Medication administration, not following the rules

[hotflashion]

Hi,

I'm a recent grad with little nursing experience. Graduated in May 2009, worked at a rest home for 4 weeks and a summer camp for 2 weeks. Both places dispensed medications not according to the rules, i.e., pre-packed meds. In both settings, I did not feel this was dangerous, and at the rest home I certainly thought it was the only safe way to dispense meds to so many people. (I'm not arguing with the legitimacy of it pre-packing, just stating my opinion about the safety in these two settings.)

A classmate of mine was recently fired from a new job (at a residential program for very troubled adolescents) after 2 hours because she questioned the fact that the nurse she was following pre-packed and then signed the MAR before giving the medication.

So, I'm just wondering how many nurses don't follow the rules in this regard? Coming across this kind of non-compliance is a big shock for those of us new grads who have had it drilled into our heads that you dispense medications to one patient at a time, sign the MAR when the medication is given, and you never, ever pre-pack. It seems like there are rules for ideal situations and rules for real life.

I liked the summer camp I worked at and hope to return next year. The kids are all healthy, even if they have to maintain their health with regular medication. I'm thinking about the medication administration method used at the camp and wondering if I will try to change it next year, if I go back.

Any thoughts, comments, opinions welcome.

[tainted1972, ASN, RN]

in my facility, we sign for the medications when they are pulled, if the med is not given or refused then we circle it.

The reason we do it this way is because, what if you get interrupted while pulling medications.. lets say you have pulled half of the medications and placed them in the med cup..... someone needs you Right now... how are you supposed to know where you left off when you get back?

Lets say billy shmoe asks for some pain medication... you go to the cart, you get the pain medication, and on the way to his room you discover edna shmoe has fallen out of bed. While helping Edna.. another nurse answers Billy's call light, sees you are busy, Checks the MAR and sees that He is due for his pain meds.. does you a favor and gives Billy the meds...... you finish with Edna and proceed to give the pain meds to Billy....... you see where this is going. My point is, you should initial the Mar when the medication is pulled.. not given.

I often pull all meds for all of my residents at once.. put them in a cup and label the cup, the cup is then placed back in the drawer, and then I pass the medication. I do not pre measure liquids or powders.

I pull the meds, I label the meds, and I Give the meds.

I would never ask another nurse to give something that I already pulled, or measured. Nor would I give any medications that were pulled or measured by another nurse.

The nurses who are doing the baggie thing seems fine to me, as long as they are not passing the meds that someone else put into the baggies. And as long as they are labeling the baggies.

[mercurysmom]

When I worked as a camp nurse 3 summers (many many moons ago) I made up small envelopes just like the med tickets we used in the hospital (remember those? ) with the kid's name, unit, med, dose, and time. If I couldn't give Susie her vitamin or Jimmy didn't want his allergy med, it would come back with me in the envelope and I'd chart it not given. Any other comments I'd jot down on the ticket (envelope) and record as soon as I got back to the infirmary. Then I'd make a new ticket. Some of the units were 1/4 mile from my cabin and although 95% of the time the kids came to me, there were some I had to chase down.

I always, always made the tickets myself and gave the meds myself, and charted everything afterwards. I only gave PRN's if the kids came to me, though. I don't think I could've pushed a cart up and down the trails!

BTW, I LOVED camp nursing! DH and I worked at summer camps as newlyweds, and every year when I drop off my (teen) daughter at camp I feel a little jealous!

MM

[Joyfull77]

This is an interesting thread! I think it depends on the facility. For example, I work in an Assisted Living Facility, and we have to prepare all the meds for all the residents before we go on the floor to administer them. Our building is three stories high with four different wings and there is no way we could push around a med cart and give everyone their meds on time if we didn't prepare them (pre-pour, or prepackage) before hand. In addition to that, I sign out the meds as soon as I prepare them, because there are various people that may be working with the same MAR that I am working with and if I don't sign it out before hand, its assumed that I didn't prepare them or administer them.

[KareBear0609]

I am a CNA at a LTC facility. We have two floors with one nurse on each floor. So each nurse is assigned to 60 patients. Every nurse I have worked with pre dispenses their meds. But, with that many patients, I don't think you would be able to get it done any other way.

[Whispera, MSN, RN]

I've worked lots of places and in each and every place pre-pouring was expected. We poured for the big med-pass times for all the patients, then locked this little labelled thingie (a tray with individual spots in it for individual patient's meds)that was made for pre-pouring, in the medication room. I would think the alternative would be to pour and lock individual's medications in their individual med drawers, if they have them. You could also put the little thingie in the med cart drawer or lock it in a cabinet. We also signed/initialed as we poured and circled if for any reason the medication wasn't given.

What surveyor's are looking for, more than whether you pre-pour or not, is that meds are kept locked away so the wrong person doesn't take them.

[systoly]

I'm anxious to see how pre pouring will be handled when going all electronic.

[ashleyisawesome, BSN, RN]

This is an interesting thread! I think it depends on the facility. For example, I work in an Assisted Living Facility, and we have to prepare all the meds for all the residents before we go on the floor to administer them. Our building is three stories high with four different wings and there is no way we could push around a med cart and give everyone their meds on time if we didn't prepare them (pre-pour, or prepackage) before hand. In addition to that, I sign out the meds as soon as I prepare them, because there are various people that may be working with the same MAR that I am working with and if I don't sign it out before hand, its assumed that I didn't prepare them or administer them.

thats weird, do you just have one med cart for all those people? i work in ALF too and we only have two floors. floor one has about 10 residents, floor two has like 28 i think. each floor has its own cart and pca/lpn to give meds. i have never "pre-poured". i take the cart to each room do my triple check against the MAR, put them in a cup, lock my cart, go in the room and give the meds, make sure they swallowed them all, come back out and sign the MAR. repeat.

im not sure if i am fully understanding this "pre-pour" phenomenon. it seems like an easy way to make more mistakes. i think it would confuse me..

[eslvn]

There were things I was concerned about. We have a one hour window on each side to give 8am meds, well for 34 resident that aint gonna happen sorry. One of the nurses that oriented me said it perfectly "the expectations are unrealistic". But pre-pouring is a no-nooo!!! So easy to get them mixed up, yes I know you write their names down or what not, but its bad practice. I pass meds to a lot of people and I dont and wont do that. Thats just asking to get fired and putting your license on the line. Yes the real world of nursing is much different from school, but use your judgement to decide what is safe and what is not.

[Joyfull77]

No we have have four carts for all of the residents, but two people do the main med pass while there is a third person to also do the med pass and do most of the paperwork. On top of that there are two nurses on duty and another person who is within health services that can pass meds, so communication is really key among all of us when it comes to passing meds. I always make sure to sign the MAR, however, others I work with don't. To be honest, one of the reasons I sign the MAR after each pill is prepared, is so that I can avoid med errors by ensuring that I actually punched that pill. And our meds are prepared in little cups with lids, and each lid has the room number, resident name, and time for the med, on the med cup. It would be great if our building was small enough to push the cart around, but with 3 stories and four wings, one med pass would take us forever.