What do you think of this Ambien order?

Nurses General Nursing

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I could I also title this "Did I make a med error?" :)

I have a new skilled res with an Ambien order that reads: Ambien 5 mg po Take 1-2 tabs at HS prn

Twice in the last few weeks, I have given her one Ambien at about 2200 and then have found her still awake at around 2400 so I would give the second Ambien. I would never repeat the dose if she had been sleeping for a few or several hours. I mean how do you know if you need one or two Ambien when you're trying to get to sleep? Anyway, the day nurse threw a fit saying that I'd made a med error and now I"m just waiting to hear what the skilled supervisor thinks. The order is now going to be clarified so that it won't be an issue in the future but I'm interested to hear what you all think of this.... Do you think I made a mistake?

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I can see why she thinks it is a med error, which is why my hospital does not allow orders like that. However, you stayed within the parameters of the order in my opinion.

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Specializes in Peds, PACU, ICU, ER, OB, MED-Surg,.

I don't think you made an error. If it was prescribed to me personally the way it is written, I would take one and if I had not gone to sleep would take the second. On what grounds does the day shift think you made an error?

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Specializes in Family Nurse Practitioner.

The order is flawed and I would have gotten clarification but no I don't think you made a med error. I give 10mg all the time so that wouldn't have raised any red flags. I'm surprised the day nurse would be nasty about this even though I think she is correct in wanting clarification. :confused:

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Specializes in Oncology.

I do not think you made an error.

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You were technically within the parameters of the poorly written order.

Should have had a clause of, give 1 and if not effective in 1 hr give another 5 mg. Or something to that effect.

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Specializes in Geriatrics.

Definately not a med error. Our Dr often orders pain meds like this, this way the patient can take 1 and if it works great, if not then they can have another. Of course if the pain med is Q4hrs, the 4hrs part starts when the second pill is given, and the second pill has to be given 1 hour after the first one, this way they can not be requesting a pain med every 2 hours.

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Thanks for the input! I agree that it is a poorly written order that I should have had clarified from the beginning but I'm relieved to hear that you don't think its an error. This particular day nurse seems to be one who is always trying to catch the overnight nurses doing something wrong (superiority complex maybe?) Anyway, thanks again for the input!

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Specializes in PACU, CARDIAC ICU, TRAUMA, SICU, LTC.

The way the order is written is not an acceptable order in the state where I work. It must be written as "Ambien 5 mgm po qhs prn. May repeat x1 before 1 a.m. (or may repeat in 1 hour)." By giving the patient Ambien 10 mgm upfront (if you had done so), you are, in, essence, outside the scope of nursing practice because you have arbitrarily made the decision of how much Ambien to give. Therefore, you are considered to be "prescribing" medication. When you repeat the medication after giving the 1st dose, you have made this decision based on your nursing assessment. Don't forget to document your assessment!

Years ago, it was standard practice to have orders such as this: Morphine 5-8 mgm sc q 3 hrs prn pain. Now the order has to be written using the pain scale:

Morphine 5 mgm pain 4-5, etc.. It is not within the scope of nursing practice to decide the dosage arbitrarily. This has been mandated by the state Dept. of Public Health and the Nursing Board of Examiners.

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Not a med error.

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The way the order is written is not an acceptable order in the state where I work. It must be written as "Ambien 5 mgm po qhs prn. May repeat x1 before 1 a.m. (or may repeat in 1 hour)." By giving the patient Ambien 10 mgm upfront (if you had done so), you are, in, essence, outside the scope of nursing practice because you have arbitrarily made the decision of how much Ambien to give. Therefore, you are considered to be "prescribing" medication. When you repeat the medication after giving the 1st dose, you have made this decision based on your nursing assessment. Don't forget to document your assessment!

Years ago, it was standard practice to have orders such as this: Morphine 5-8 mgm sc q 3 hrs prn pain. Now the order has to be written using the pain scale:

Morphine 5 mgm pain 4-5, etc.. It is not within the scope of nursing practice to decide the dosage arbitrarily. This has been mandated by the state Dept. of Public Health and the Nursing Board of Examiners.

FWIW your state is obv different than others. I've seen people w/ debilitating injuries rate their pain as a 5/10, while others that have a scraped knee in for obs state their boo boo is a 10/10. No matter how much education you give, they will continually state that this is their pain level. This being said, the order written as "for pain scale of 'blah' to 'blah'" is a flawed way of administering meds. In our state we still write, "PRN-pain" (all that is legally needed for written orders in my state). We alternatively will see "PRN-severe pain" / "PRN-mild pain".

As far as the "if you give the full dose you're technically "prescribing", ... not really. The physician has deemed that the patients injuries are severe enough to have an upper limit of "x"mg in a given time period. I'm not saying you should be giving a 10mg morphine dose to a narcotic naive patient, but if you walk in and a patient is screaming / crawling out of their skin, tears are flowing, and vitals are elevated, you might need more oomph than the lower 2mg limit. What I'm saying is YOU are not prescribing what the patient is getting. You may have written the verbal order, yes, but that was after speaking w/ the prescriber and obtaining their expertise and verbal order in the first place.

Finally, to the OP, technically the way the order was written in MY experience would have been giving 1 tab at HS and if that didn't work the next night increase it. This is the way the order was interpreted in my mind... It doesn't give the option of giving a second dose later on. It says to give one to two tabs at HS not another tab in 4 hrs if not effective. This said, I would not think twice about them saying you made a med error, because of the way the doc wrote the order, technically they obtained a total of 10mg dose in a night's span, which was the original intent of the order.

Also, FWIW someone else said something about an order (ex: Oxy IR 5-10mg Q4), if they only took one, found ineffective, and took another in 2hrs that the 4hr window would start after the second dose? That's a bit harsh... If you think about what you're technically doing, say they waited two hours to take the second tab. You're effectively only letting them take 10mg in a 6hr window by doing this. If a patient's desire is to get 5mg now and 5mg in two hours, wouldn't this be allowed? If you think logistically they're not receiving more than 10mg in any rolling 4hr window, which is what the order states "Q4h". Food for thought.

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Hi IowaLPN,

Just by looking at the way it was written, you had 2 choices, either 1 pill or 2 pills at HS. If your hospital's HS time is 2200, then that is when she receives her medication. If by 2400, she is still not asleep, then the doctor needs to be called for a new order. The doctor did not set any parameters for this medication. Just my opinion...from a nursery LVN.

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