Medication administration confusion???

[Mike DBD]

Hello everyone! I am a nurse who is newer to dialysis. I have only been working there for a short period of time, but I am concerned about their medication administration to patients. There is a charge nurse (RN) who is responsible for drawing up all of the medications for the clinic. If there is a LPN, or RN who is running a pod of 4 patients they are expected to administer the medication. I have a few concerns with this process. The charge nurse draws with a syringe from a vial, after drawing from the vial she labels the syringe, with the medication and initials. Once this is completed she drops them off for the other nurses to administer. This goes against my fundamental principles of what I have been taught and practice as a nurse, You don't give medications you do not draw up yourself, and then chart them off! How am I supposed to do my rights of medication administration? I didn't see what was drawn up into that syringe.... I have to rely on the charge nurse to draw the correct medication, and then label it correctly. I am looking for advice, because the manager doesn't care about my concerns. I mentioned it to the charge nurse as well and she agrees with me and about the nursing standard of practice, but she says this is how it works, we're in the real world not the ivory tower. How should I approach this? what should be done?

[JKL33]

MAR note: "Dose prepared by ____________,RN, Charge Nurse."

Both sides are valid, but it's true - there's really no reason to trust pharmacy staff more. Yes, they print out a label - they still have to put the right med in the syringe/put the right label on a syringe with medication in it.

The label placed by the Charge Nurse must contain all of the elements necessary to verify med administration rights.

[Penelope_Pitstop, BSN, RN]

When I worked in the ICU, we would prep Levophed bags for each other and I never thought twice about it...but we did have a huge, obnoxious sticker that we needed to fill out and place on the bag if the medication was prepared by a nurse vs. pharmacy staff. It included all details, including concentration, date, time and name of whomever prepared it. As far as MAR documentation, not sure how that would work as we used eCare for any drips.

[canoehead, BSN, RN]

When pharmacy prepares the med, they are dispensing, and I know RNs are NOT able to dispense meds. I'd have to email the Board on this situation to see if it was legal.

I know that pharmacy has two people to check their work, and education and environment to maximize safety. OP, your situation makes me very uncomfortable. If the RN draws up the med, and you give it, who signs it off? Who takes responsibility for the administration? Does your facility have a policy for med administration that includes one or two people? If you hunt, you might find the policy expressly forbids giving a med you didn't prepare.

Check your policies, and email your professional group. They may have some clear answers for you. In the meantime, email your concerns to your supervisor, so they have been notified in writing that you are uncomfortable, and doing some research. If you have that proof, you'll be in a better position if something goes badly in the meantime.

[MunoRN, RN]

When pharmacy prepares the med, they are dispensing, and I know RNs are NOT able to dispense meds. I'd have to email the Board on this situation to see if it was legal.

I know that pharmacy has two people to check their work, and education and environment to maximize safety. OP, your situation makes me very uncomfortable. If the RN draws up the med, and you give it, who signs it off? Who takes responsibility for the administration? Does your facility have a policy for med administration that includes one or two people? If you hunt, you might find the policy expressly forbids giving a med you didn't prepare.

Check your policies, and email your professional group. They may have some clear answers for you. In the meantime, email your concerns to your supervisor, so they have been notified in writing that you are uncomfortable, and doing some research. If you have that proof, you'll be in a better position if something goes badly in the meantime.

"Dispensing" as a regulatory term is actually different from what the pharmacy does when they prepare a med for use by an RN. "Dispensing" refers to receiving and interpreting a prescription and preparing and labelling it for use by someone not licensed to "administer" a medication. As nurses, we are licensed to administer medications, which means we can legally skip the "dispense" step and instead directly interpret the physicians order and administer the medication without it being "dispensed".

[dudette10, MSN, RN]

This is exactly what happens when the pharmacy sends a pre-filled medication syringe or bag to an inpatient unit. You didn't see the pharmacist draw up the medication either, but do you go to the nurse manager and refuse to give the medications sent from pharmacy? No. You check the label on the syringe with your order and give the med and sign it out. It's not a violation in practice to give a medication that another trained and licensed professional prepared.

Technically, there were two people in the pharmacy who already did a check on it--the pharm tech and the pharmacist. In this scenario, there is no way to do a check. It's completely gone.

Not to mention, NO ONE will let the administering RN off the hook if it was the wrong med. All the rationalizations in the world using a different role with different scope to compare it to will change that.

[dudette10, MSN, RN]

ETA: I find it sad that some of you have so little trust and confidence in your coworkers that you would refuse to administer a medication prepared by one of them.

It's got nothing to do with lack of trust; it has everything to do bypassing the rights of med administration in a system that just doesn't have to be that way.

What is the point of doing it the way they do it? There isn't one!

[dudette10, MSN, RN]

I would agree that having another nurse draw up the med for you to give is adding an unnecessary extra step that is presents an opportunity for error, but I think some are also maybe being a bit irrational in what that risk is compared to other processes that occur prior to administering a med. We're also trusting that the pharmacy tech calculated, measured, and labelled the med correctly. As for charting who drew up the med, every MAR I've ever seen has some way for you to chart who drew up the med. It's certainly not an ideal way to do it, but the sky isn't falling either.

The sky will fall with the first error. You're right about one thing though, it's not the ideal way to do it.

Then why do it that way at all?

Anyway, the "other processes" also have their safety checks.

[dudette10, MSN, RN]

"Dispensing" as a regulatory term is actually different from what the pharmacy does when they prepare a med for use by an RN. "Dispensing" refers to receiving and interpreting a prescription and preparing and labelling it for use by someone not licensed to "administer" a medication. As nurses, we are licensed to administer medications, which means we can legally skip the "dispense" step and instead directly interpret the physicians order and administer the medication without it being "dispensed".

Can you provide a link to where you got this information? The way you have described the word "dispense" hinges on who (RN or patient) will actually be administering the medication, licensed or not and not all the checks that pharmacists do.

I'm not a pharmacist, so I'm not sure if it would be appropriate for me to interpret a physician's order. I have not been trained in med interactions or all the lab values that need to be reviewed or all the indications for a med before being ok with a medication order.

[Alex Egan, LPN, EMT-B]

Ok so the reason this works is because of the setting, and the label system.

On the dialysis unit I worked on the medication labels were printed the night before. They have the patents name, MRN, drug, dose, and then a spot for your initials and the time. A nurse draws them up completing the label. More often then not I would give them myself but if the RN was charging that day I would often pick up the drugs and give them. They are correctly labeled, you know what's in there as well as you do when you get meds from the pharmacy. Which is to say you really don't. You don't know what pill looks like what or what clear liquid in a syringe is REALLY, you trust the label.

The administering nurse walks over to the patent, confirmes the correct patent, checks the order on the chair side charting against the label, administers and documents.

The trick here is that it's dialysis. There are maybe five push drugs routinely given, and maybe the same number of IV infusions. There are no narcotics, so unless you want to divert iron that's not a concern. It's a leagal and well established practice that is done by the one of the big two I worked for in every clinic I worked at.

As far as LPNs, they can practice right up the the limits of the nursing act. I think a lot of folks would be supprised what LPNs can leagaly do. My state is a my not state, so LPNs May do anything not specifically forbidden in the practice act. Facilities may restrict obviously, but unless the law says no, it's leagal.

[AnnieNP, MSN, NP]

I have only given meds drawn up by someone else in an emergency situation. I'm curious to hear what "Bjwojcik" has to say.

[chare]

To those of you saying that you would only give medications drawn by another during an emergency situation, what makes this different? If your concern is that the medication wasn't properly prepared, don't you think that the increased stress and anxiety during an emergency is going to greatly increase the probability that an error will occur?

[Double-Helix, BSN, RN]

Technically, there were two people in the pharmacy who already did a check on it--the pharm tech and the pharmacist. In this scenario, there is no way to do a check. It's completely gone.

Not to mention, NO ONE will let the administering RN off the hook if it was the wrong med. All the rationalizations in the world using a different role with different scope to compare it to will change that.

As was stated earlier in this post, the pharmacist is not directly observing the tech draw up the medication, print out the label, and label the syringe. The pharmacist is verifying the the information on the label and volume in the syringe match the order. The potential that the person preparing the med drew up the wrong drug exists in either scenario.