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Morphine Authorization

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I'm new here and not sure if this is posted in the right area. I've always loved coming to this site as a lurker but decided to join :) The other night I was working (NOCS) and had a pt. who was given an order for Morphine on PMs. The ADON and the PM nurse before me took the Morphine out of narcotics and administered it without authorization from pharmacy, although they did have the MD order. The PM nurse reported to me that pharmacy was going to be calling and giving authorization. Well...pharmacy called at 11 pm while the PM nurse was still there and refused authorization. When the pt's family asked why I didn't give the morphine later that night, I simply stated that I didn't have authorization right now but I could give something else if needed (he was comfortable and slept all night). I called my boss in the morning and I was the one who got scolded. She said I should have followed up with pharmacy asking why they didn't authorize it, etc. My question is, was I legally correct not to give the morphine? Also, why would I call pharmacy for NOCS when they had just called the facility at 11pm to deny authorization? Thanks for any input!

vampiregirl, BSN, RN

Specializes in Hospice. Has 11 years experience.

Where I work, a narc requiring authorization is not administered w/o actually having the authorization. So, to answer your question, I would not have administered the med either.

Our pharmacy provides a reason for the denial, and usually it's something that just requires something faxed or a call from the doc.

If your patient was sleeping and not in obvious discomfort and you also had other med options, I would have just continued to monitor the patient as you did. If something had changed, you could always contact the doc.

Just a thought, it will come back to the facility that meds were taken w/o authorization. This isn't something pharmacy takes lightly. Your boss may have been upset at the breach of protocol and not you personally. Everyone was counting on the authorization, you just were the unlucky person who received the denial.

Psychtrish39, BSN, RN

Specializes in MDS RNAC, LTC, Psych, LTAC. Has 13 years experience.

I almost dont want to answer this one because I have worked in LTC where we have to get authorization with DEA numbers in order to pull from the E-kits for narcotics . Is this what you are supposed to do in your facility? and is it LTC? I have no idea why pharmacy would have not authorized it unless the physician ( at least in my state a RN or LPN in LTC in some facilities can't get a telephone order for a narcotic, the huge pharmacy group in my state has stopped nurses from doing that for about 2 years now. It makes me angry but other nurses say it was because of diversion ( nurses stealing narcotics) I dont think so I think big pharm wanted more control of the LTC market and control of when narcotics are sent to facilities for payment reasons. ) I would think perhaps they would have not authorized because the physician had not called in a telephone order to them. It leaves the nurses hands tied. I feel you should not have been scolded if pharmacy and a pharmacist would not give you the authorization there was nothing you can do about it or you would be in trouble for pulling from the E kit without authorization. Alot of this happens in LTC because the medication isnt reordered within 7 days of being out. I have been stuck so many times with calling pharmacy to get this authorization and it is a pain in the bottom when you have 23 other residents to pull meds for.

Basically when this happens the nurse who is left with no authorization gets in trouble but your hands were tied. Its because LTC wants big pharm to handle their medication issues and have taken the power of the nurse to get her patients pain relief in a timely manner away from her or him. I wrote a paper on this and researched it and there are no state laws in my state about RN or LPNs not having the right to take telephone orders. It has been the facilities and pharmacies that have done this and who really pays is the patient . Hope this helps but it isnt your fault it is your facilities for allowing pharmacies so much power. :mad:

Sounds like you are in LTC and that's mostly unfamiliar territory for me, so I don't deal with having to get authorization from the pharmacy, and I'm not even really sure what authorization is all about.

However, if I knew I needed this authorization in order to give an ordered medicaton, I would have wanted to know why the pharmacy would not give it because it might have been for some reason that could have overcome by supplying them some information or straightening out some misunderstanding.

For me, it wouldn't be so much about right or wrong. As a nurse, or even just a lay person, when I'm told "no" to something I need or want, I need to have an explanation so I know if I truly can't get what I need, or if there is something I can do to turn that "no" into a "yes." Does that make sense?

Thanks. I was pretty upset that my boss felt like I dropped the ball or something. I didn't even talk to pharmacy, the PM nurse got the authorization denial! I guess I was just the scapegoat lol. I feel a little better haha. And yes, I do work in LTC and we are supposed to get the DEA number and pharmacist name. My ADON and the PM nurse decided to just pull it and get authorization later. I was left with the mess :)

Psychtrish39, BSN, RN

Specializes in MDS RNAC, LTC, Psych, LTAC. Has 13 years experience.

Thanks. I was pretty upset that my boss felt like I dropped the ball or something. I didn't even talk to pharmacy, the PM nurse got the authorization denial! I guess I was just the scapegoat lol. I feel a little better haha. And yes, I do work in LTC and we are supposed to get the DEA number and pharmacist name. My ADON and the PM nurse decided to just pull it and get authorization later. I was left with the mess :)

Actually the ADON and PM nurse dropped the ball and you work NOCs ( I have been there ) and the PM nurse ( I have been there ) should have gotten the authorization before they did pull them earlier or called the doc and asked him to fax pharmacy. Sorry you got chewed you werent wrong at all. :o

miss81, BSN, RN

Specializes in Surgery, Tele, OB, Peds,ED-True Float RN. Has 8 years experience.

Where I work Pharm has no say in the matter. Can you tell me why they would have any authorization to say "No"? (just wondering...:specs:)

Where I work Pharm has no say in the matter. Can you tell me why they would have any authorization to say "No"? (just wondering...:specs:)

I'm wondering the same thing. Pharmacy authorization is a foreign concept to me.

We need pharmacy authorization if we're pulling the narcotic out of our contingency-pharmacy hadn't sent the narc. because the order was from that day and delivery doesn't come on NOCS. Any time we pull from our narcotic contingency we need approval.

miss81, BSN, RN

Specializes in Surgery, Tele, OB, Peds,ED-True Float RN. Has 8 years experience.

We need pharmacy authorization if we're pulling the narcotic out of our contingency-pharmacy hadn't sent the narc. because the order was from that day and delivery doesn't come on NOCS. Any time we pull from our narcotic contingency we need approval.

Ok, I understand that but I was wondering more along the lines of "WHY" they wouldn't authorize it? It'd those situations that contingency is for?

My understanding was that the pharmacist on-call wasn't at his facility as it was after hours and had no access to the MD order to verify anything so he denied authorization. And that's what contingency is for-if we don't have the meds delivered. However, for narcotics we still need pharmacy to approve us going in and pulling the med out.

We need pharmacy authorization if we're pulling the narcotic out of our contingency-pharmacy hadn't sent the narc. because the order was from that day and delivery doesn't come on NOCS. Any time we pull from our narcotic contingency we need approval.

Ok, but I still don't get why authorization from the pharmacy to give a medication is even necessary, AT ALL, let alone in a situation like this. It's like pharmacy can override the doctor's order to give the med. Who cares that the pharmacy hasn't sent it? If you have a valid order and you have access to it, that should be good enough. I realize that LTC plays by their own set of rules, but this one is just plain stupid, IMO.

Edited to add: OP, I just read your last post. I appreciate you trying to explain it, but I still don't see the rationale behind it. Like I said, it's a stupid rule.

I agree. That's why there's always these issues. I haven't worked in hospitals before but I think pharmacy has more control/say in LTC. I'm all alone on NOCS for over 50 pts. so I try my best. It just sucks when my boss/management thinks that I'm doing a crappy job.

miss81, BSN, RN

Specializes in Surgery, Tele, OB, Peds,ED-True Float RN. Has 8 years experience.

My understanding was that the pharmacist on-call wasn't at his facility as it was after hours and had no access to the MD order to verify anything so he denied authorization. And that's what contingency is for-if we don't have the meds delivered. However, for narcotics we still need pharmacy to approve us going in and pulling the med out.

Thanks for your explanation, I understand what you are talking about now! Still weird to me tho'... like GM2RN said, if a Nurse with a brain, a license and assessment skills AND a Doc with a brain and a medical license can't figure it out then there's something wrong... who is a Pharmacist to refuse it? I agree GM2RN, stupid...

I agree. That's why there's always these issues. I haven't worked in hospitals before but I think pharmacy has more control/say in LTC. I'm all alone on NOCS for over 50 pts. so I try my best. It just sucks when my boss/management thinks that I'm doing a crappy job.

Yeah, well, you have to play by their rules but you don't have to let them get into your head. You know what's what so just let it roll off your back. I'm sure you have better things to do than spend your time thinking about some idiots in suits. :up:

We have to have authorization from pharmacy where I work as well which is a LTC facility for our narcs. And the only reason we wouldn't get it would be if there is something wrong with the signed script from the doctor which is what they need in order to send the auth. number. Sometimes the MD leaves out how often to give or doesn't put on how many pills to be filled and so forth. And no matter what time of night it is we have an emergency line to page the on-call pharmacist. So we can get what we need at any time.

If we pulled without the auth. number where I work we would be in trouble.

So I'm curious about the pharmacist not being in his facility to see the order so he denied it? What if you needed to give the medicine? Give it before they authorized you to do so? I mean if you follow policy and wait for the number but have no pharmacist available isn't this delay in care? I think some of the hoops we have to jump through are ridiculous. I work on our rehab. side of the building so we get admissions all the time who are post surgery and so forth so we are always getting auth. numbers. And it can be time consuming.

I learned recently at a nursing meeting that nursing homes are more regulated than nuclear power plants! I believe it is for that reason that these asinine scenarios occur. In sub-acute(non-hospital), we have an narcotic box for emergency situations, and with frequent admissions, "emergency" becomes a daily occurrence.

I have had times when the pharmacy would not finish processing the admission order because there was not a date on the script. OK, I'll date it, could you please send my patient's meds? Also, I have been told that I could not pull the narc from the e-kit because the delivery was "on its way." "On its way" could, I am not kidding, mean five hours later! Meanwhile, I have a patient in front of me crying in pain. It is at that point that I call the doctor and have him call in to pharmacy another 2 or 3 pills until the drugs arrive. The problem is that they are held accountable to the federal government for EVERY SINGLE PILL. Abuse of narcotics by health care professionals has led to this increased regulation. Has it fixed the problem? Um, no. Anyway, just my:twocents:.

From the DEA, Office of Diversion Control's website:

"Many of the narcotics, depressants, and stimulants manufactured for legitimate medical use are subject to abuse and have, therefore, been brought under legal control. Under federal law, all businesses that import, export, manufacture, or distribute controlled substances; all health professionals licensed to dispense, administer, or prescribe them; and all pharmacies authorized to fill prescriptions must register with the DEA. Registrants must comply with regulatory requirements relating to drug security and recordkeeping. The DEA is also obligated under international treaties to monitor the movement of licit controlled substances across U.S. borders and to issue import and export permits for that movement.

Diversion investigations involve, but are not limited to, physicians who sell prescriptions to drug dealers or abusers; pharmacists who falsify records and subsequently sell the drugs; employees who steal from inventory and falsify orders to cover illicit sales; prescription forgers; and individuals who commit armed robbery of pharmacies and drug distributors."

ETA: You did nothing wrong. I would have acted in the same manner. The patient was in bed, and he was resting comfortably. Unless this was a scheduled med to be given, then I would have followed up further.

Edited by Art_Vandelay

sharpeimom

Specializes in ortho, hospice volunteer, psych,. Has 20 years experience.

sounds as though you happened to be in the wrong place at the wrong time. you did nothing at all wrong. hang in there, because when your manager calms down a little bit, she'll realize you didn't

make an error.