Med error and Pyxis

[Michnurse1]

I'm a new nurse two months into orientation. I've been bounced around between preceptors and am starting to worry about my Pyxis history.

I was told multiple times if you pull non narcotic meds from the Pyxis and the patient doesn't take them or refuses them and they are unopened you can simply put them in the return bin outside of the Pyxis. A month later I'm told by another nurse that you must sign into Pyxis say you're returning the Med and then dispense into the return bin. I'm worried that this will show as Med discrepancies although they aren't meds that need to be witness wastes for example Tylenol, stool softeners etc - since the pyxis shows the Med was pulled but it was never given. If it was a scheduled Med I always document that the patient refused or whatever the case was. Is this an issue or am I over thinking the situation?

[JKL33]

I will assume you don't have an internal med return bin/pocket in your machine... (?)

I think the second nurse's instruction keeps things a bit cleaner; that's the way I would do it. I would want the med credited back to the patient account, and I would want the pyxis record to show it was returned. If for some reason your return bin (which sounds external) is not secured, I would pursue the idea through unit councils, etc. I would never return CSs in an unsecured manner, and always return them via your machine (create a pyxis record of the return).

You are correct to document additional info in the medical record as well as creating a pyxis record for your returns.

To assuage your worries, simply talk to your manager and explain that you've been told two different methods of returning meds that aren't controlled substances, and ask which way is correct. If you are told that it should be done the second way, ask what you are to do about the meds that have previously been wasted according to the first instructions you received. There's no need to sit and worry about stuff like this - just have conversations (go to an authoritative source with questions).

Does that help clear things up?

[chare]

JKL33 said:

I will assume you don't have an internal med return bin/pocket in your machine... (?)

We use an external return bin as well. It has a drop area similar to a mailbox. We open the lid to reveal a drop area that is completely enclosed in the bottom similar to an letter drop in the post office. We drop the medication into the receptacle and lose the lid, allowing the medication to drop into the locked container. We return all medications in the Pyxis prior to placing them placing them in the bin. If it is a controlled substance a return slip prints, which we place in a bag with the medication.

This came about, at least in NC, as a result of a recent board of pharmacy ruling that returning it to the Pyxis was considered restocking, which is not in an RN"s scope of practice.

JKL33 said:

...There's no need to sit and worry about stuff like this - just have conversations (go to an authoritative source with questions).

I agree with this. I might add that I generally try and conduct this type discussion via my work email, and BCC myself to my private email. Doing so creates documents the discussion and creates a record, which can be helpful if questions arise in the future.

Best wishes.

[Kallie3006, ADN]

We return ours under the patient, to credit them in the pyxis, and place them in an external bin that sounds the same as chare's return bin. We also go and waste all meds under the patient in the pyxis as well (all meds; example pt has 10 mg atorvastatin and dispensed is a 20mg tab)

[JKL33]

Thanks for the info - I just wanted to make sure what we were talking about. Some machines have a secured internal return bin within one of the large drawers - you can return CS or other smaller meds (tabs/caps/vials, etc) via a one-way deposit mechanism and can't get them back out; pharmacy still has to retrieve meds returned to this internal bin and officially restock them. IME, there is usually also an external bin such as the one you describe because not all items will fit into the internal return bin mechanism. But I've also seen just an open plastic basket/bin used for returning medications (non-CS) - thankfully it's been a while since I've seen that. Regardless of return method I still use the machine interface/program to indicate that the med is being returned.

[psu_213, BSN, RN]

Everywhere I have worked, unopened meds are returned to the Pyxis under the pt's name. If the packaging is opening, it is wasted under the pt's name (not witness required if not a controlled med), and the med is disposed of per policy (trash, sink, wasted med bin). I did work one place that had a mailbox style bin for wasted/unused meds. The med still had to be wasted in the Pyxis. Either way, ask you manager about the correct policy. I like the idea of doing by email to keep a "paper" trail.

[mtmkjr, BSN]

chare said:

We use an external return bin as well. It has a drop area similar to a mail box. We open the lid to reveal a drop area that is completely enclosed in the bottom similar to an letter drop in the post office. We drop the medication into the receptacle and lose the lid, allowing the medication to drop into the locked container. We return all medications in the Pyxis prior to placing them placing them in the bin. If it is a controlled substance a return slip prints, which we place in a bag with the medication.

This came about, at least in NC, as a result of a recent board of pharmacy ruling that returning it to the Pyxis was considered restocking, which is not in an RN"s scope of practice.

I agree with this. I might add that I generally try and conduct this type discussion via my work email, and BCC myself to my private email. Doing so creates documents the discussion and creates a record, which can be helpful if questions arise in the future.

Best wishes.

That's interesting... I guess we didn't get the memo yet.

We return non-scheduled meds to the Pyxis back to the original cubby where it was dispensed from, scanning both the unopened pill and the cubby. Scheduled meds are returned within the Pyxis to a box with a swing door cutting off access once it is dropped in.

We do not have an external bin. All meds are returned only after logging in.

Exception: Open non-scheduled meds are just discarded in the gray bins for that purpose.

[chare]

mtmkjr said:

That's interesting... I guess we didn't get the memo yet.

rules.3400.pdf

Quote

(d) Medication Reuse. Any drug that has been removed from the automated medication system shall not be replaced

into the system unless:

(1) the drug's purity, packaging, and labeling have been examined according to policies and procedures established by the pharmacist-manager to determine that reuse of the drug is appropriate; or (2) specific drugs, such as multi-dose vials, have been exempted by the Multidisciplinary Committee.

[OyWithThePoodles, RN]

For non-controlleds we go under the patients name in the Pyxis and hit that we are returning, then it goes to an external bin sitting on the counter for pharmacy to restock.

Some will say you don't have to return under the pyxis, just to put the med in the bin, which I guess technically you can, but I like to show that I am returning it and not going home with a pocket full of miralax

[kataraang, BSN]

***Always check policy, asking a manager would be a good idea. Proper practice vs. what actually happens varies.

But in my experience, there are times where I don't return to the pyxis..Like if a patient decides after I have opened the med that they won't take it. There's also no way to document that I dropped a med on the floor. And I have on very rare occasion came home to find a senna in my pocket. Obviously with controlled substances you must always return through Pyxis with a witness.

[JKL33]

kataraang said:

But in my experience, there are times where I don't return to the pyxis..Like if a patient decides after I have opened the med that they won't take it. There's also no way to document that I dropped a med on the floor.

What is the reason that you are not able to use the waste function in both of these (and all similar) instances?

Based on accounts written here and my personal observations of general attitudes of recent, I would strongly advise figuring out how you can account for your actions with every single med you handle, not just controlled substances. For example, I have personally been present in large meetings where staff was told/reminded that since "diversion" encompasses stealing, it is not just about controlled substances, but about any med, since these are the employer's property. Regardless of my own personal feelings or beliefs about whether something is reasonable or not, I listen when people say stuff like that.

My actions with every single med I handle are documented in one place or another. I also document a name of who witnessed what in the eMAR (in addition to using the MDC waste/witness function).

If a patient refuses an opened/prepared med or drops their pill on the floor, I will document that in an eMAR note as well as going back to the MDC to record the waste.

[Golden_RN, MSN]

Check with your pharmacy about what your facility's policy is.