overdose on RX meds

EmergencyNrse · Nov 8, 2011

Nope, not your Rx.

Up to the Doctor to write the script after H & P and examination.

You might print out a visit history to help out but ultimately the

doctor's responsibility for narc seekers not you.

Trauma Columnist · Nov 8, 2011

In IL, we have the Prescription Monitoring Program website which allows providers with DEA numbers to somewhat monitor their pts narcotic and controlled substance use. It does run about 2 weeks behind. However, it includes all controlled substances prescribed to a pt and includes all insurances as well as the pts that pay cash.

Double-Helix, BSN, RN · Nov 8, 2011

We give patients necessary medications to control their symptoms when they are in the hospital (or home care). We give the patient the prescribed dose and we check to make sure the ordered dose is safe.

We should be educating them about their medication and the side effects and importance of taking the prescribed dose.

We don't overdose the patients.

In the hospital, the patient should be brought off the medication as quickly as possible. If it's for pain, switch to an non-opiod medication when they can tolerate it. If it's chronic pain, they may really need the narcotic. Psych meds may be very necessary. If the patient goes home on the medication, they should be educated about possible dependance and what to do if that occurs.

Nurses do not contribute to the overdoses by correctly and safely giving medication to patients while they are under our care. What the patient does when they get home is out of our control. Nurse's are responsible for so much already that we should not have to feel responsible for the patient's choices after discharge.

Esme12, ASN, BSN, RN · Nov 8, 2011

Do we as nurses in the ER be held accountable for the recent rise in RX meds overdose. I know the doctors write the RX but we give it to them. I see the same people every week yelling if they don't get their lortab/norco. my hospital ER gives it out like tic-tacs due to increase in survey numbers. just wanted to hear everyone's thoughts.

How are we as the ED nurses overdosing patients? Abuse and Addiction are two different situations from overdose. The Abuse of prescription meds is not our fault. Yes, the MD's write the meds and we administer them, but how does that make us accountable for the patients abuse of their home meds? What is it about your emergency department's policy is bothering you? How much is being given and prescribed? What exactly do you mean by "overdose"? How much are you giving at one time that would be considered and "overdose" versus addiction and abuse of prescription meds? Is your hospital allowing unethical behavior to increase scores or volume to increase porfits?

Many state's now have, or will soon have, programs that monitor the prescribing practice of MD's and/or the patients overall consumption of narcotics or filling of narcotics and reported/watched by the DEA.

You are responsible for the meds you give, but not that the patient is addicted or seeking, unless the amount you are giving is not safe, you give the med in a manner that is not prescribed or safe (injecting lortab or allowing someone to crush and snort oxy's right in front of you). If your hospital/EDMD's is engaging in unethical behavior then you need to report them but you are not responsible for their behavior.

pm2rn · Nov 8, 2011

maybe "overdose' is too strong of a word. we have the system to monitor RX given to the pt. But if a pt is a known pill seeker and we con't to give them RX norco/lortab etc aren't we part of the problem. Nothing "unethical" going on but maybe not the best course of action. keep seeing report of the increase of RX overdoses and see how far ER's go to maintain good survey numbers.

CrunchRN, ADN, RN · Nov 8, 2011

You have no power in that situation so I wouldn't worry about it. If the doc orders it then what can you do? I would not want to go there as far as trying to change their practice..... you can only lose. Leave that to others.

Esme12, ASN, BSN, RN · Nov 8, 2011

maybe "overdose' is too strong of a word. we have the system to monitor RX given to the pt. But if a pt is a known pill seeker and we con't to give them RX norco/lortab etc aren't we part of the problem. Nothing "unethical" going on but maybe not the best course of action. keep seeing report of the increase of RX overdoses and see how far ER's go to maintain good survey numbers.

Even "seekers" have pain. How do you tell if you are ignoring the pain of a seeker just because they have an addiction problem. Prescription meds have long been used as a method to OD to hurt oneself and certain prescription drug have been sold on the streets for abuse. I remember when Talwin (nor longer manufactured) was melted and shot up or valium snorted or other of label uses for prescription pharmaceuticals. SOme ED 's have a higher incidence that others but drug seekers and frequent flyers #1 know what ED's put out and will return and #2 frequent ED's and become obnoxious when they "run out" at home.

Responsibility....not yours.

Munch · Nov 8, 2011

Absolutely NOT. In triage(at least in the hospital that used to work at and the hospital I'm at now), the nurse asks what medications they are on(and if they do indeed take medications at home, especially opiates and benzos) the triage nurse asks if they took the medication that day, the time of day and the dosage(of course some patients can lie).

I remember floating down to the ED a couple of times(NEVER AGAIN) and a patient was yelling about their back and neck hurting so the doctor ordered 2mgs of dilaudid and 2 mgs of ativan(for muscle relaxation) both by IV because they said they were a chronic pain patient(we tried calling the number of the doctor the patient gave us and the line was busy, actually we tried calling a couple of times)PM doctors usually have a narcotic contract with the patient stating the patient can only get certain medications only FROM their PM doctor or the doctors partner(s) unless the patient ends up in the emergency room(the doctor recommends going to the hospital they are affiliated with, but according to this patient the hospital the doctor practices at was 45 minutes away from where the patient lived). So we called and called and no answer. So the patient said at triage that they took oral dilaudid and oral ativan so the doctor figured we would give the patient the same medication, document it and fax it over to the hospital that the patients doctor was affiliated with.

So a nurse(not me I was working on the other side of the ED) administered the medications. We all know that IV medications can work quickly. About a half an hour-45 minutes they called a code on this patient. The patient went into respiratory arrest, lost consciousness and went into VF. The code team worked on the patient for a little less than an hour and the patient expired. No one understood why. The ER docs went over everything with a fine tooth comb. 2mgs of dilaudid and ativan wouldn't kill a chronic pain patient, especially if they were taking the medications already and for a while...also wasn't an allergic reaction to anything..the patient came in with neck and back pain.

The patients emergency contact came in(the patient was there alone) and was asked questions such as allergies, if the patient may have eaten something they didn't know they were allergic to, etc. The emergency contact said the patient didn't take ANY medications at home except maybe some antibiotics for certain things but that is it. The contact didn't want to do an autopsy unless they couldn't figured out what happened. The bottles were brought to the pharmacy to examine what was inside(this emergency contact WAS appointed power of attorney to this person so the contact did give permission to have the medications examined)...turns out the bottles did NOT have antibiotics in them but one had a few types of narcotics in it, another had two types of benzos in it and another had a strong muscle relaxant in it. The contact said this person was never prescribed any of these medications, maybe a milder narcotic a couple of times for tooth problems.

So the patient lied, got Strong IV medications with PLENTY of medication already in their system. Tox screen showed extremely night amounts of narcotics...enough to numb a cow. Then we called the hospital the patient told us about...the doctor did exist and did see patients a few times a week and worked the rest of the weekdays in the hospital, however the doctor was on vacation so we don't know if the doctor knew the patient or not.

Anyway with this incident no nurses or doctors got reprimanded, however the director of the ED did call a meeting with everyone that was in the ED that day myself included(and I work the floors..I was just a float for one day). The director just said to become more conservative when giving out medications and if a person is under the care of a pain management doctor to actually speak to the doctor before administrating any medication.

Altra, BSN, RN · Nov 8, 2011

This is a kind of chicken or egg question.

Our culture is such that we are pretty intolerant of symptoms. "Rest" and "time to heal" are not popular concepts. Nearly 20 years of direct-to-consumer pharmaceutical advertising has made us acutely aware that there is a pill out there for pretty much any symptom you wish to alleviate.

This is reflected in the health care subculture. What is health care, after all, but management of symptoms while attempting cure, if possible? Anything less than a full court press, aggressive approach to symptom management is seen as *ahem* poor care. And lacking in compassion, too.

And so we get into what could politely be called *generous* prescribing practices. It has become an expectation. If I have come into the ER because my xxxx hurts, then of course I expect that you're going to do something to relieve the pain in my xxxx.

Prescribers are definitely wedged between rocks and hard places, particularly so in the ER. When there are emergent patient needs, a full waiting room, and a nontraumatic xxxx pain ... what is the most expedient way to clear some things off the deck?

As nurses, we are caught up in this larger cultural phenomenon.

I have seen some push back in the last couple of years, such as drastically scaled back administration of IV Dilaudid in ERs in my region and more seasoned ER providers being less willing to write out that Rx for Percocet/Vicodin/etc.

Editorial Team / Moderator · Nov 8, 2011

I have seen some push back in the last couple of years, such as drastically scaled back administration of IV Dilaudid in ERs in my region and more seasoned ER providers being less willing to write out that Rx for Percocet/Vicodin/etc.

I've seen this as well, and it changed drastically for me going from civilian to Army ... I can count the times I've given a narcotic IV in my last couple shifts on one hand, vs. running out of both hands in one shift. :) I think I give Toradol and Zofran more than anything else. Our providers also don't write many narcotic prescriptions unless the patient has something acute going on. It's nice. We can also look up everything that a patient has had filled, and this includes family members, not just active duty soldiers.

thelema13 · Nov 9, 2011

Our ED docs during the day seem to give out less narcs than the night docs. Opposite of what I thought. We have one doc that labels everyone as a seeker. A huge part of the problem is drug companies advertising to the public, in our society we need a magic pill to fix problems NOW. People do not follow discharge instructions. Our society is partly to blame. People are the main problem.

In my ED our narc Rx are for 4-8 tabs and referral to our pain management doc, who hates to give narcs for everyday pain. He is awesome and is trying to minimize abuse/ addiction.

What people do at home is beyond our control. I feel bad for the old folks ODing because they are confused. I do not feel bad for the kid trying to get really high. Never understood using pain meds like that, they become zombies. Not the life I want to live.