I have a problem that I neded your opinions on-First, let me say that what I'm about to describe DID NOT happen to me, or in the hospital where I work. I was talking to another nurse who works FT in a nearby hospital, and occasionally with us. At her FT job, she is a Charge Nurse of a med/surg floor days.Last week her floor got a patient who was a DNR.This patient was an elderly lady who's family agreed to comfort care. She was placed on a morphine drip and trans. out of the ICU, to the floor to let nature happen. The pharmacy sent the 50ml bag of NS with 50 ml morphine for a 1ml/hr drip around 1230. The patient got to the MS floor around 1430ish. The patient's family was there. The granddaughter was there, along with her MD boyfriend. I do not know who this MD is (the nurse wouldn't tell me his name), but apparently he is known to that hospitals' staff- I got the impression he might have been employed there at some time, but isn't now???(Loss of privelages??) So- Grandma gets settled in, and the boyfriend/MD approaches her nurse and states "Can we get her a morphine bolus to speed things along?" She directs him to the CN, who immediatly tells him NO, and calls the supervisor to let her know what was said. The boyfriend/MD insists on speaking with the attending MD, who just happens to be inhouse at the time. Again, the boyfriend/MD asks if he can order a bolus to "Hurry things along." The attending calls the CN, asks how the patient is looking- Cn tells him resps are 8/minute and pt. doesn't appear to be in any pain. Attending Doc says OK, keep everything the same, NO BOLUS ordered.The family and Boyfriend are made aware. Approx. 1/2 hr later, the call light goes on- BF says "She needs another IV bag, cause this one is EMPTY"- There should have been at LEAST 40 ml of NS/morphine left in the bag.Supervisor and Attending MD are called, up the hospital chain of command it goes, hospital lawyer gets called in, EVERYONE has to submit an incident report. The CN puts right in hers that she felt the bf/MD did it.Now here is where It gets even worse. The administrators/lawyer orders the pump taken out of the room.It isn't saved for the police. Either is the IV bag. The hospital tells everyone involved that they will handle it internally, and NOT to speak about it.The lady had severe liver damage to begin with, and didn't die for several hours.Am I wrong, or is the hospital trying to cover up a possible attempted murder? Aren't they bound by law to alert the police?? Isn't that "Elder abuse" if nothing else, and a state reportable incident? The pharmacy was contacted and made aware that 40 mgs of morphine is gone.Don't they have to account for controlled drugs? And what about this MD?? I really don't like the idea of someone like that being around patients.Obviously the hospital will try to cover it's own buttocks, but what about the poor nurse who had the patient. Couldn't she get in trouble because 40 mg of morphine is missing? What about the other RNs involved. Couldn't they have problems with their liscenses, ect. if it comes to light that they knew about a possible felony, but never called the police/nursing board ect.? Don't they have a legal responsibility to alert someone about this possible murdering Doc.? I was floored that she didn't seem concerned about those things. She felt that because she reported it to the hospital, she is covered. But if a patient is suspected of being abused and they are child/elderly the nurse HAS TO REPORT IT, even if it turns out not to be true, they are still mandated to report it. How is this ANY different?? What would you have done? I urged her to contact a lawyer-better to be safe than sorry.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Right! Maybe the hospital wants to cover their butt because they know they are in violation of federal law in regards to securing schedule II narcotics.
that was what I was thinking. I know here NO ONE hangs narcs on unsecured lines, ever. And TWO nurses have to verify orders and drip rates, as well as sign when they are initiated. And we also must document every 4 hours the histories on each pump, on each MAR. Cumbersome? yes,but I think THESE are practices that fall into proper guidelines and prevent exactly the sort of situation being discussed in this thread. I am glad we do this the way we do where I work......
MS and Demerol only come in PCA form in my area. If my pharmacy supplied Fentanyl, Ativan, Diprivan, etc in PCA form I would love to use it. Unfortunately they do not. Our only option is to mix these drips in a bag and hang it on a regular pump with a lock button...and in ICU we can watch closely.
Perhaps this will soon become a JCAHO requirement to use PCA setups or closed hard line systems (like epidural pump types) to infuse narcs... probly a good idea. :)
Who will get screwed should said narcs go unaccounted for or someone dies???? And who is keeping track of how much is used and how???? This is very poor practice, and I doubt JCAHO would like this one....
No one has ever died because we hang our narcs the way we do. Our patients are constantly monitored. An RN is literally at the bedside/in the room 24/7 and that's probably why JCAHO is okay with this.
Per JCAHO standards, we also have 2 RNs check and document the drip when we hang this high alert med. When a new drip is started, we take the amount in the bag (typically 100ml), subtract what it takes to prime the tubing (usually 16ml) and enter the volume to be infused (84 ml for a new drip) into the pump. At change of shift we document the remaining volume to be infused. So say a patient was getting fentanyl at 100mcg/hr. The concentration of the bag is 50mcg/ml. At the end of a twelve hour shift, the volume remaining will be documented as 60ml (84ml at the beginning minus 24mls used during the 12 hour shift). Again two nurses verify this.
Also per JCAHO standards, we change our bags q 24 hours. A bag rarely runs out before the 24 hours is up. So in the above example, if the drip was hung at 0200 on 12/4, at 0200 on 12/5 the bag will be changed, the remaining volume wasted (in this case 36ml witnessed by 2 RNs) and a new bag hung. When the new bag is hung, the volume to be infused is entered as 100ml (the total in the bag because new tubing does not need to be primed). So at shift change after 12 more hours, the volume left for the nurse coming on will be documented as 76ml.
If a bolus is given from a bag, we subtract the # of mls used for the bolus from the VTBI on the pump. We document the bolus on our prn meds.
So while it's not perfect (and actually I hate the way we keep count of our narc drips), it meets JCAHO standards and we've been doing it this way for years and years.
I'll also add that our charting is computerized. So if we stop the drip for whatever reason or temporarily, we do not chart that it's been given. The pharmacy can track what's been given by looking at the totals in our charting.
This is what I don't like, because there certainly is room for abuse there. But I would NEVER think that any of our nurses would do that. Maybe I'm naive, I dunno, nobody I work with strikes me as being that stupid.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
As I did not realize ANYONE ran narc drips on any unsecured pump. Now, where you work, an RN or other qualified person watch said drip constantly? Narcs are locked up for a reason! Also do your pumps keep histories on patient use/attempts? I cant' understand why any place runs narcs on any pump that is not locked up like a PCA. It's really risky practice.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
I'll also add that our charting is computerized. So if we stop the drip for whatever reason or temporarily, we do not chart that it's been given. The pharmacy can track what's been given by looking at the totals in our charting.
This is what I don't like, because there certainly is room for abuse there. But I would NEVER think that any of our nurses would do that. Maybe I'm naive, I dunno, nobody I work with strikes me as being that stupid.
never say never. i worked with nurse doing just that with morphine and demerol being her drugs of choice...we were all shocked, to say the least as she was "such a good person who did not seem stupid enough"
...hence our double signature requirement and q 4 h history documentation!!!!!!
OP could not really do much except to ask the nurse involved to report,,,,she is getting her info third-hand and she doesn't know the particulars,,ie date..name of md/bf..or the name of patient..
this can be a lesson learned and suggestions can be made to her facility so that proper precautions can be installed if they are not already
Now, where you work, an RN or other qualified person watch said drip constantly?
Like I said, an RN is continuously at the bedside - 24/7. So I guess the answer is yes, someone is always there to "watch" the drip.
Also do your pumps keep histories on patient use/attempts?
Remember that a drip is a med that runs continuously. Kinda like a basal rate on a PCA. There aren't any "attempts" made by the patient as there is with PCAs.
Where I work we use PCA pumps for all CII inufsions c every 2 hour documentation of pain level, sedation level, pump settings, syringe volume, demands, injections. Any bolus' are documented on the same flowsheet so every cc is accounted for. Any time the PCA is opened there must be 2 RN's present. That includes changing settings, bolus, or clearing the pump at the end of the shift. A nurse is not allowed the PCA key without another RN present and then the key is placed back into a secure location. In our case back to the Pxyis.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Like I said, an RN is continuously at the bedside - 24/7. So I guess the answer is yes, someone is always there to "watch" the drip.
Remember that a drip is a med that runs continuously. Kinda like a basal rate on a PCA. There aren't any "attempts" made by the patient as there is with PCAs.
Ok I missed that, I am sorry. That constant bedside presence is rare as most of us are never staffed for such a thing.At any one given time, we may have 5 or 6 (or more) post ops on our OB/GYN floor, in addition to laboring woman and post-partum couplets-----so you can see how unrealistic it would be to be at the bedside at all times, let alone find coverage for bathroom or food breaks. Your place must have incredible staffing. Bravo! That is a rare things these days in the "do more with less" environment in which most nurses practice. :)
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Yes, this is the trouble with Morphine drips infusing outside a PCA...it is easily tampered with...particularly by a healthcare worker with access to a syringe.I have had family members attempt to tamper with narcotic infusions before...
So this might be a theft situation vs a mercy killing or whatever. sounds like baby doc was either playing God or had a habit.
yes that lack of real accountability is what concerns and sidelines me here. Sorry to have hijacked the thread regarding PCA use in narc drips.....I just see the staff potentially getting hung out to dry on this one, without a leg to stand on.
Ok I missed that, I am sorry. That constant bedside presence is rare as most of us are never staffed for such a thing.
Bravo! For sure. We do have great staffing...it's a great place to practice nursing. Our unit is unique in the way it is set up. It enables each nurse to be bedside (in the room) 24/7. ANd it is an ICU, quite a different beast from OB/GYN.
The boyfriend/MD insists on speaking with the attending MD, who just happens to be inhouse at the time. Again, the boyfriend/MD asks if he can order a bolus to "Hurry things along." The attending calls the CN, asks how the patient is looking- Cn tells him resps are 8/minute and pt. doesn't appear to be in any pain. Attending Doc says OK, keep everything the same, NO BOLUS ordered.The family and Boyfriend are made aware. Approx. 1/2 hr later, the call light goes on- BF says "She needs another IV bag, cause this one is EMPTY"- There should have been at LEAST 40 ml of NS/morphine left in the bag.Supervisor and Attending MD are called, up the hospital chain of command it goes, hospital lawyer gets called in, EVERYONE has to submit an incident report. The CN puts right in hers that she felt the bf/MD did it.Now here is where It gets even worse. The administrators/lawyer orders the pump taken out of the room.It isn't saved for the police. Either is the IV bag. The hospital tells everyone involved that they will handle it internally, and NOT to speak about it.The lady had severe liver damage to begin with, and didn't die for several hours.Am I wrong, or is the hospital trying to cover up a possible attempted murder? Aren't they bound by law to alert the police?? Isn't that "Elder abuse" if nothing else, and a state reportable incident? The pharmacy was contacted and made aware that 40 mgs of morphine is gone.Don't they have to account for controlled drugs? 
And what about this MD?? I really don't like the idea of someone like that being around patients.Obviously the hospital will try to cover it's own buttocks, but what about the poor nurse who had the patient. Couldn't she get in trouble because 40 mg of morphine is missing? What about the other RNs involved. Couldn't they have problems with their liscenses, ect. if it comes to light that they knew about a possible felony, but never called the police/nursing board ect.? Don't they have a legal responsibility to alert someone about this possible murdering Doc.? I was floored that she didn't seem concerned about those things. She felt that because she reported it to the hospital, she is covered. But if a patient is suspected of being abused and they are child/elderly the nurse HAS TO REPORT IT, even if it turns out not to be true, they are still mandated to report it. How is this ANY different?? What would you have done? I urged her to contact a lawyer-better to be safe than sorry.
SmilingBluEyes
20,964 Posts
that was what I was thinking. I know here NO ONE hangs narcs on unsecured lines, ever. And TWO nurses have to verify orders and drip rates, as well as sign when they are initiated. And we also must document every 4 hours the histories on each pump, on each MAR. Cumbersome? yes,but I think THESE are practices that fall into proper guidelines and prevent exactly the sort of situation being discussed in this thread. I am glad we do this the way we do where I work......