medication mismanagement?

applewhitern, BSN, RN · Jul 25, 2013

Not all hospitals have a pharmacist 24/7. When the med-dispense machines first become available, the idea was so that a hospital would not have to pay a pharmacist 24/7. They could fill them, and the nurses could get meds out in the middle of the night.

applewhitern, BSN, RN · Jul 25, 2013

This makes me feel embarrassed for our profession. Why bother to develop those "critical thinking skills?"

BrandonLPN, LPN · Jul 25, 2013

To play the devil's advocate for a minute here (and it pains me to do so, 'cause I really feel for the OP), I'm going to guess the past history of diversion is the real meat of the issue here.

I bet the OP was under super close scrutiny, and that any sort of substitution/slight variation in dose delivery of a narcotic would have rasied a red flag. They (management) panicked and jumped the gun.

It's still unfair and illogical, but I guess it just goes to show one really can't be too careful when working under such a microscope.

But I still don't undrstand what exactly the employer could have reported to the BON in this case. There's nothing to report. It was purely a violation of facility policy. It would be like reporting a nurse to the BON for calling in sick too much or something.

RN2B123 · Jul 25, 2013

Um I've done this same exact thing before (all the time actually if the one I need isn't available) , albeit not w a narcotic but if it was a narcotic I wouldn't have an issue with it. That is absolutely ridiculous - some of these hospitals I read about on this site have the silliest policies. If I called a doctor to get a new order to give the 2nd option of a dose I'd be yelled at for calling about something idiotic.

RN2B123 · Jul 25, 2013

And btw that's treating a nurse like they are 5 yrs old and can't make the appropriate decision to give the other available dose - its not like you gave the '' wrong'' dose or even the ''wrong' 'form - there was NO error.

jadelpn, LPN, EMT-B · Jul 25, 2013

http://www.jointcommission.org/assets/1/6/Ped_Field_Review.pdf

This is a medical surgical floor. There should be a pharmacist. There should be a policy regarding substituting one medication for another.

Again, the correct patient received the correct dose, the correct drug. However, there was not an order that reflected this appropriately. And according to whatever hospital policy states, this decision was made independently, there was no communication regarding the lack of the ordered medication (as in 2 tabs) and should have been resolved by notifying pharmacy per protocol.

Yes, may be considered dumbing down of nursing. However, an important part of acute care nursing is to follow the procedures and protocols set forth. As ridiculous as it may sound. Much like LTC (where I most recently learned that PRN pain medication can not be given until 952 non medicine interventions are attempted first--and documented or it affects reimbusement) there are procedures that fall within the Joint Commission standards.

So, unless the RN in question notified Pharmacy that the med was out, that she needed an order for a substitution, and followed the pharmacy's guidelines, then there was mismanagement on that aspect of things.

There was also some thoughts about "but I give 2mg of morphine from a 4mg vial and waste". Yes, but the order should be "2 mg of morphine" and not 1ml of morphine. Same with toradol. The order could be for 15mg of toradol, (that you would draw from a 30 mg vial). Not "give 1ml toradol".

Yes, pharmacy may have dropped the ball on this one, at unfortunetely the expense of someone's job. That is why is it so important that your order is reflective of exactly what you are giving, and that you follow whatever policy the unit has on what to do if it is not available as ordered.

~PedsRN~, BSN, RN · Jul 25, 2013

Ridiculous.

However, on my floor - to make such a substitution (and it has been done before, on more than one occasion, when time is of the essence) - it would make your scanning impossible. I could give the med without scanning it, but if I attempted to scan the med - it would flag me as making an error. I'm kind of OCD about my scan compliance (LOL) - so I would have called pharmacy and have them make the appropriate changes on the mar so that I could scan the med (they needed to be notified anyway that your omni was out of necessary pain medication).

But in a time crunch, and you have a patient in pain that needs meds - they need pain meds.

I'm sorry, OP.

CrunchRN, ADN, RN · Jul 25, 2013

To play the devil's advocate for a minute here (and it pains me to do so, 'cause I really feel for the OP), I'm going to guess the past history of diversion is the real meat of the issue here.
I bet the OP was under super close scrutiny, and that any sort of substitution/slight variation in dose delivery of a narcotic would have rasied a red flag. They (management) panicked and jumped the gun.
It's still unfair and illogical, but I guess it just goes to show one really can't be too careful when working under such a microscope.
But I still don't undrstand what exactly the employer could have reported to the BON in this case. There's nothing to report. It was purely a violation of facility policy. It would be like reporting a nurse to the BON for calling in sick too much or something.

That makes the most sense to me.

Esme12, ASN, BSN, RN · Jul 25, 2013

The Joint Commission state a pharmacist must be available....not in the building.

The op has a "history"

Eyerly There actually is more to the story. In 2003 I hurt my back at work and quickly became dependent of opiates, which led to diversion. After about 3 months I turned myself in to my DON. I voluntarily surrendered my license, completed rehab and was on probation for a year (as well as submitting to random drug testing). I was advised to take a few years off from nursing. I went in to medical sales for about 5 years and, even though the money was great, I missed nursing. During the time that I was in sales I went back to school to become a WOCN. When I interviewed for the postion that I was just fired from, I was totally honest about my past. The CEO told me she would give me a second change. For 2 years, there was not a single problem. I ran my own wound clinic and was very successful at it. When this incident happened with the substitution the CEO told me I blew my second change. The CEO also turned me in to the board of nursing. I have a hearing coming up soon and am just trying to get others' perspective on the situation.

I feel bad for the OP and I do not know all of the details, of course, but there is more to this story.....and this is a clinic....was it completely innocent? I think so.....will that matter? I hope so.....I wish the OP all the best.

monkeybug · Jul 25, 2013

I was fired once for suggesting that since I worked night shift, and night shift charted in red ink, and that other than work I'd never use red ink- so maybe the facility should buy my red pens? To top it off, I was just being facetious. Canned. Got unemployment for a few days, just to have my termination officially declared unjustified (funny, how in nursing, you really can't seem to count on an accurate evaluation from a former employer? Prior to the 'pen' incident, a week prior, I was given a raise and told "We're so glad you're part of our little family").

Wow. I've come to think that there's no one as sensitive as an administrator or manager. Question their perfection, and they decide to hurl lightening bolts from their gilded thrones. I once knew a hospital employee who put rather honest (anonymous) comments and "suggestions" in the comment box. Nothing profane, just honest reflections on the realities at the facility. Administration went through medical records until they could match the handwriting, and then she was fired. Don't question their godliness! You might hurt their wittle feewings.

morte, LPN, LVN · Jul 25, 2013

typewriter/Word...

MunoRN, RN · Jul 25, 2013

http://www.jointcommission.org/assets/1/6/Ped_Field_Review.pdf
This is a medical surgical floor. There should be a pharmacist. There should be a policy regarding substituting one medication for another.
Again, the correct patient received the correct dose, the correct drug. However, there was not an order that reflected this appropriately. And according to whatever hospital policy states, this decision was made independently, there was no communication regarding the lack of the ordered medication (as in 2 tabs) and should have been resolved by notifying pharmacy per protocol.
Yes, may be considered dumbing down of nursing. However, an important part of acute care nursing is to follow the procedures and protocols set forth. As ridiculous as it may sound. Much like LTC (where I most recently learned that PRN pain medication can not be given until 952 non medicine interventions are attempted first--and documented or it affects reimbusement) there are procedures that fall within the Joint Commission standards.
So, unless the RN in question notified Pharmacy that the med was out, that she needed an order for a substitution, and followed the pharmacy's guidelines, then there was mismanagement on that aspect of things.
There was also some thoughts about "but I give 2mg of morphine from a 4mg vial and waste". Yes, but the order should be "2 mg of morphine" and not 1ml of morphine. Same with toradol. The order could be for 15mg of toradol, (that you would draw from a 30 mg vial). Not "give 1ml toradol".
Yes, pharmacy may have dropped the ball on this one, at unfortunetely the expense of someone's job. That is why is it so important that your order is reflective of exactly what you are giving, and that you follow whatever policy the unit has on what to do if it is not available as ordered.

No medication substitution is occurring. Same med, same route, same form. The JC has no problems with medication orders being read as the total dose. Our medication reconcillation process involves re-ordering home meds as inpatient meds, these are often written based on how they are dispensed, such as "1/2 tab 50mg metoprolol". The MD signs the order when it is still in this form, however it can be given as a whole 25mg pill, this process was implemented by a group that included a JC surveyor. Basically, the "2 tab" part is just a factor by which the dose is multiplied. They can write it as "2 times x dose", "1/2 y dose" or "pie divided by the square root of the speed of light minus z dose", it doesn't matter to the JC so long as the final dose is what was ordered.