicell/Accu-dose and removed a tablet of some kind of medication to administer to your patient? Where was the pharmacy check there?

    It was when they checked that they med and dose was appropriate and put in on the patients MAR for you to check when you pulled the med. The pharmacist doesn't have to come pull the med and hand it to you personally.
  6. by   dudette10
    Quote from Julius Seizure
    Have you never gone to the Pyxis/Omnicell/Accu-dose and removed a tablet of some kind of medication to administer to your patient? Where was the pharmacy check there?

    It was when they checked that they med and dose was appropriate and put in on the patients MAR for you to check when you pulled the med. The pharmacist doesn't have to come pull the med and hand it to you personally.
    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.
  7. by   JKL33
    Quote from dudette10
    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.
    Your concern about transcription error is equivalent to any other type of mislabeling error.

    In lots of situations where RNs routinely have to prepare doses of medications, the unit has syringe labels printed for the ones used most frequently. You complete the label and apply it to the syringe that has the appropriate medication in it. Some version of the essential elements of this process is done by everyone everywhere who prepares meds in a syringe for a particular patient.

    If the Charge RN draws up the med, right time cannot be checked
    How is that? It's either time to give it, or it isn't. The date and time prepared will be on the label prepared by the CN/RN/Pharmacist/Pharm Tech/Etc. If you're saying that the preparer can't guarantee that it will be given at the right time because s/he is not the one who will be administering it, well that is true of every dispensation on pharmacy's part.

    How are you verifying the right anything by what pharmacy sends you? If you don't watch them prepare it, then you are utilizing an element of trust in their labeling procedure that you're simply not acknowledging here.

    Not trying to make this any more perturbing. It's just that you haven't actually demonstrated a difference in the inclusion of essential elements between these two processes. When done correctly, everything is in order. When not, they're not - but this process not being done correctly does not involve errors that can only be made by RNs, nor that can only be made in this type of scenario.

    Charge nurse:

    Verifies order for X patient. The order is complete and appropriate to the situation.

    Draws up the correct dose of correct medication as indicated by the order, using appropriate technique.

    Applies correct label to medication with all elements needed for 2nd check at bedside.

    Delivers medication to the correct patient station.

    If you have a problem with any of the first (3) of these ^, then you have a problem with any RN drawing up/preparing any medication anywhere, ever, including ones someone would draw up to administer to their own patient.
  8. by   JKL33
    Quote from dudette10
    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.
    That actually depends entirely on where one works (unit) combined with policies in effect for that unit. It may not even involve an override...
  9. by   psu_213
    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.
  10. by   MunoRN
    Quote from dudette10
    The sky will fall with the first error. You're right about one thing though, it's not the ideal way to do it.

    Then why do it that way at all?

    Anyway, the "other processes" also have their safety checks.
    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.

    Quote from dudette10
    Can you provide a link to where you got this information? The way you have described the word "dispense" hinges on who (RN or patient) will actually be administering the medication, licensed or not and not all the checks that pharmacists do.

    I'm not a pharmacist, so I'm not sure if it would be appropriate for me to interpret a physician's order. I have not been trained in med interactions or all the lab values that need to be reviewed or all the indications for a med before being ok with a medication order.
    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.

    An example of a regulatory definition of "dispense":
    Dispense
    The act of dispensing includes the selection and labeling of prepackaged medications ordered by the physician or advanced practice nurse to be self-administered by the client. Medications may only be dispensed by a physician, pharmacist, or registered nurse.
    Public Health Nursing Manual | Local Public Health Agencies | Health & Senior Services
  11. by   Alex Egan
    Quote from psu_213
    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.
  12. by   dudette10
    Quote from MunoRN
    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?
  13. by   dudette10
    Quote from JKL33
    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.

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