medication mismanagement?

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Hello All,

This is my very first post! I visit this site often, but have never posted. My situation is this: I worked on a Med/Surg floor at a small hospital. I was assigned to a wound patient that needed a dressing change and orders to pre-medicate before dressing change. His order was for (2) 5/325 hydrocodone. The omni was out of 5/325's so I gave him (1) 10/650 instead. I was fired for medication mismanagement. I have since talked to a few pharmacists that have said this is a perfectly appropriate substitution. Any thought?

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What's the rest of the story? Have you been spoken to before about not doing such substitutions? Were you on probation for something else? I'm just having a hard time seeing how someone could be FIRED over something like this.....because unless I'm missing something significant, it doesn't make sense.

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Specializes in CMSRN.

I'm a new nurse graduate (just passed NCLEX 6/10/13) so I can't say I've ever encountered anything like this as a nurse. That being said, as long as this was charted appropriately and the dose was given correctly, I can't see how these are any different. I understand that as far as the actual pill goes, you gave a different one, but as far as the dose goes you were right on the mark. He essentially ordered 10 mg of hydrocodone and 650 mg of acetaminophen, which is what you dispensed. Did you properly chart why you gave the different pill, instead of the separate two? I'm so sorry you've lost your job over this.

I would absolutely love to hear from experienced nurses what went wrong here or how this nurse could have addressed this differently and will be following the thread.

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

Did you first visit another floor/unit to see if their Omni/Pyxis machines had Norco 5/325mg pills on hand? Unfortunately, each facility has its own policies, some of which do not make a great deal of sense in the real world.

At some previous workplaces that were far more regulated, I would have had to call the doctor, explain to him/her that we're out of Norco 5/325, and obtain an order that specifically reads "May administer Norco 10/650mg until Norco 5/325mg becomes available."

Again, this situation is unfortunate. However, some facilities are anal about DEA rules that govern the administration of controlled medications. Two 5/325mg pills is the same as one 10/650mg pill, but you still must cover your butt when it comes to narcs. Good luck!

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I am still a nursing student, so I can not say what happens in the real world, but in school we are taught that we, as nurses, are not allowed to make substitutions. One student had an order for a 250mg of something (I can not remember the medication) and all she had was 500's. She used a pill cutter to 1/2 it, and she was almost thrown out of the program because of it. Not quite the same thing that happened to you. I am not sure if this is a school, scope of practice or hospital rule, but it is something that has been drilled into my brain.

I am sorry you are going through this. Keep your chin up!

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Yes, any variation of the order requires an MD order. The order as I understand it was for 2 tabs. That is where the error happend. As nuts as that sounds. There are a number of units now that are requiring doses only, and not "2 tabs, 1/2 tab...." just for these variations in the dispensing.

I would also go to the pharmacy and say "such and so has an order for 2 5/325 percocets, and they are not loaded in our pyxis. Could they be reloaded, or may I pull from an alternate pyxis?" Let your supervisor know.

I have not heard of anyone being fired over it, however, as noted by a pp, some facilities are really strict on this--some that have had this an issue with an audit in the past.

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Specializes in Pedi.

This is stupid. Two pills of 5/325 and one pill of 10/650 are the exact same thing.

We did stuff like this all the time when I worked in the hospital and fortunately no one cared. If the patient was ordered for 10 mg of diazepam and the pyxis was out of 10 mg pills, we gave two 5 mg pills. If the patient was ordered for 10 mg oxycodone, the pharmacy might list the dose formulation as "liquid" because it was just their habit to do so without bothering to check what formulation the child would actually tolerate. 10 mg of liquid oxycodone is 10 mL and it's NASTY. If the child could swallow pills and oxycodone comes in 10 mg pills, we gave that.

I don't really see the difference between that and what you describe.

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Specializes in PACU, pre/postoperative, ortho.

We substitute equivalent meds when one form is out in the pyxis. Sometimes, the pyxis does it for us or we contact the supervisor to bring us what is available. Of course then the med won't scan so I have a second nurse verify that what I am giving is equivalent to what is ordered & then document on the eMAR as an administration comment that it was verified with "Susie, RN" or whoever & that the ordered form was not available.

Edit: Just thought to add though that I've never done this with a controlled substance (in ortho, the narcotics are always full!). Usually just something like K+. Maybe that's why they are making such a stink over it?

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Specializes in Critical Care.

A medication error would be giving the wrong med or wrong dose, you gave the correct medications (hydrocodone and tylenol) and at the correct dosages, so it's not a medication error, it was just a reason for someone to fire you who probably actually had other reasons to fire you (which these days usually means they want to lay people off but don't want actually lay people off and be on the hook to chip in for their unemployment, so they take every chance to fire people no matter how obviously ridiculous the reasoning might be).

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In my hospital, this would be considered an error, too.

We have no leeway in doing substitutions.

In this case, I would have to get an order to use the Norco 10 / 650 since the 5/325 isn't available.

Substituting a liquid form isn't allowed, either. Recently a nurse gave a patient a 25 meq KCl fizzy since she couldn't swallow the horse-pill 25 meq tab. Big no-No for her.

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Specializes in ICU.

Huh??? This is absolutely not a medication error. I am so sorry that you got fired over this, and it sounds like something else must've been going on. The pt received the correct medication, correct dose, correct route. No error. If the hospital wants to act like this over it, maybe they should keep their Pyxis stocked.

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However, if the order read "2 tabs" that is the error. And I KNOW that sounds nuts, however, it is an error as the order did not reflect the number of tabs given. And this drives the JHACO and other auditor people crazy. Not to mention (and I know NUTTY) that the hospital loses money (ah, the almighty dollar) because 2 tabs can be billed at a higher rate than one tab.

Good rule of thumb, see about having orders in dosages only--that is what is required by our facility by our pharmacist at present.

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