nurses mixing meds

SharonH, RN · Jul 30, 2006

Hi! I need opinions. I am in my first year of nursing on a small med surg floor. I work 7pm-7am and our pharmacy closes at 9. We get coverage from 9pm till 7am through fax and computer, under a contract made with another area hospital. As far as I can tell, that pharmacist will review new med orders and unlock those med drawers in the PYXIS under the name of the pt for whom the drug has been ordered. Many times, we mix our own antibiotics because they were not brought to the floor before pharmacy closed for the night, even standing orders. However, the antibiotic can usually be over ridden, removed from the PYXIS and mixed appropriately. I have never been comfortable with this system as I am not a pharmacist. Two nights ago, I had an order for IGG serum IV. I did not find it on the floor. I then paged the nursing supervisor who went to the pharmacy, got the vials, and told me to mix them. I opened the first box and discovered that it was a powder, and had no real useful instructions for mixing. I paged the supervisor who told me to take the vial to ICU and they could help me with it. Well, to make a long story short, they could not tell me. We sat down together to look at the instructions and discovered that the vials could not be mixed in the % necessary for the dose ordered. That's when I said "not doing this!" I paged the nursing supervisor again, explained the best I could. She sighed, came back to the floor and picked up the 2 vials and took them back to pharmacy. I found out in the morning when pharmacy opened back up that the drug need to be mixed under strict procedure and under a hood and takes an hour to do properly.
On the very next shift, I had just taken report on a care and comfort pt who was awaiting a morphine drip. Pharmacy had closed even earlier this day, due to "staffing issues" The nursing supervisor who had promised to go get the med. When I walked out of the report room, there was the nursing supervisor (different supervisor from the night before). She handed me the vial of morphine (10 mg per ml for a total of 10 mls) said "Here", turned heel and disappeared up the hall. I looked up how to mix it in the drug reference book, but then felt EXTREMELY uneasy. I took the vial back to the nursing supervisor and told her I was not comfortable with mixing it. She gave me verbal instructions on mixing it, and along with the instructions in the drug book, I mixed it. The other nurses on my floor said they would have refused to mix it but my pt was in a great deal of pain (severe COPD, and a broken vertebrate) and I felt a duty to her and her family.
NOW-Sorry for the long post, but has anyone else had this experience? And by the way, I am told that we USED to have a full time pharmacist. What do you think I should have done? Previously this pt had been on 2-3mg q 30 minutes.

I think you need to start looking for another job ASAP. They are asking you to do procedures for which you have clearly not been trained for or educated on and they are endangering patients and your license in the process. I wouldn't have done it under any case. Good luck on your job search.

Nieuport · Jul 30, 2006

Hi, Alongbella

I work under a very similar situation. Only one of the night nursing supervisors do I trust for following medication orders. But this might help at least a little.......

I've tried to develope some rapport with the pharmacists at the "pm-am outside pharmacy". They're very good at what they do (OK.....when you can actually get through to them on the phone. LOL) But the couple of guys it seems I always talk to don't mind in the least talking me through preparations or even at times actually writing it out and faxing it to me. Also, we use emar and frequently they will include mixture instructions in the "View More" history administration under a med. And then there's always the doc's.....sounds nuts I know, but I'm talking more about reference knowledge more so than pharmaceutical experience. One doc and I waited through 3 phone pages of another physician getting back to us the other night with instructions on delivering peritoneal antibiotics. But it was worth it while frustrating. The doctor wrote up the instructions as an order in the chart. The delivery then made sense to me. So was able to administer the meds as originally ordered and felt fine doing it...just took a bit of frustration time waiting to get it done properly.

Don't let this stuff get to you. Cultivate your resourses around you. They may be in some unlikely places! Good luck and keep caring.

TazziRN, RN · Jul 30, 2006

I work in a small facility at which, until very recently, we had a pharmacist in house only two days a week. He tried to have things stocked so that all the supe had to do was go in and grab what we needed, but it was not uncommon to have to mix things ourselves. If you are not comfortable mixing something and there is no one else willing to do it for you, DO NOT MIX IT! Call the doc and let him know that the IV form is temporarily unavailable and get an order for another route.

I also agree with the first response......find another job.

LoriAlabamaRN · Jul 31, 2006

How frightening! We have a pharmacist on call. There's no way I would mix medicines. I'm not trained for that, and the potential for error is enormous.

nursemary9, BSN, RN · Jul 31, 2006

I would definitely start loking for another job!Many, Many years ago, we also didn't have a night time pharmacist, but as I say, that was in the dark Ages. Every place I have worked at now has a full-time nught phatmacist.

I really would not be mixing those things. As you said, some things require a hood; and some things are just so specialized that we are not qualified to do the mixing.

The potential for error is HUGE.

If you are not comfortable, don't do it. Let the Supervisor do it.

Mary Ann

military spouse · Jul 31, 2006

Last job was in a hospital where all after hours meds were mixed by the house supervisor. That worked out well for us, but probably not so well for her:wink2: Now, I work corrections where we mix the majority of our own meds, usually they are ABT and simple. I would refuse to mix/give ANYTHING that made you uncomfortable. I would also document who you notified and all that good stuff!

begalli · Jul 31, 2006

Is it no wonder that 1.5 million Americans are effected by med errors each year?

In the ICU we used to mix mag and calcium in 25ml piggyback bags. We don't even do that anymore except in emergency situations. Our abx either come pre-mixed and refrigerated or we have the (shoot, I can't remember what they're called - senior moment!), bags with the vials attached to the top and you just pop the cap and mix it into the diluent.

IVIG?? That's outrageous and extremely dangerous.

Rarely do we mix anything.

You must draw the line in your practice somewhere.

Good luck to you.

RNsRWe, ASN, RN · Jul 31, 2006

Wow. I worked too hard for my license to lose it because of a mistake in mixing meds--a mistake I was not trained to avoid.

I'm a nurse, not a pharmacist; when you're short-staffed, do the pharmacists come up and do your patient assessments??

No way.

begalli · Jul 31, 2006

By the way OP, in my reply I don't mean to make you feel bad. It sounds like you are in a really tough situation and you're trying to do the right thing.

I would really take your concerns to your Nurse Manager. It's just way beyond any RN's scope of practice to be doing the work of a licensed pharmacist. If they are not willing to see the error of their ways or make it safer, then it is probably time to move on.

Sounds like you may be in a rural area? Hopefully there is somewhere to move on to?

Kev702 · Jul 31, 2006

Maybe I'm missing something here. I've been mixing my own drugs for the better part of 17 years or so as a RN (in ER). I have never (to my knowledge) mistakenly mixed the wrong components (diluent or drugs). I must admit that when I have mixed some of the heavier, expensive drugs, I have been a little more careful than usual, but NEVER have I refused or flat out given up on mixing a drug for my pt.

What's the issue? Did you not take a full pharmacology course in college?

Hey, I'm not flaming anyone, just surprised! Isn't this a PART of nursing? I've worked places where the Pharmacist is only in during normal business hours. No one freaks 'cuz the Pharmacist is home. As long as the needed meds/diluents are available, what's the problem?

RNsRWe, ASN, RN · Jul 31, 2006

Maybe I'm missing something here. I've been mixing my own drugs for the better part of 17 years or so as a RN (in ER). I have never (to my knowledge) mistakenly mixed the wrong components (diluent or drugs). I must admit that when I have mixed some of the heavier, expensive drugs, I have been a little more careful than usual, but NEVER have I refused or flat out given up on mixing a drug for my pt.
What's the issue? Did you not take a full pharmacology course in college?
Hey, I'm not flaming anyone, just surprised! Isn't this a PART of nursing? I've worked places where the Pharmacist is only in during normal business hours. No one freaks 'cuz the Pharmacist is home. As long as the needed meds/diluents are available, what's the problem?

I don't believe the OP is talking about the normal mixes we learn in school: simple reconstitutions, or diluents for IV pushes. She described something far beyond that....read her exact post on what she was expected to do, and how she had to go through several people for a confusing med order only to find it was NOT something she should do, it SHOULD have been a pharmacist only, and in the pharm lab.

No, what she described goes beyond our scope of practice.