Medication aides and errors

JKL33 · Apr 2, 2018

I personally would not work in a position (as an RN) that required me to delegate this particular type of duty to unlicensed assistive personnel.

ruby_jane, BSN, RN · Apr 2, 2018

There are many settings (school included, where I practice) where we are allowed to delegate medication to an unlicensed person or aide.

Just because you CAN, doesn't mean you should. There are things I feel I cannot delegate to my very competent, expertly trained health aide. Because I like my license just the way it is.

If I were you, I'd review my BON rules on what can/cannot be delegated. Then I'd review what the BON says about my delegation. My BON tells me that if I train someone and delegate medication management to them, I may still held responsible if they make an error. So I document training often.

I realize I am in a different practice setting than you are. Is management retraining the aides who make the mistakes? The one you describe is a doozy of a mistake.

Dobbysanurse, BSN, RN · Apr 2, 2018

Believe me, after this mistake I took the narcotic keys back and said I would be administering them in place of the TMA's. I talked to my DON and apparently the TMAs practice under her license but I don't know how accurate that is as I was the one who was technically responsible for the narcotics at that point and in charge of delegation. I sincerely hope re-education will occur with this TMA - She did feel absolutely awful regarding the mistake and surprisingly she is one I would usually have more trust in than some of the other med aides but it goes to show how there are definitely different levels of skill. She wasn't even aware of the difference of the medication. I should add that to be a TMA within my facility you don't have to take the actually med administration course, you simply have to have completed a pharmacology course - we have nursing school drop outs suddenly given narcotic keys just because they made it through the program past that class. It just blows my mind.

Another thing that doesn't help is the facility I work at is very different than most SNF/LTC facilities - we have 4 units with 20 pts a piece that either one nurse or one med aide is in charge of for medication administration. If there is a TMA on a unit, the neighboring nurse is in charge of dressings/assessments etc. Still that leaves a med aide to administer entire med passes without a nurse even on the same unit - often being unaware of the status of the patients that day. I've brought up in several meetings that I don't feel TMAs should be relied on so heavily but I was told that if we don't use them nurses are going to have to work more 12-16 hour shifts which would result in burn out. I almost responded well then the errors would be under their license, not mine.

JKL33 · Apr 4, 2018

I've brought up in several meetings that I don't feel TMAs should be relied on so heavily but I was told that if we don't use them nurses are going to have to work more 12-16 hour shifts which would result in burn out. I almost responded well then the errors would be under their license, not mine.

So are you looking for another position?

They probably believe the false dilemma response they gave you is quite clever, since it works as both a threat and and/or could imply that they care about nurses not getting "burned out." But it also makes it pretty clear that they aren't serious about serving their patients better and feel perfectly fine with this dangerous method for provision of care.

Here.I.Stand, BSN, RN · Apr 6, 2018

There are many settings (school included, where I practice) where we are allowed to delegate medication to an unlicensed person or aide.
Just because you CAN, doesn't mean you should. There are things I feel I cannot delegate to my very competent, expertly trained health aide. Because I like my license just the way it is.
If I were you, I'd review my BON rules on what can/cannot be delegated. Then I'd review what the BON says about my delegation. My BON tells me that if I train someone and delegate medication management to them, I may still held responsible if they make an error. So I document training often.
I realize I am in a different practice setting than you are. Is management retraining the aides who make the mistakes? The one you describe is a doozy of a mistake.

Honest question... and to be clear, I don't love the use of TMAs. But if the facility has chosen to staff with them, how feasible is it for the nurse to do the TMA's med passes AND all of the stuff that truly can't be delegated? (e.g. assessments, treatments, nursing documentation, family concerns, calling the doc.......) The staffing matrix -- at least in my experience -- allows for MORE pts per nurse, as the nurse has help with the time-intensive med passes. How does the nurse do her own work which often exceeds the hours in a shift, PLUS 2-3 hours of med pass?

I don't suppose there's an easy answer. :no:

Guest219794 · Apr 6, 2018

Believe me, after this mistake I took the narcotic keys back and said I would be administering them in place of the TMA's. I talked to my DON and apparently the TMAs practice under her license but I don't know how accurate that is as I was the one who was technically responsible for the narcotics at that point and in charge of delegation. I sincerely hope re-education will occur with this TMA - She did feel absolutely awful regarding the mistake and surprisingly she is one I would usually have more trust in than some of the other med aides but it goes to show how there are definitely different levels of skill. She wasn't even aware of the difference of the medication. I should add that to be a TMA within my facility you don't have to take the actually med administration course, you simply have to have completed a pharmacology course - we have nursing school drop outs suddenly given narcotic keys just because they made it through the program past that class. It just blows my mind.
Another thing that doesn't help is the facility I work at is very different than most SNF/LTC facilities - we have 4 units with 20 pts a piece that either one nurse or one med aide is in charge of for medication administration. If there is a TMA on a unit, the neighboring nurse is in charge of dressings/assessments etc. Still that leaves a med aide to administer entire med passes without a nurse even on the same unit - often being unaware of the status of the patients that day. I've brought up in several meetings that I don't feel TMAs should be relied on so heavily but I was told that if we don't use them nurses are going to have to work more 12-16 hour shifts which would result in burn out. I almost responded well then the errors would be under their license, not mine.

I am pretty sure that is inaccurate. I think this idea of one person acting under another's license is one of those nursing myths.

A CNA who exceeds his/her scope of practice is responsible for the actions. Along with the certification comes a responsibility to know, and abide by, limitations of scope of practice.

An RN who instructs a CNA to exceed their scope of practice has also acted unprofessionally, and could likely be subject to sanction.

Also- did you actually delegate this task, or is it part of their job description? I work in an ER. If the hospital allows a CNA to draw blood, or start an IV, it is not my responsibility. I don't look at their job description, or read their scope of practice. If, on the other hand, I ask a CNA to adjust the rate on a pump, that is clearly my responsibility.

BTW- the environment you describe sounds terrifying. 2 years in the ICU and 12 in ER. If my only option as an RN was to do your job, I would work construction or deliver pizza. I really don't know how LTC nurses do it.