Is this SOP for hospital pharmacies? Convuluted story but ...

[qaqueen]

In three years of nursing, this is the first time I have seen this. Our facility uses IV pumps that are programmed with medication guardrails to improve pt safety.

I was setting up a medication for a very ill pt. For this med, the IV pump required that I enter the amount of the medication, the amount of diluent, and the pts weight. Upon entering the data, the IV pump immediately flagged that the dosage was above the safety guardrails.

Being a reasonable nurse (?), I stopped and called the pharmacy. The pharmacist stated that she "would not give a dose above the guardrail". I asked her why pharmacy prepared the excessive dose for the pt when the order was written for 5mg/kg. She said that the doctor had written for an amount, and pharmacy had rounded up to an even number. At this point my patience was getting a bit thin. I asked why the the amount entered on the eMAR (by pharmacy) exceeded the safe dose, she replied "we entered the amount that is in the bag on the eMAR".

Significantly, this pt had lost over 5kg since admission. The pt was weighed daily and the weight entered into EHR. The pharmacist indicated that yes, she saw his current weight.

(Mind you, this is a pharmacist, not a new tech. Prior to this conversation, I always believed that pharmacists were more astute than doctors about medications.)

The conversation went on for a couple of minutes, both of us getting testy.

Me: Are you saying that I should reduce the dosage based on the pts weight?

Her: No, the dose on the eMAR is what you are supposed to administer.

Me: But, you told me that you would not exceed the med guardrails for this particular med.

Her: Yeah, that is a pretty nasty drug.

Me: I'll just call the doctor.

Prior to reaching the doctor, I spoke to a nurse who had administered this medicaiton to this pt earlier in the week.

Me: Did you get a guardrail flag for this?

Her: Yep, I just bypassed it.

Big help there.

When I finally reached the doc (dose is now hours late), doc says, "what is the correct dose" (glad I did the math before he called back). I give him the number, he says, "why did pharmacy make too much?" Uhhhh.... I ask him how he would like this handled, he says give the appropriate, calculated dose and dispose of the rest.

So after all that, my question is, Does your pharmacy dose wt based medications based on the pts current weight, the pts admission weight, or just make a rounded number dose for convenience?

Thanks for your feedback

[KelRN215, BSN, RN]

This is how it was when I worked in the hospital. Weight was documented on admission and that weight became the "weight for calculation", which is what was used for medication dosing. If the patient had surgery and then was slow to recover and lost weight/ended up on NG feeds or what have you, they'd likely be getting daily weights. Where you documented the daily weight was different than where you documented the "weight for calculation" and only the nurse could document the weight for calculation. So if your CNA documented a weight and the child had lost a few kg, unless the nurse remembered to go back in and click the 18 buttons it took to get to the "weight for calculation", that weight never got updated. The system waited 30 days before it prompted you for an updated weight. Even if you updated it, you couldn't guarantee that that's the weight the doctors were using when they did their calculations because they had excel spread sheets that they used for sign-out and they never changed the basic information on it. If a 5 month old had a 3 month long admission, their notes would still say "5 months old" on them because they just copied and pasted everything- a bad system all around. The weight flagged in the computer was what pharmacy and nursing based their calculations on but, again, the system didn't automatically update the med calc weight every time the patient was weighed. That was brought to administration's attention and the people who worked with the computer system multiple times. Guess what changed? Right, nothing.

[morte, LPN, LVN]

Maybe a nice, professional letter to risk management?