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 work in a very small rural hospital and I have mixed all my abx. Whenever we (charge nurse and I) come accross something we are unsure of how to mix....we call the pharmacist. I mix most of my meds though.
If I were you I would go to the nurse manager and bring it to her attention. Maybe there needs to be an inservice or something if the noc nurses are going to be repeatedly put in the position of mixing there own piggys or drips. If this doesnt help, find another job....
In Illinois JCAHO has taken issue with this. RN's are NOT to be mixing IV medications, only in emergencies ie: codes.
Unfortunately where I work they have not taken issue with pt's not receiving antibiotics etc... until the next day because there is no pharmacist on duty at night.
If I'm not mistaken, when JCAHO takes issue with something it's nationwide.
I think this whole issue of nurses should not mix drugs was part of JCAHO's 2005 (?) "goals" for medication safety. Near the end of 2004 is when we stopped mixing our replacement lytes (we never mixed K+ btw) for piggyback and we started the "high alert" meds thing.
For nurses who are truely doing the work of a pharmacist, check out your NPA and what your BON has to say about it. I'm pretty sure RN's should NOT be doing what the OP describes.
If I'm not mistaken, when JCAHO takes issue with something it's nationwide.
I think this whole issue of nurses should not mix drugs was part of JCAHO's 2005 (?) "goals" for medication safety. Near the end of 2004 is when we stopped mixing our replacement lytes (we never mixed K+ btw) for piggyback and we started the "high alert" meds thing.
For nurses who are truely doing the work of a pharmacist, check out your NPA and what your BON has to say about it. I'm pretty sure RN's should NOT be doing what the OP describes.
OH my gosh!! Really?!! This is really interesting because I mix EVERYTHING!! K+, ABX, and many more!!! Can someone give me more info as to where I can find out about this?? I live in Texas and..... I'm an LVN.
Is there a difference between mixing meds and reconstituting them? Because while our pharmacy is running 24/7, there are still some medications that we have to reconstitute at the bedside because they are only stable for an hour or so after they've been prepared - example: Ampicillin. We don't have standard times for Ampicillin, so pharmacy would forever be mixing up vials of it for us when they have other things they need to be doing.
We mix: Ampicillin, Cefotaxime, and Ceftazidime on a regular basis. We used to do a lot more (Penicillin G, Indomethacin, Nafcillin, more...) but now pharmacy does most of our reconstitutions. For the ones that we do happen to do - either reconstituting powder with liquid or diluting down concentrated solutions - we have very strict guidelines on how to do this. Our unit has it's own PharmD that works M-F 9-5, and part of her job is to research the optimum concentrations of IV meds and what solutions to use for constitution or dilution. Everything is in a book at every single bedside - tells you what to use (sterile water or normal saline), how many cc's, what the final concentration will be, if it needs to be diluted further for a peripheral IV vs a central line (and if so, dilution instructions) if it's compatible with TPN, if it needs a special flush before or after (like Ampho), etc.
JCAHO has been on our unit many times and never made a stink about this.
The last place I worked was a small rural hospital. Nurses mixed all of their own abx, K+, steroids, etc. Never anything that required a hood, though. I heard that nurses are no longer allowed to mix K+ in that hospital.
Hi, Gompers.....I think the OP is talking about something quite different. We've all been taught how to do reconstitutes in school, ATB, etc; she had something that after going through several people no one still knew how to do it, yet it was sent to the floor to prepare. And it turned out she needed a lab and a hood to do it!
Yes, well you have all given me something to think about. The hospital I work in is rather small but opening a large wing in December. I'm told at that point there is still no plans for a on site pm pharmacist. As far as diluting meds and mixing them, much of it is uncomfortable because I am still fairly new. I have done a fair amount of vancomycin but morphine drips make me nervous. And may I add that no one supervises us when we mix. The Morphine made me nervous because I asked for supervision and no one would supervise. No I did not have a full pharmacology course in school. Pharmacology was integrated into regular class work. Also, we must hang an antibiotic within 5 hours of getting the order or we can get written up. So we are forced to do a certain amount of reconstituting or mixing if the drug is unavailable in its finished form. I guess I'm not a happy camper.
No nurse should be preparing IVIG or morphine drips or any drips.
IVIG is NOT an abx.
Of course we reconstitute meds and those include abx. Apparently some places still prepare their own replacement lytes for piggyback.
I will mix 40 mg of protonix into a 25ml ns bag after reconstituting it and piggyback it just so I don't have to stand there and push it.
There are several drugs when I do this, but NEVER morphine and never something like IVIG. Especially IVIG would be like adding blood to a bag of normal saline and then hanging it for your patient. Would you really feel good doing that? Does it really sound very safe?
I wonder if someone needs an epi drip and because there is no pharmacist, the nurses go get a vial of concentrated epi and "mix" it with some diluent and then hang it for titrating for their patient.
Again, NOT taking about the re-constituting, etc. that nurses do every day. What I read from the OP is MUCH different.
Yes, well you have all given me something to think about. The hospital I work in is rather small but opening a large wing in December. I'm told at that point there is still no plans for a on site pm pharmacist. As far as diluting meds and mixing them, much of it is uncomfortable because I am still fairly new. I have done a fair amount of vancomycin but morphine drips make me nervous. And may I add that no one supervises us when we mix. The Morphine made me nervous because I asked for supervision and no one would supervise. No I did not have a full pharmacology course in school. Pharmacology was integrated into regular class work. Also, we must hang an antibiotic within 5 hours of getting the order or we can get written up. So we are forced to do a certain amount of reconstituting or mixing if the drug is unavailable in its finished form. I guess I'm not a happy camper.
The OP's question doesn't pertain to the usual reconstitutions we do as part of our jobs. You are expected to reconstitute atbs, you'll just have to get used to that. You may be uncomfortable now, but that IS within your scope of practice. You are NOT expected to mix morphine for drips. Very different!
CyndieRN2007
406 Posts
I work in a very small rural hospital and I have mixed all my abx. Whenever we (charge nurse and I) come accross something we are unsure of how to mix....we call the pharmacist. I mix most of my meds though.
If I were you I would go to the nurse manager and bring it to her attention. Maybe there needs to be an inservice or something if the noc nurses are going to be repeatedly put in the position of mixing there own piggys or drips. If this doesnt help, find another job....