Preceptor issues

londonflo · Apr 25, 2022

2 hours ago, atlnurse7 said:

she was like let’s go ahead and waste it

Does this mean she said it?

2 hours ago, atlnurse7 said:

It would horrify me if I accidentally brought a narcotic home with me because I wasted it when I pulled it and forgot to toss it.

The odds are this may happen if you continue this practice. And it is very serious to walk around with a narcotic on your person. So serious that you may be accused of diverting.

atlnurse7 · Apr 25, 2022

I empty my pockets every day before I leave. I typically waste it right after I give it. I don’t waste it before I give it because that’s basically not possible if im going to give the medication. To me it makes more sense to waste it after so I can actually toss it in the blue bin. Wasting it before I give it feels like lying bc I haven’t had the chance to actually waste it. That’s what my preceptor had taught me before this anyways.

londonflo · Apr 25, 2022

I am confused by your reply. Don't you draw up what you are going to give in the med area out of the vial or are you drawing it up at the bedside? You need to bring the vial to the bedside to scan I assume but why keep the "to be wasted" in the vial? BTW may be it would clarify if I knew your institution's recommended way to waste. I use to go to 2 hospitals. One had us waste in the sink (I think this is not recommended now for any medications as it can eventually get into the drinking water), the other onto a kleenex and to put the kleenex in the needle disposal box.

atlnurse7 · Apr 25, 2022

we don’t have an area like that at my hospital. We are supposed to draw up the medication at the bedside. I only draw up what is needed from the vial. In our little med room that has our omnicell, there is a blue bucket for the drugs that we are supposed to waste. Rooms also have similar buckets for our IV drips, etc for us to put them in when they are done. But we are supposed to draw them up at the bedside.

londonflo · Apr 25, 2022

15 minutes ago, atlnurse7 said:

there is a blue bucket for the drugs that we are supposed to waste. Rooms also have similar buckets for our IV drips, etc for us to put them in when they are done. But we are supposed to draw them up at the bedside.

But you do waste them (disgard the waste -- how?), don't you before you put the vial in the blue bucket?

I am retired but it used to be an understanding, that to prevent med errors, you should only bring to the bedside what you intend to give. ( or are you making the decision how much to give when at the bedside for a variable dose?)

Your pharmacy would have established a policy on this. Perhaps you should call them.

atlnurse7 · Apr 25, 2022

You have the option to waste now or waste later. Another nurse has to be in there with you to scan his or her finger print as a witness to you wasting it. You can say waste later after you go to the bedside and draw it up. Go back to the omnicell, log in. Select your patient and the drug you just gave, say waste. It makes someone else use their finger print and type their password in. Then you select how much you wasted, for example if I gave 50mcg/1mL that was a 100mcg/2mL bottle I would say I wasted 50mcg into the blue bucket bc I administered 1/2 the vial since that’s what was ordered for my patient. Say it is a pill even and the patient is ordered 2.5mg and the drug is a 5mg tablet. After I scan the med at the bedside, I manually entire 2.5mg since I scanned a 5mg tablet. I put the pill in the pill splitter and put 2.5mg in the drug wrapper and give the other half to my patient. I go back into the med room with another nurse as my witness, I select the patient, select waste, select the medication. It asks for another nurse/pharmacist/supervisors witness. They scan their finger print and enter their password and then a prompt comes up with options and I select administered half of the tablet as per ordered, another prompt to ask what I did with the other tablet and I select placed unused tablet in blue bin. Then I put it in the blue bin

londonflo · Apr 25, 2022

9 minutes ago, atlnurse7 said:

, for example if I gave 50mcg/1mL that was a 100mcg/2mL bottle I would say I wasted 50mcg into the blue bucket bc I administered 1/2 the vial since that’s what was ordered for my patient.

Do you draw up the wasted amount (squirt it into the blue bucket) or keep it in the vial when you place the vial in the blue bucket? Is the blue bucket sealed so that no one can get into it?

atlnurse7 · Apr 25, 2022

Bucket is sealed, you can only drop things in. The med room is only accessible by nurses and pharmacists that have a badge or know the code depending on the unit

JKL33 · Apr 26, 2022

21 hours ago, atlnurse7 said:

Then you select how much you wasted, for example if I gave 50mcg/1mL that was a 100mcg/2mL bottle I would say I wasted 50mcg into the blue bucket bc I administered 1/2 the vial since that’s what was ordered for my patient.

Problem: How does your "witness" know exactly what you did?

I stopped signing my initials to procedures like what you describe--because of the utterly hateful way nurses are treated while trying to handle controlled substances; nothing personal. Do it in front of me or find someone else. If the hospital doesn't have enough staff to facilitate that in a timely manner, it's their problem.

The only way to cover all bases is to have your witness present when you remove the cap and draw up all the medication out of the vial, properly expel (waste) what you don't intend to give, leaving the portion you intend to administer in the syringe, affix proper label as appropriate. If your policy says something other than this it is asking someone involved in the process to take on an unnecessary risk.

JKL33 · Apr 26, 2022

On 4/25/2022 at 8:33 AM, atlnurse7 said:

So my preceptor and I have butted heads a few times.
I always try to explain my thought process, when I’m wrong, with the intention of letting her know where my thought was based so she can redirect my thought process. I’m really looking for her to say instead of doing that, you would do x, y, x because ….”
but she perceives it as arguing. We have had this discussion plenty of times. But it doesn’t seem to be working and it makes me super anxious.

It could be you or it could be her, but since things aren't working for you, you might as well review your part in it.

You actually don't need to explain your thought process every time, and unless you are a very perceptive and skilled communicator there's a very good chance it will come off as either arguing or excuse-making. Both of which are distracting and annoying after about the first ONE time that they happen. So unless you have an actual question or are being given significantly contradictory advice about an important issue, it might be wise to take a pass on explaining yourself.

Try not to be overconfident that you have things figured out. Example:

On 4/25/2022 at 8:33 AM, atlnurse7 said:

here’s the issue. whenever I pull a narcotic, I NEVER waste it in the moment. NEVER. mainly because I always check my pockets by the end of the shift and I would forget to throw the vial away, the vial is my reminder to go back and waste it. It would horrify me if I accidentally brought a narcotic home with me because I wasted it when I pulled it and forgot to toss it. 

Here you describe your foolproof process for remembering to waste (instead of wasting in real time) but then state that you would be horrified if you forgot to throw out a med. But how would you forget to throw it out if you're always checking your pockets? On the other hand, if you dispose of the substance properly with a witness and document in real time, you won't have to worry about forgetting to waste or forgetting to throw unused controlled substances away. This is just my opinion but you are hanging on this idea that admin wants meds drawn up at the bedside--but it doesn't exactly sound like they have the resources/process in place for that. Rather, they have just told you all to do something. Instead of making it possible to do the waste process at the point of care where they want the meds to be drawn, they tell you to draw up the meds at the bedside and they then refuse to care about the other practical parts of the process that nurses worry about.

^ You can't fix this, I am pointing it out to demonstrate an example of the LARGE number of things that nurses get up in arms with each other about, rather than directing their confusion, dissatisfactions and concerns in the appropriate direction.

Compared to the things that nurses get ramped up about, there is relatively LITTLE that is worth it. You need to do a safe process that protects your patient and yourself, that's the bottom line. If there is a problem with part of the process, talk to admin about it.

sleepwalker, MSN, NP · Apr 26, 2022

I wouldn't sign off on a wasted medication if I didn't see it drawn up and administered. You're essentially wanting someone to agree that you're wasting a medication (e.g. fentanyl) when it could be that you've diverted the wasted dose to another syringe and instilled NSS into the vial to be wasted...there's no way to know what's in that vial if the draw and administering wasn't witnessed. Same concept with pill administration.