Med error?

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I have a question regarding pain meds. Let's say you have a patient with kidney stones that it awaiting surgery, until then you are keeping them comfortable with pain meds. Ordered meds are norco 10mg q4 prn for moderate pain and dilaudid 0.5mg q2 prn for severe pain. Pt is a large built male, tolerating meds without issue except always has a pain level of 8. Has been in hospital for a day, dilaudid is given for initial pain of 8 and norco is given at the same time for when the dilaudid wears off. Nurse A says this administration method is ok bc the dilaudid acts in about 15 minutes and wears off in about 45 minutes to an hour, and the norco doesnt start to work for about 45 minutes to an hour. Nurse B says this is incorrect and the norco must be given first and dilaudid given 45 minutes to 1 hr after. Nurse A believes Nurse B is incorrect because both meds would be kicking in at the same time with Bs administration method. What do you all think? Note: patients pain is more controlled with As admin schedule vs Bs.

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Specializes in Clinical Leadership, Staff Development, Education.

I would administer by pain rating and WHO ladder. If pain level 8 and dilaudid given, reassess 30 to 1 hour later. If patient still with unacceptable pain level, administer Norco. Recheck pain level 1 hour and go from there. I would not use both at same time- risk of oversedation.

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One way or another technically these orders are not working for this patient (assuming "8" is considered "severe pain"), since it doesn't say "give norco for when the dilaudid wears off," it says to give it for moderate pain, and he's really never reporting moderate pain. Phrasing like that boxes us in, and ever since admins have decided to become downright hateful about what RNs do with narcotics, I follow these things to the letter. I would contact the physician and get the type of orders needed to serve the patient. I have a very low threshold for speaking with providers, even if it's to discuss technicalities or interpretations. I just will not accept any risk of someone saying I didn't handle/administer narcotics the way I was supposed to.

If it is desired that this patient receive both the norco and the dilaudid pretty much ATC, then the order needs to be phrased such that he gets the norco 10 q 4* and the dilaudid for "breakthrough pain" or for reports of severe pain despite norco. Or something to that effect. Bottom line, the order has to say what I'm expected to do.

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One thing I know for sure, kidney stones are painful as F.

If the patient has no hx of tolerance to pain meds./narcotics, please provide them the appropriate dose.

A pain level of 8 is usually considered as severe so give them what is appropriate and you being a deligent and prudent nurse will be and should be assessing the pt's v/s, s&s (subjective and objective) and pain medication effectiveness before and/or after med. administration.

However, if you do have a policy about pain medication administration, probable but highly improbable, follow that or simply follow the attending doctor's parameters or orders.

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Both nurses are incorrect. At least where I work you can't give two pain medications at the same time unless one is scheduled and the other is as needed. The other thing is that you technically can't give the Norco unless the patient is reporting moderate pain (usually 4-6) according to this doctor's order. So the proper action is to give the Dilaudid (assuming it hasn't been given in the last 2 hours) and reassess pain in 30 minutes. Then you could administer the Norco if the patient is reporting pain 4-6.

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Specializes in Travel, Home Health, Med-Surg.
lrobinson5 said:
Both nurses are incorrect. At least where I work you can't give two pain medications at the same time unless one is scheduled and the other is as needed. The other thing is that you technically can't give the Norco unless the patient is reporting moderate pain (usually 4-6) according to this doctor's order. So the proper action is to give the Dilaudid (assuming it hasn't been given in the last 2 hours) and reassess pain in 30 minutes. Then you could administer the Norco if the patient is reporting pain 4-6.

...depending on hospital policy, ours was that no narcs could be given within 1 hr of each other.

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Specializes in Travel, Home Health, Med-Surg.
JKL33 said:
One way or another technically these orders are not working for this patient (assuming "8" is considered "severe pain"), since it doesn't say "give norco for when the dilaudid wears off," it says to give it for moderate pain, and he's really never reporting moderate pain. Phrasing like that boxes us in, and ever since admins have decided to become downright hateful about what RNs do with narcotics, I follow these things to the letter. I would contact the physician and get the type of orders needed to serve the patient. I have a very low threshold for speaking with providers, even if it's to discuss technicalities or interpretations. I just will not accept any risk of someone saying I didn't handle/administer narcotics the way I was supposed to.

If it is desired that this patient receive both the norco and the dilaudid pretty much ATC, then the order needs to be phrased such that he gets the norco 10 q 4* and the dilaudid for "breakthrough pain" or for reports of severe pain despite norco. Or something to that effect. Bottom line, the order has to say what I'm expected to do.

Agree, but miss the good ole days when nurses were able to use nursing judgement to provide the best care/pain relief

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Just curious, OP... you titled this post "Med Error".

Was there an actual med error written up for either A or B?

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No! Just wondering if it's technically a med error. It's hard when doctors wont give anything else for pain. Sometimes you have to work with what you've got, but the gray area makes it difficult.

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Daisy4RN said:
...depending on hospital policy, ours was that no narcs could be given within 1 hr of each other.

You are right! I am thinking under my current hospital's rules, but another hospital I worked for had the hour rule.

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TraumaQueenRN4 said:
No! Just wondering if it's technically a med error. It's hard when doctors wont give anything else for pain. Sometimes you have to work with what you've got, but the gray area makes it difficult.

Technically, someone could cause trouble over it for the reasons already described above. There's really no gray area the way these orders are written.

Facility policies aside for the moment, the only way the order written in the OP can be done technically correctly is to administer the dilaudid q2* if the patient always reports 8/10 pain.

That's what the orders say.

The best action is to explain to the physician the limitations of the orders as written and ask for some kind of compromise/alternate order. They don't even need to order something more, they just need to rephrase in order to allow both medications to be administered - if that's their intention. It may not be their intention.

Your best bet is to communicate your concerns, document having done so along with the physician responses - in a neutral fashion - and document the observable signs of pain along with the patient's reports. You make your judgments about how much to push the physician based on your overall assessments.

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The pain management example from a surgeon perhaps can help your question.

https://orthosports.com.au/handouts/pain-management/

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