Multiple doses in same syringe?

Nurses General Nursing

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Hi all, I just started working in an outpatient PACU and I already made a mistake =( 7 years as a nurse and the only med error I've ever made was giving 200mg IV thiamine instead of 100mg. I'm used to drawing up only the amount of a med I'm giving and wasting the rest. So if giving 25mcg fentanyl from a 100mcg/2ml syringe, per hospital policy I would just draw up the 0.5ml and waste the rest. Then if I need another 25mcg, do it again. I know it wastes medication but that is how we did it, never walked around with fentanyl in our pockets. 

Here there are orders for fentanyl 25mcg q 5 mins up to 150mcg. Their policy is pull the whole 2ml, give 0.5ml at a time and waste what is left. I feel nervous pushing in only a portion of what's in a syringe, and about holding on to a syringe with narcotic in it. They do have a box you're supposed to lock the syringe in for the 5 mins between doses but no one uses it. I was doing OK when they had 3ml syringes because it was easy to see the markings for 0.5ml, but now they ran out and today I had to use a 5ml syringe with no clear markings other than each 1ml. I wanted to just draw up 0.5 at a time but they said we can't re-access the vial even if clean w/ alcohol pad. I drew up the whole 2ml and when trying to push in 0.5ml accidentally gave almost 1.5! so pt got 75mcg instead of 25mcg. Pt was fine and ended up getting another 25mcg anyway, but I still let the manager know. He was very nice about it, and said it's OK to draw up 0.5 at a time and re-access the vial. He said just don't do it again but don't freak out or beat yourself up. I am so embarrassed to mess up on week 3, but glad pt is OK. What do you think of this protocol and how bad should I be feeling? I usually blow things out of proportion so need perspective!

klone, MSN, RN

14,790 Posts

Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

I'm kinda old school, and we used to draw up an entire vial of Nubain and only give part of it, hold onto it, and give the rest later (I would tape the vial to the syringe). So that doesn't bother me. But I disagree with the policy about not re-accessing the vial if it's for the same patient in the same day. What is their rationale for that, I wonder?

JBMmom, MSN, NP

4 Articles; 2,537 Posts

Specializes in New Critical care NP, Critical care, Med-surg, LTC.

I understand where you're coming from. For example, we have normal PRN orders for 20 mcg fentanyl Q 15 minutes for pain. The vial is 100 mcg fentanyl and technically we are supposed to pull a new vial every time and waste the remaining 80 mcg. This is extremely wasteful and while we also aren't technically supposed to access the same vial multiple times, most nurses will leave it in the locked cabinet in the room and reuse a vial before discarding at the end of the shift. If, however, the state were to survey during the shift and find an open vial, this would be considered some sort of offense. I agree that pulling up a whole syringe and administering only part is difficult, I'm sure others have made the same mistake. Don't be too hard on yourself, these things happen. 

Specializes in Community Health, Med/Surg, ICU Stepdown.
20 minutes ago, JBMmom said:

I understand where you're coming from. For example, we have normal PRN orders for 20 mcg fentanyl Q 15 minutes for pain. The vial is 100 mcg fentanyl and technically we are supposed to pull a new vial every time and waste the remaining 80 mcg. This is extremely wasteful and while we also aren't technically supposed to access the same vial multiple times, most nurses will leave it in the locked cabinet in the room and reuse a vial before discarding at the end of the shift. If, however, the state were to survey during the shift and find an open vial, this would be considered some sort of offense. I agree that pulling up a whole syringe and administering only part is difficult, I'm sure others have made the same mistake. Don't be too hard on yourself, these things happen. 

Thanks! I'm so glad the pt was OK. I agree wasting tons of medication is wasteful, but I'm used to it and don't like walking around with syringes full of narcs LOL also at the hospital we had to record the wastes in the Pyxis and would get in trouble for giving multiple doses from same syringe. sucked when etoh patients got 10mg valium q 15 mins and it came in a 50ml vial! wasting 40ml over and over felt bad. thanks for your reply!

Specializes in Community Health, Med/Surg, ICU Stepdown.
1 hour ago, klone said:

I'm kinda old school, and we used to draw up an entire vial of Nubain and only give part of it, hold onto it, and give the rest later (I would tape the vial to the syringe). So that doesn't bother me. But I disagree with the policy about not re-accessing the vial if it's for the same patient in the same day. What is their rationale for that, I wonder?

I guess infection risk? I always clean with alcohol pad between accessing. Insulin vials with multiple doses you have to do this, and with some other meds in my experience. I think I'm going to just do it that way, but I find drawing up 0.5ml into a 5ml syringe is hard to not get air bubbles. so maybe I'll draw it, then dilute it with saline. Manager said it's OK! thanks for your reply! at least pt is fine and I'm not fired and on my way back to my covid unit LOL even though now I feel like I deserve it =( =(

MunoRN, RN

8,058 Posts

Specializes in Critical Care.

The 'official' regulatory rule regarding "single-dose / single-use vials is that the "single" part refers to a single procedure, case, or administration.  For instance, the process of recovering from anesthesia is considered a single procedure.  If the medication is ordered as a range and your are starting with the lower end of the range, assessing, and then giving additional dosages within that range then that is considered a single 'administration', and can be done from the same vial.  CMS and state regulators defer to the CDC guidance on repeated accesses of the vial, which it discourages but does not outright prohibit.  Their preferred method is to draw up the amount of medication potentially needed in one access, then give repeat doses from that syringe.  They do say however that the person administering the medication can use their judgement as to whether repeated accesses may outweigh the risks if doing so makes measuring the dose more accurate because you are able to use a smaller syringe.

Wuzzie

5,116 Posts

The last place I used Fentanyl it was in an ampule so we either wasted or drew up the entire amount and saved the syringe. Of course it’s been awhile and apparently the world has turned upside down because our compliance officer just dinged us for having unopened saline syringes in graduate cylinders which nurses have been doing since the dawn of time. 

MunoRN, RN

8,058 Posts

Specializes in Critical Care.
5 minutes ago, Wuzzie said:

The last place I used Fentanyl it was in an ampule so we either wasted or drew up the entire amount and saved the syringe. Of course it’s been awhile and apparently the world has turned upside down because our compliance officer just dinged us for having unopened saline syringes in graduate cylinders which nurses have been doing since the dawn of time. 

Certainly one of the frustrating things about regulatory requirements isn't so much the requirements, it's the wide variation in how well people understand what they are, including surveyors and even the hospital's own compliance staff.  Saline syringes are a good example since they aren't even considered to be medications by regulatory definition, they are classified as a "device" since they are not used to treat or diagnose a medical condition, they are used for the maintenance of a medical device.  

Wuzzie

5,116 Posts

23 minutes ago, MunoRN said:

Certainly one of the frustrating things about regulatory requirements isn't so much the requirements, it's the wide variation in how well people understand what they are, including surveyors and even the hospital's own compliance staff.  Saline syringes are a good example since they aren't even considered to be medications by regulatory definition, they are classified as a "device" since they are not used to treat or diagnose a medical condition, they are used for the maintenance of a medical device.  

She wasn’t even upset about the saline it was the “inappropriate use of a medical device” ie. the graduate cylinders. ? She honestly tried to make us believe we would be fined for it. She’s just awful.

JKL33

6,777 Posts

Just me:

Once worked where there was a safe in which we were to store labeled syringes of controlled substances for the exact type of situation you're talking about. The safe was in a high-traffic area in a chaotic department and every nurse had the means to access it.

I stopped using that safe was the day I sat in a staff meeting which was a lecture that included random ranting, hateful tones of voice, waving of fingers and threats of BON reporting if there were any aberrancy with controlled substances. I decided then that I wasn't putting any narcotics that had been withdrawn from Pyxis in my name, into that safe.

Going forward, I decided to properly cleanse and re-access my vials to administer subsequent doses of meds if I was staying at that patient's bedside. If it was a situation where I would be leaving that patient's bedside to attend to another patient, I did the waste and started over with a new vial for the next dose.

 

MunoRN, RN

8,058 Posts

Specializes in Critical Care.
13 minutes ago, Wuzzie said:

She wasn’t even upset about the saline it was the “inappropriate use of a medical device” ie. the graduate cylinders. ? She honestly tried to make us believe we would be fined for it. She’s just awful.

Her concerns was 'off-label' use of graduated cylinders?  I'd hate for her to see all the things we use plastic wash basins for (non of them are as wash basins).  Or tourniquets for that matter.

Specializes in Mental health, substance abuse, geriatrics, PCU.
11 hours ago, klone said:

I'm kinda old school, and we used to draw up an entire vial of Nubain and only give part of it, hold onto it, and give the rest later (I would tape the vial to the syringe). So that doesn't bother me. But I disagree with the policy about not re-accessing the vial if it's for the same patient in the same day. What is their rationale for that, I wonder?

Nubain, now there's a drug I haven't given in a LONG time. Is there anyone left in our society that's opiate naive enough to even get this drug? 

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