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?

[ruby_jane, BSN, RN]

The individual who give the med takes all responsibility, the charge nurse name is no where documented.

Um....nope! Is this one particular shift or is it policy?

[Twinmom06, ASN, APN]

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.

You beat me to the punch...I also work HD and unless you're anemic and need a shot of epogen, there isn't anything to divert.

[dudette10, MSN, RN]

But the original scenario isn't bypassing pharmacy...

1) The physician ordered a med.

2) Pharmacy checked the order, put it on the patient's MAR.

3) Then the charge nurse got the med out of whatever drug vending machine they use and put it into a syringe.

4) Then the patient's nurse gave the med.

Pharmacy is right there in step #2.

Because this thread has many concepts brought into it, the flow of the discussion is important to consider. My original stance was unsafe due to safety checks. The counterpoint to that was "why trust pharmacy if you don't trust the nurse?" Then someone mentioned is dispensing to which another person defined dispensing as not limited to the pharmacist role. Then, my response to that, which you quoted.

The quote was about two or three steps away from my original comment that you are now looping back to.

Whew! Love these discussions but JFC do we all have to be so smart?

[Julius Seizure]

Because this thread has many concepts brought into it, the flow of the discussion is important to consider. My original stance was unsafe due to safety checks. The counterpoint to that was "why trust pharmacy if you don't trust the nurse?" Then someone mentioned is dispensing to which another person defined dispensing as not limited to the pharmacist role. Then, my response to that, which you quoted.

The quote was about two or three steps away from my original comment that you are now looping back to.

Whew! Love these discussions but JFC do we all have to be so smart?

I'm just too slow for you guys!

[1TiredOldNurse]

No one in the OP scenario is acting as a "practitioner's assistant" but rather as a practitioner in their own right, performing duties they themselves are duly licensed to do.

Nurses are not considered practioners or dispensing practioners, only physicians,dentists,podiatrists,and veterinarians (at least in Georgia). I understand why the OP's facility does things the way they do. I am just wondering if the facility policy is in violation of state law. You might be surprised at the number of policies some facilities have that are not in accordance with state law. Nurses are responsible for knowing what their individual state nurse practice act allows them to do. I have learned the hard way to never take anyone's word for something that could potentially cost me my nursing license. I'm too old to learn to do anything else :)

[LostMyPen,RN, BSN]

Dialysis RN here. I've been in outpatient HD for 5 years, 3 of which as charge nurse. As foreign a practice as this may seem, and contradictory to what we learn in nursing school, this truly is the most efficient way of giving meds. Keep in mind:

-This is an outpatient clinic setting where patients are stable and medications change very little

-There are no narcotics of any kind. We give IV vitamin D, epogen, and Venofer. Occasionally an antibiotic.

-"clean" and "dirty" are a big deal in this setting. You must prepare the medication in a clean area away from patients. Then, after donning full PPE (sheild,mask,gown,gloves) you administer and document at the chairside. You must remove and store all PPE before returning to where the meds are kept. If you tried to repeat that procedure for all patients on that shift, you would run out of time before their treatment ends and its now a missed dose. There can be 20-40 patients dialyzing simultaneously.

-In our clinic we have a clean and a dirty nurse. The clean nurse is usually charge that day. She stays in the clean area preparing meds with preprinted labels. The dirty nurse double checks the dose against the order and administers so that there is no cross contamination between the clean med prep area and dirty chairside station.

-The only potential side effect of an incorrect med being given is a minor change in lab results. None of these medications are fast acting. The first time a med is given we monitor for allergic reaction.

-You work with the same nurse day in and day out. These meds aren't being drawn by a stranger. In this setting you know and trust your team mates. Outpatient HD is very much a team care model with many different caregivers at once (RN,CCHT,PCT)

-In this state (NC) LPNs can administer IV push medications. Our unlicensed dialysis technicians push IV heparin that has been drawn up or checked by the nurse.

The state auditors and Joint Comission regularly inspect and approve this procedure of medication administration

Just my $0.02

[Nurse Beth, MSN]

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.

The important difference is that Pharmacists prepare and dispense medications. Nurses do not.

[brownbook]

Dialysis RN here. I've been in outpatient HD for 5 years, 3 of which as charge nurse. As foreign a practice as this may seem, and contradictory to what we learn in nursing school, this truly is the most efficient way of giving meds. Keep in mind:

-This is an outpatient clinic setting where patients are stable and medications change very little

-There are no narcotics of any kind. We give IV vitamin D, epogen, and Venofer. Occasionally an antibiotic.

-"clean" and "dirty" are a big deal in this setting. You must prepare the medication in a clean area away from patients. Then, after donning full PPE (sheild,mask,gown,gloves) you administer and document at the chairside. You must remove and store all PPE before returning to where the meds are kept. If you tried to repeat that procedure for all patients on that shift, you would run out of time before their treatment ends and its now a missed dose. There can be 20-40 patients dialyzing simultaneously.

-In our clinic we have a clean and a dirty nurse. The clean nurse is usually charge that day. She stays in the clean area preparing meds with preprinted labels. The dirty nurse double checks the dose against the order and administers so that there is no cross contamination between the clean med prep area and dirty chairside station.

-The only potential side effect of an incorrect med being given is a minor change in lab results. None of these medications are fast acting. The first time a med is given we monitor for allergic reaction.

-You work with the same nurse day in and day out. These meds aren't being drawn by a stranger. In this setting you know and trust your team mates. Outpatient HD is very much a team care model with many different caregivers at once (RN,CCHT,PCT)

-In this state (NC) LPNs can administer IV push medications. Our unlicensed dialysis technicians push IV heparin that has been drawn up or checked by the nurse.

The state auditors and Joint Comission regularly inspect and approve this procedure of medication administration

Just my $0.02

This is so great, explains the situation, and makes sense. I wonder why the original poster's facility didn't seem to be able to tell him why it was done that way?????

[sarbo1010]

you are correct about trusting the pharmacy and I did catch an error in a pharmacy draw of chemo about 25 years ago. a physician gave some chemo to a few patients through the omaya reservoir and 2 of them had adverse reactions. I pulled the syringe with the remaining medication out of the discard bucket ( a big no no) and return it to pharmacy in order to find out just how much of this medication the patient had received. They did a recheck and at that time discovered that they had used the wrong dilution and so the patient got 10s of time more medication than they should have, an antidote was administered but it did no good. So yup, nursing and being a patient is fraught with trusting others not to screw up. I still wouldn't like giving meds that another nurse drew up, that being said what is the policy there - is there one that will protect you if she screws up?

[glasgow3]

There is an excellent article which I "googled up" entitled "Understanding the Basics of Medication Administration" by Nancy Brent, MS, JD, RN. Despite the rather broad subject matter implied by the title, the entire article focuses upon the matter at hand. I believe you will find her credentials and experience (listed in an About the Author section appearing below the body of the article) quite impressive.

Simply put, my takeaway from the article is that nurses should not routinely be giving IV medications drawn-up by another nurse, nor should a nurse routinely draw-up medications for other nurses to administer.

Now obviously, first and foremost we want what's best for our patients, however, we all practice within a legal/regulatory environment as well; I would not want to be in the position of defending myself in the context of a process which violates what this author describes as a Cardinal Rule. Actual administration aside, there are also potential legal issues arising from this process with the medication documentation which I didn't even consider until reading this short article.

And lastly, if I were a betting person, I would bet that there isn't even a written policy addressing this unique medication preparation/administration process at the OP's facility; Sadly, I suspect that they would throw the OP under the bus in a proverbial heart beat.