Meds in unlabeled bags... Is it safe?

LoveMyBugs, BSN, CNA, RN · Sep 12, 2015

Looks and sounds like a potential for a med error. What is the policy for storing meds? Labeling?

Are the meds locked on your WOW?

You already stated that he is mislabeling room numbers, so med error waiting to happen

Editorial Team / Admin · Sep 12, 2015

We aren't permitted to remove more than 2 patients meds from the Pyxis due to the possibility of error. Your scenario sounds like a setup for disaster at some point.

sailornurse · Sep 12, 2015

Anytime you bypass the system that has been implemented for safety protocols, you are headed for trouble. If you can lock the meds in the WOW, why not put a label on them?

Here.I.Stand, BSN, RN · Sep 12, 2015

A place I worked at, when we went to barcode scanning and got WOWs, advised us to pull all meds to save time going to and from Pyxis.

That said, each WOW had 6 or 8 drawers that locked. We labeled each drawer by room number, so no names visible. Also important to not was all meds stayed in their blister packs -- we didn't have, say, a big bottle of Tylenol like a SNF might. So although not labeled by name, as long as we were doing our 5 rights before giving the meds, pts got the correct ones.

So say I accidentally put pt in room 143 into 144's drawer, I'd see from the eMAR that pt 144 does not take the metformin that was in the drawer.

We were also very careful -- as we are with giving the meds -- to pull and store them correctly.

At the very least, I'd need to see each med pharmacy labeled, e.g. in the blister pack, or in a prefilled syringe w/ label affixed.

BiohazardBetty · Sep 12, 2015

The meds do stay locked in my WOW when I'm not actively getting something out... Most of them are not pulled from the Pyxis, they are sent from pharmacy- in labeled bags or envelopes with name, room, & med rec number on them. He insists on removing those labels in favor of writing the room number. Personally, I either put a pt chart sticker on the bag he prepares or I put the meds back in the bag sent from pharmacy.

Our policy says that only one person's medications should be removed from the locked cart at a time, so it is in compliance with hospital policy to have several patients' meds in the WOW as long as I only take out one at a time... But let's say it wasn't okay & I only had one persons meds in it at a time... Would I be out of compliance with any of joint commission's regulations if I had a bag only labeled with a room number? (The medications themselves are all clearly labeled regardless of the type of bag they are in)

BiohazardBetty · Sep 12, 2015

Just to clarify, the meds all remain in their individual, pre-packaged blister packs.

RainMom · Sep 12, 2015

I would not have a problem with it if I was the one pulling the meds in the first place. I find it odd that the charge takes it upon himself to get meds ready for everyone.

Working nights, I frequently pulled all my am meds for my pts, placed the pills in their packaging in a labeled med cup by room # & locked them in my wow. However, for days or eve shifts, I usually did not take out more than 2 pts' meds at a time since there were so many more pills to pass & to minimize the chance of mixing them up or losing one.

meanmaryjean, DNP, RN · Sep 12, 2015

If each individual med is still in the blister, I wouldn't have a problem with this. You still have to perform the 5 rights- none of those steps are skipped by this process.

edmia, BSN, RN · Sep 12, 2015

Oh my gosh! Yes, I would have a problem with that. He may be trying to be helpful, but it is reality a disaster waiting to happen. I would not take unlabeled medications from anyone. I am responsible for administration, so if the wrong drug was in there, it's my problem.

If he wants to be so helpful and put the meds in bags, he needs to be a good nursing professional and administer the meds himself.

edmia, BSN, RN · Sep 12, 2015

Just to clarify, the meds all remain in their individual, pre-packaged blister packs.

Oh! well my previous post was really about a bunch of pills in a plastic bag, as that is what I imagined from the OP.

Now that you clarify... I guess it's not that bag as you still have the opportunity to check the MAR before actually giving the med.

Here.I.Stand, BSN, RN · Sep 12, 2015

Most of them are not pulled from the Pyxis, they are sent from pharmacy- in labeled bags or envelopes with name, room, & med rec number on them. He insists on removing those labels in favor of writing the room number.

Does the pharmacy ever send pre-filled syringes, or reconstituted IV meds? I would be VERY concerned, and personally refuse to administer any of those with evidence of label tampering, if those had labels removed in favor of a charge RN's homemade label. Stuff like that, the only way I know what is in it is by reading the label affixed and/or verified by the PharmD. I would not be at all okay with 100 ml of NS with a handwritten label saying Zosyn 3 gm.

Individual pills in blister packs, again you still know what's in them, so that doesn't bother me so much.

But a question I do have, is if they are locked in a drawer, why the heck is the charge RN taking precious time to relabel everything? Isn't there something better he could be doing, since he has this time on his hands? Oh, like answering call lights, helping pass the meds, helping w/ treatments, helping w/ hourly rounds?

THAT, I don't get.