Pre-pulling Medicatons

SunnyAndrsn · Oct 25, 2009

Well, for one thing, it's against state regulations. This is something that you would get tagged on during state survey.

Second, it really doesn't save that much time. I do not pre-pull any meds, while I have co-workers that do. They don't get done any sooner than I do. I do any needed treatments as I'm passing medications, and I know which residents have meds do first, and which ones are last (and prefer to be last)

The only time it's legally acceptable to pre-pull medications is when they are being sent with a resident on LOA, and a responsible (or authorized) family member is giving the medications. You can also send with the the A&O patients. That's how I document it as well.

Some of my co-workers argue that it is a time savings. While I'm taking my cart down the hall and getting VS at 6:30 in the morning, they are pulling and labeling meds while chatting. Fine, it's their decision, not mine.

I have pulled ES tylenol for more than one pt. at a time--I have several pts. at the noon med pass who get *JUST* ES Tyelnol, so I will get two cups ready and pass them at the same time. I would not do that when State is visiting!

I have also seen multiple nurses "forget" medications in the top drawer of their cart. Or they tell the NOC nurse during report "I got the meds ready--they are in the top of the cart". And of course the NOC nurse forgets, the AM nurse comes in and there is 3mg of clonezapam and 2 vicodin sitting in the top of the cart all night.

I know I'm going to get bashed for this, but really...what is so horrible about pre-pulling medicatons? I'm not talking about a hospital setting where you have different patients on a daily basis. I'm talking about a setting where the patients get the same medications every single day. I'm not exactly pro for pre-pulling but I can understand why some nurses do it. Medications are the "easy" part of nursing, if you will. By having them out of the way (medications) and already pulled with a patients name or number on a cup to make sure your are giving the right medication to the right patient, you can spend time doing other essential things that are required. For example: You can have all the night medications already pulled and labled before it is time to pass. You can go assess each patient and do other essential duties. Then, when it IS time to pass, you will have them ready. Again, a hospital setting is different and I would be COMPLETELY against it in this situation...as you do not know the patients. I'm not for or against...but I do know some nurses who practice this way in a long term care setting. These nurses seem to have more time to spend with their patients. So...be honest here, does anyone or has anyone ever pre-pulled? (By the way...sorry for the bad grammer, haven't slept in 24 hours).

SunnyAndrsn · Oct 25, 2009

i have a coworker who is particularly sloppy. she just doesn't get that she has other co-workers who work that wing! pretty much at the start of her shift, she doesn't want to get "caught" without any stock meds, so she just grabs extra bottles of 81 asa, ibu, senna, colace, etc...so then there are lots of extra bottles that don't need to be in the cart just sitting there. we have a lot of newer grads right now, and it just adds to the confusion for them.

so...the days that i work her cart, i have to take a good 20 minutes or so to clean it. i take all the extra bottles out, make sure that they are labeled and dated, check for expired meds, pull the d/c'd meds to go back to pharmacy (or to get destroyed). it's very maddening! even when she orders new meds, i'll find empty cards or the plastic baggies with the pharmacy stickers still in the cart.

don't get me started on ordering insulins or dating insulins, eye drops, or nasal sprays!

the nurse that follows me after i clean? "oh good, sunny worked today! the cart will be clean!"

take your garbage out after lunch, and put the darn med pass back in the fridge--with a date! or else put it on ice (we have small coolers we fill with ice for the applesauce, etc)

vent over.

i positioned my quotes backwards... i'm sorry.
it makes it so much easir when you don't follow either an untidy or outright slob when you have to pour or pass or even just get a med for a patient or patients -- i.e. when you need a liquid prn psych med that's sticky, it's maddening to grab the large bulk-sized bottle only to discover that it was never wiped off before the numbskull -- i mean nurse -- ahead of you couldn't be bothered to either wipe it off or put it away when she was done. :angryfire:down:
ditto for getting rid of her trash, empty cans, bottles and other assorted crappola!!
kathy
sharpeimom:paw::paw:

kermitlady · Oct 25, 2009

I honestly don't see how pre-pulling your meds saves any time whatsoever. In all actuality, it actually INCREASES the amount of time you spend w/your med pass. You have to go through the MAR, pull the meds for that person, label that cup with a name, and hide it in the drawer of the med cart. AND THEN, you have to actually go down the hall, open said drawer and spend time FINDING the right cup of meds. And, hopefully, your hand doesn't bump any of the other cups sitting there b/c what would you do if you knocked over more than one cup of pills? Would you guess who gets which "little white pill?"....Sorry, but in my honest opinion, not only is pre-pulling your meds a huge waste of time but it is completely unsafe.

SunnyAndrsn · Oct 25, 2009

oh gosh, i knew this was going to happen. i respect your opinion but have you ever worked in a long term care setting taking care of 30-40 patients? if so, i would like to know how you survived. i bet some of the patients didn't get there meds if something horrible went down (like a patient falls or you have to send someone out to the emergency room, family crisis, etc) as they so often do in a nursing home setting. it would be completely different if you had 5-10 patients in a hospital setting...well, in a nursing home you have a higher patient load; hence,more interruptions.

and when do you have time to grab the meds in this situation? i'd rather hand the keys to a coworker and ask them to give a particular pt. meds if they were time critical. or if i have a cna who is working who also happens to be a tma i've asked them to help with this as well. or i ask a coworker to help me with vs for a fall, page md's for me, help me print the paperwork to send a resident to the hospital...etc...i ask my fellow nurses for help.

sharpeimom · Oct 25, 2009

when i was much younger and working my first stint at the state psych hospital, i followed the wife of one of the retired senior partners in my dad's law firm. this lady had been an army nurse during both wwii and in an army psych hospital afterwards and to say she did not see me as a fellow adult and responsible nurse was a gross understatement. she not only treated me as though i were six, she left the meds room a complete shambles. she left the meds room neat and tidy for the other (all much older than i was then) nurses so i think a lot of it was an age thing. she reminded me of hot lips houlihan and part june cleaver. as i remember, my mom was very sympathetic but said i wouldn't change her at that point. i think if she'd been a contemporary or if there hadn't been the family connection, i'd have handled it differently.

kathy

sharpeimom:paw::paw:

iwanna · Oct 25, 2009

Once upon a time, I must confess that I committed this crime. Also, I almost made a horrible med error. Thank God the patient recognized the pills were her roommates and not hers. She was allergic to what she had in the med cup. She announced it to the other residents, and I was humiliated.(which I deserved) But, I learned a very big lesson, and trying to save time by cutting corners can be life threatening.

I was not alone in pouring the meds ahead of time. In fact,this is what I was taught to do because of limited time. But, it was frowned upon by the DON. I did come up with an alternative plan, in asking the techs to work with me, and allow one resident out at time to get meds. Some of them were very agreeable and others did not like my plan, as they wanted the meds passed quickly between groups. But, they did not have a license to protect.

The staffing ratios are ridiculous, everywhere. And, nurses have fudged their charting, to appear that all of their jobs were done. e.g. charting mythical vital signs. Yes, vitals done on every shift on medically stable psych resident was a bit much. However, as long as nurses lie about what has been done, administration will believe that it can be and expect it to be accomplished. I know this is not the only place where corners were cut. I have seen it done in various medical facilities. But, we as nurses, need to protect our licenses, and if something is not done, then we say that it was not done and explain why.

skittlebear · Oct 25, 2009

i have also seen multiple nurses "forget" medications in the top drawer of their cart. or they tell the noc nurse during report "i got the meds ready--they are in the top of the cart". and of course the noc nurse forgets, the am nurse comes in and there is 3mg of clonezapam and 2 vicodin sitting in the top of the cart all night.

oh, i didn't think about that one...good point!

skittlebear · Oct 25, 2009

and when do you have time to grab the meds in this situation? i'd rather hand the keys to a coworker and ask them to give a particular pt. meds if they were time critical. or if i have a cna who is working who also happens to be a tma i've asked them to help with this as well. or i ask a coworker to help me with vs for a fall, page md's for me, help me print the paperwork to send a resident to the hospital...etc...i ask my fellow nurses for help.

hmmm...another good point.

skittlebear · Oct 26, 2009

once upon a time, i must confess that i committed this crime. also, i almost made a horrible med error. thank god the patient recognized the pills were her roommates and not hers. she was allergic to what she had in the med cup. she announced it to the other residents, and i was humiliated.(which i deserved) but, i learned a very big lesson, and trying to save time by cutting corners can be life threatening.
i'm sorry you had to go through that. great thing she did recognize her medications.
i was not alone in pouring the meds ahead of time. in fact,this is what i was taught to do because of limited time. but, it was frowned upon by the don. i did come up with an alternative plan, in asking the techs to work with me, and allow one resident out at time to get meds. some of them were very agreeable and others did not like my plan, as they wanted the meds passed quickly between groups. but, they did not have a license to protect.
i find that as well. the techs just want you to hurry up and get it over with so they can do what they need to do. it's horrible working with techs who are unhappy with the way you do things (even if it is the right thing). it seems as though they all stick together too. if one tech is mad at you, all the others seem to follow their outlook, lol. if you have a bunch of techs that are angry at you, it can certainly make your job a lot harder.
the staffing ratios are ridiculous, everywhere. and, nurses have fudged their charting, to appear that all of their jobs were done. e.g. charting mythical vital signs. yes, vitals done on every shift on medically stable psych resident was a bit much. however, as long as nurses lie about what has been done, administration will believe that it can be and expect it to be accomplished. i know this is not the only place where corners were cut. i have seen it done in various medical facilities. but, we as nurses, need to protect our licenses, and if something is not done, then we say that it was not done and explain why.

i've never faked v/s or a bs ever. i do suspect some nurses do this, and that is horrible. i completely agree with you that the staffing ratios are rediculous. i know of a nurse who told me that she had 2 whole wings to herself...60 pts!!!! she worked first, 12 hour shifts. i asked her how she did everything. she said, "well, i couldn't do everything." she said that some of those medications, blood sugars, ect just didn't get done. when she complained to her supervisor, her supervisor just told her she had to do it. well, they never fired her, she just quit. but...they still expected her to come in the next day and have 60 patients again. (her supervisors were fully aware that her patients did not get full nursing treatment but i guess they didn't care, since they asked her to come in the next day short-staffed again). now that....makes me angry! :angryfire

Midwest4me · Oct 26, 2009

first of all...
no need to yell at me! why the heavy sarcasm?
i have never worked in a ltc setting but i was a staff nurse and supervisor in a state mental hospital with equally high patient ratios and never ever -- not one time -- preassembled my meds. it was illegal, easier to make a mistake, easier to give a patient the wrong med or meds, plus which, my patient population was legally able to refuse their meds (unless they had been court committed) which many did. for many of the years i worked there, virtually all of the meds were bulk and were stocked in bottles of 1000 pills or as liter or pint bottles. can't pour it back once it's out...
kathy
sharpeimom:paw::paw:

i don't think there was any yelling meant. each environment is difficult to work in--with ltc you have 30-50 pts--that is asinine--and i know---i have worked many ltcs. too many chances of med errors---and no one can finish amed pass in the allotted time(2 hours total) on time--if he/she says it can be done, it's malarkey---too many med crushes, syrups, etc, admissions, falls, deaths, md rounds to do anything but meds. there were times i even had to take 1-2 pts as my pts because cnas couldn't be counted on to show up to work----ltc is a madhouse--and a setting to make a nurse lose his/her license---i left because there was just too much to do in too little time and always stayed 2 hours over to finish up!

iwanna · Oct 26, 2009

I didn't last long in LTC, either. I was only there for six weeks. It was way overwhelming. The other nurses told me that it would get easier. I took almost 2 hr. and 15 minutes to do one med pass. Then, there was all the charting afterwards. I would end up doing paperwork off the clock. God Bless nurses in LTC. I surely do not have the stamina for it.

Nancy2009 · Oct 26, 2009

also, for a nurse that doesn't pre-pull medications, i could see that nurse make a med error much easier than someone that does. for example, you pre-pull at a time when things aren't busy. if you don't pre-pull and are going strictly by the book and something happens to one of your patients...what's more important? finishing the medication you are pulling at that time or running to go see what's going on with your patient? you can easily get flustered and behind! when a nurse is flustered and behind and pulling medications at the same time trying to catch up (b/c they didn't pre-pull), a med error can easily be made.

sorry, i don't mean to bash, but i simply don't agree with your statement concerning "a nurse that doesn't pre-pull medications, i could see that nurse make a med error much easier than someone that does." sadly, i find some nurses pre-pouring and they mostly are sitting at the station for most part of the shift. i think it's a lazy practice. the facility could be cited, the pharmacy is against such practices. in fact, in one recent incident, a cna took a picture using her cell phone camera, of a nurse pre-pouring and handed it to the don. the don, of course, acted upon receiving it. besides that, why on earth will a competent license nurse not want to practice the 6 rights of med pass, i strongly believe med pass rights are there for guidance & for safety reasons. med-errors is very easy to make, whether you pre-pour or not. though, there's a higher risk if you make pre-pour your practice.