I've been working a nursing contract for almost 3 months at a hospital over an hour from my home. This weekend I had a MRSA pt restarted on Vanco q 24, he didn't get the first dose until 1700. The next day, the Vanco was timed for 1000.
Now, this patient had multiple problems, including renal insufficiency. I called and asked to speak to one of the pharmacists. I asked her, wouldn't she like to reschedule when that Vanco was scheduled, because if she looked at the CareT computer med charting from yesterday she'd see that I gave the Vanco at 1700. As you all know, Vanco is nephro and oto toxic and must be given on time, as ordered, to avoid too high of levels.
She responded that she had been told that q day dosing should be at 10 AM for the convenience of nursing. 'Hello! What kind of pharmacist are you?' I thought. I responded by mentioning that this was Vancomycin we were talking about here, and shouldn't we have the next dose 24 hours after the previous one? She impatiently responded "I don't care when it's scheduled, whatever you want will be fine". She repeated the line "I don't care" more than once in our conversation, although she did agree to rescheduled the Vanco to 1700.
Frankly, this seems to me to be an utter dereliction of duty on the part of the pharmacist. This wasn't a pharmacy tech I was speaking to but a pharmacist. Pharmacists are supposed to be the first guardians at the gate of med administration. At my usual hospital the pharmacists are very meticulous about timing medications based on when they were started. I'm talking about medications were the dosing interval is imperative, such as Vanco.
This hospital where I'm doing this contract is extremely busy and I've seen many things fall through the cracks, but this incident seemed like blatant disregard for professional standards. What do you think?
At this hospital there is an electronic medical administration system that is highly pharmacy dependant, with a hand held scanning device that prompts you to give meds when scheduled. It's a ridiculous system spurred by Joint Commision regulations and demands.
We have that system too where I work and it is very difficult to schedule meds on "off times" :PPPPP to Joint commissiion!!!!
When the MD decides to order a med, such as Vancomycin, he/she writes an order. This order is then processed by the unit secretary. The pharmacy then receives a copy of the order. In the case of Vancomycin, often the physician will leave the dosing to the pharmacist who will look at the patient's weight and also creatine clearance which assesses kidney function.
The pharmacist then processes the order and the pharmacy techs prepare the medication, which is then delivered to the unit for administration.
The time that this process takes is highly variable. The nurse then gives the medication and then charts when it was given, either on an electronic or hard copy medical administration record (MAR). The pharmacists receive these MAR at the end of 24 hours.
The pharmacists then have the responsiblity to review the MAR to see when the first dose of the Vanco was given, and then to schedule it accordingly. Also, pharmacists are responsible to order routine Vanco troughs and review them, then adjust the doses. Pharmacists also keep track of the patient's kidney function lab values.
So, for a pharmacist to act like she is indifferent when a nurse brings to her attention that the Vanco schedule is incorrect show me that there is something seriously wrong here. There is also a system error with the pharmacy at this hospital where this pharmacy responsiblity is not being fulfilled.
Just change the time on the MAR, since you know about the situation.
When the MD decides to order a med, such as Vancomycin, he/she writes an order. This order is then processed by the unit secretary. The pharmacy then receives a copy of the order. In the case of Vancomycin, often the physician will leave the dosing to the pharmacist who will look at the patient's weight and also creatine clearance which assesses kidney function.
The pharmacist then processes the order and the pharmacy techs prepare the medication, which is then delivered to the unit for administration.
The time that this process takes is highly variable. The nurse then gives the medication and then charts when it was given, either on an electronic or hard copy medical administration record (MAR). The pharmacists receive these MAR at the end of 24 hours.
The pharmacists then have the responsiblity to review the MAR to see when the first dose of the Vanco was given, and then to schedule it accordingly. Also, pharmacists are responsible to order routine Vanco troughs and review them, then adjust the doses. Pharmacists also keep track of the patient's kidney function lab values.
So, for a pharmacist to act like she is indifferent when a nurse brings to her attention that the Vanco schedule is incorrect show me that there is something seriously wrong here. There is also a system error with the pharmacy at this hospital where this pharmacy responsiblity is not being fulfilled.
Oh jeez...what a mess. Yeah, I see your point on this one.
A 'good nurse' has to depend on others to also do their jobs correctly in order to deliver safe, efficient patient care in a timely manner. Unfortunately, there is not time to thoroughly research all orders and previous MARs by 10 AM to make sure that systems in place have been carried out by all members of the healthcare team.
As in most hospitals, they had their "set times" for certain meds - 10am for "daily," 6am, 2pm, and 10pm for "q8h," etc....
The MAR was made up by Pharmacy, times and everything. We couldn't just "change the time" with this scanning stuff. We had to call pharmacy to get them to change it. They were usually very nice about it, although occasionally I got attitude, "we can't change this," or "get the doc to write an order timing it for whenever." Please. Waste of time.
My new job has a system where we can change the time if needed, and no scanning.
Scanning is a cool idea, but it was hellish in ICU where there is no pharmacy. Any change pharmacy made to the order (even if it was just the time), changed the barcode, and we needed a whole new label. Couldn't scan the one we had in our hands, even though it was the right med, dose route, etc! The time wasted and aggravation was unbelievable. I don't miss scanning.
A 'good nurse' has to depend on others to also do their jobs correctly in order to deliver safe, efficient patient care in a timely manner. Unfortunately, there is not time to thoroughly research all orders and previous MARs by 10 AM to make sure that systems in place have been carried out by all members of the healthcare team.
I always check my q 24 hour meds for last dose given. Sometimes I get lucky and can skip it on my shift.
Thank you to BradleyRN and jlsRN for continuing this discussion. (And all the other posters) This has been an education for me as a relatively new nurse. Also, I am so thankful that there are nurses who REALLY care and who deem it as being important to be professional and proficient. I knew you had to be out there somewhere!!!
I guess I have a little different perspective. Most hospitals have policy. One may say that for example Q24 hour antibiotics are given at 10 am. Another may be that Q8 hour meds are given at 8am, 4 pm and midnight. These times are usually arrived at by pharmacy and nursing discussing how the medication administration affects the nursing work portion, pharmacy work portion, pharmacy ordering stream etc. (this is in a perfect system, most policy seems to be developed by drunken lemurs with access to a computer). When you have a system like this usually you can start at whatever time the order gets put in but then the medication is moved to the appropriate time as soon as possible. With antibiotics like Vancomycin it is usually best to measure troughs when in the steady state which is usually the third dose. Therefore the best time to move it to a standard time is after the first dose. You will not change the trough much and the peak for Vanco is essentially irrelevant. This was probably the thinking when they moved the timing.
The second part is that the fact that the patient is getting Q24 dosing means they have crap for renal function. It really doesn't matter when the patient gets the Vanco as they are not going to clear it well no matter what. You could literally give the doses an hour apart and get similar troughs three days later. From that point of view "I don't care" while not politic is appropriate. It is kind of passive aggressive. The pharmacist should be explaining why it is better to give the dose at 1000 and not at 1700.
The issues with continuing a 1700 administration are that you are going to be in off hours when trying to calculate the trough and waiting til the next day for the pharmacy to do the levels. A 10 am administration means that they have most of the day to figure out the pharmokinetics.
For a review of vancomycin pharmokinetics I recommend this:
Sometimes I get lucky and can skip it on my shift.
CHATSDALE
4,177 Posts
if the initial dose was given a change of shift then all subsequent doses would also be given at the same time
but changing a dose time would have an effect on trough/peak
pharmacist should have bag ready for evenly spaced does but nurses can schedule with a little leeway