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]

I'm trying to think back a few years here...I don't think I've actually ever been taught not to administer a properly labeled medication prepared by another RN.

What we were taught was not to take "a syringe" that someone else prepared and push it - the (usually stated but possibly unstated) implication of this instruction was that we don't know what's in such a syringe because we didn't prepare it ourselves and it has no label. Over time and with poor understanding, this has morphed into the instructions we are seeing on this thread, but the bottom line is that this has always been about the label. The label is the key - that's why, without one, pushing medications that we ourselves pre-drew can easily become dangerous, too.

The more I think about this, it's nonsensical that students are being taught to not administer a properly-labeled medication for which the patient has an order simply because it was prepared by another RN. How does that make sense? That would also have to mean that the nurse can't administer a medication s/he pre-drew and properly labeled him/herself. Either it is in an RN's scope of practice to read an order, draw up a medication and label it, or it isn't. If you're going to say that pharmacy must prepare all medications that you don't prepare yourself, then you should be saying that pharmacy must prepare all medications because no RN (including yourself) should be doing so.

There just isn't something magic about the way a pharmacy tech or pharmacist puts on a label compared to the way a nurse does it (as far as the basic duties that must be performed).

This "never administer a medication prepared by another RN" sounds like something where, over time 1) The original admonition has been twisted and 2) the personal preferences of individual RNs have been passed on to the point where it is being taught as a rule.

[AnnieNP, MSN, NP]

For me I was referring to code situations in the ER (and this goes back 10 years!!!!). I am now in private practice and hope to never need emergency drugs in my office...

[dudette10, MSN, RN]

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?

I can't believe I have to explain this.

It's a benefit to harm ratio. All hands on deck for a true emergency where speed may be the difference between life and death. In those situations, we take verbal orders without protesting--even if it's against policy and procedure--or just anticipate what needs to be done and do it.

In situations where there is no emergency and no real reason to bypass safety checks, the benefit to harm ratio shifts.

[Have Nurse, ADN, 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.

I would have to disagree with this post, with kindness. The Pharmacist is a specialist in Pharmacology. While the nurse has had Pharmacology in training, it isn't the same the extensiveness as what the Pharmacist is required to do.

I would bring this unsafe practice to the Medical Director and the Board of Nursing. It wouldn't be the first time an organization was making serious mistakes.

You have a license to protect. If they insist that the Charge RN draw up the meds, then she needs to be the one to sign off and give them, not you.

[Have Nurse, ADN, RN]

I agree with smf. I was taught never to give a med prepared by another nurse.

Absolutely right.

[dudette10, MSN, RN]

I don't know why the disagreement about this is so annoying to me. Let's lay out all the potential for error by taking step-by-step the safety check bypass.

Five rights: right patient, right med, right dose, right route, right time. Transcription error.

If the Charge RN draws up the med, right time cannot be checked. The charge RN labels the syringe, introducing the possibility of transcription error. The administering RN cannot verify right med or right dose and, by extension, right patient.

And the question is why take the risk? There is no benefit to this method.

[Julius Seizure]

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.

Have you never gone to the Pyxis/Omnicell/Accu-dose and removed a tablet of some kind of medication to administer to your patient? Where was the pharmacy check there?

It was when they checked that they med and dose was appropriate and put in on the patients MAR for you to check when you pulled the med. The pharmacist doesn't have to come pull the med and hand it to you personally.

[dudette10, MSN, RN]

Have you never gone to the Pyxis/Omnicell/Accu-dose and removed a tablet of some kind of medication to administer to your patient? Where was the pharmacy check there?

It was when they checked that they med and dose was appropriate and put in on the patients MAR for you to check when you pulled the med. The pharmacist doesn't have to come pull the med and hand it to you personally.

Huh?

The pharmacy check is when the pharmacist signed off on the provider order by reviewing the indication, dosing, interactions, etc. for the med to show up on my patient's med profile. I think we agree on that.

MunoRN said "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"."

She seemed to imply that we can just see the order then go override the Pyxis and pull the med and administer without any consequences. That's just not true.

[JKL33]

I don't know why the disagreement about this is so annoying to me. Let's lay out all the potential for error by taking step-by-step the safety check bypass.

Five rights: right patient, right med, right dose, right route, right time. Transcription error.

If the Charge RN draws up the med, right time cannot be checked. The charge RN labels the syringe, introducing the possibility of transcription error. The administering RN cannot verify right med or right dose and, by extension, right patient.

And the question is why take the risk? There is no benefit to this method.

Your concern about transcription error is equivalent to any other type of mislabeling error.

In lots of situations where RNs routinely have to prepare doses of medications, the unit has syringe labels printed for the ones used most frequently. You complete the label and apply it to the syringe that has the appropriate medication in it. Some version of the essential elements of this process is done by everyone everywhere who prepares meds in a syringe for a particular patient.

If the Charge RN draws up the med, right time cannot be checked

How is that? It's either time to give it, or it isn't. The date and time prepared will be on the label prepared by the CN/RN/Pharmacist/Pharm Tech/Etc. If you're saying that the preparer can't guarantee that it will be given at the right time because s/he is not the one who will be administering it, well that is true of every dispensation on pharmacy's part.

How are you verifying the right anything by what pharmacy sends you? If you don't watch them prepare it, then you are utilizing an element of trust in their labeling procedure that you're simply not acknowledging here.

Not trying to make this any more perturbing. It's just that you haven't actually demonstrated a difference in the inclusion of essential elements between these two processes. When done correctly, everything is in order. When not, they're not - but this process not being done correctly does not involve errors that can only be made by RNs, nor that can only be made in this type of scenario.

Charge nurse:

Verifies order for X patient. The order is complete and appropriate to the situation.

Draws up the correct dose of correct medication as indicated by the order, using appropriate technique.

Applies correct label to medication with all elements needed for 2nd check at bedside.

Delivers medication to the correct patient station.

If you have a problem with any of the first (3) of these ^, then you have a problem with any RN drawing up/preparing any medication anywhere, ever, including ones someone would draw up to administer to their own patient.

[JKL33]

She seemed to imply that we can just see the order then go override the Pyxis and pull the med and administer without any consequences. That's just not true.

That actually depends entirely on where one works (unit) combined with policies in effect for that unit. It may not even involve an override...

[psu_213, BSN, RN]

I see both sides of this. On one hand we trust coworkers. I don't go back and recheck all the normal BPs that a tech got. I trust that the antibiotic that was mixed in the pharmacy was the correct med in the correct diluent. I trust the blood was drawn on the correct patient and the correct patient labels were applied. I treat (or do nothing) based on all these actions by others that I trust.

OTOH, I have worked with nurses who I thought were good nurses--yet I've seen "good" nurses throw fellow staff under the bus even though it was clearly that nurses fault. In other words, even if I generally trusted this nurse, I'm not sure I could trust that nurse enough to push a med that he/she pulled up while away from me.

I've never been a dialysis nurse, so I'm unsure of the exact workflow. Would it be unreasonable to bring the unaccessed vial of medicine to the bedside and pull it up in the presence of that nurse who will be pushing it? Could the charge pull the med from the Pyxis and bring the vial, syringe, needle/access device, etc., and the bedside nurse could then pull it up? I would definitely prefer to do either of these than push a med pulled up by another nurse.

[MunoRN, RN]

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.

If there's no reason to do it this way then you're right, it shouldn't be done that way given the additional potential for error.

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.

You're not sure if registered nurses can interpret a physican's order and administer a medication? I feel like I must not be understanding you correctly.

It's certainly a bonus and ideally should be part of the process to have a pharmacist review the order, but a pharmacist is not required for a registered nurse to interpret an order and administer a medication.

An example of a regulatory definition of "dispense":

Dispense

The act of dispensing includes the selection and labeling of prepackaged medications ordered by the physician or advanced practice nurse to be self-administered by the client. Medications may only be dispensed by a physician, pharmacist, or registered nurse.

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