Quote from glasgow3
1) The order was poorly written; as mentioned earlier a Vanco trough should be drawn immediately before (normally understood to mean less than 30 minutes before) the scheduled dose. Since the daily scheduled dose was timed for midnight, a true trough draw should have been scheduled for 2330. Since it was actually ordered as a trough (as opposed to just a scheduled lab) the physician's order should have been clarified.
Yes, & No. I have seen many, many Vanc orders during my career written just like this.
1) That you have seen many poorly written orders is hardly the point; If you can produce an authoritative source that states a Vanco trough should be drawn at a time other than as I described, I would be interested. I don't believe you will find such a source.
More germaine to the current discussion, had you carefully read the OP's later clarification, you would have learned that the scenario was NOT as originally described: That is, as it turns out the order was NOT for a 1600 trough for the midnight dose.
An actual trough drawn eight hours before the scheduled daily dose would yield a misleading value because that is way too early. Due to the potential for underdosing the next dose, the order (had it actually existed as originally described) should have been clarified.
2) The lab was "backed up" for a timed draw is NOT an acceptable excuse for it not being done until several hours late; an occurrence report should have been prepared and all notifications made per your facility's policy and procedures. (At that time you could have clarified the physician's intentions and what he/she wanted you to do now.)
Again, Yes & No. The lab being backed up is NOT EVER an acceptable excuse. But the P&P's are in place for us to use. I can almost guarantee calling the MD would have resulted in the MD telling her to just call the Pharmacist.
2) The facility Policy and Procedure manual no doubt required that an occurance report be made for a timed lab draw as late as described; such reports invariably require that the provider be notified and actually contain space to document that this had been done.
It is of no significance whether or not the provider took the news of the late draw well, or threw a fit, or told the notifying nurse to call pharmacy. The point here is that the provider has been notified of a significant deviation from the provider's order. That said, that would have been a perfect time, early in the evening, to "gently" clarify why the trough was ordered so early in relation to the scheduled dose in the first place. Catch?
3) Pharmacists never "decide how much and when to give" Vanco, but rather with a physician's order they may follow certain preapproved protocols. In some facilities only specified pharmacists may make these adjustments. In any event the "pharmacy dose" must be determined by the protocol/calculation. If the late draw conflicted with the dosing protocol they should clarify with the provider.
Sorry, but having been on Vanc myself. Your statement is 100% incorrect. My MD ordered the Vanc, but it was ALWAYS the Pharmacist who Dosed. Pharmacist are Doctors of Pharmacy. Most know their Drugs.
3) I have a great deal of respect for pharmacists and I am well aware of their extensive professional preparation and also which degree they have earned.
But the "iv Vanco, pharmacy to dose" order related by OP is proof positive that pharmacists may NOT dose a single mg of anything without a physician's order. Now the actual dosing methodology is invariably a product of the approval of one or more facility committees comprised of physicians and pharmacists etc. Make no mistake: the physicans know that the pharmacists have the bulk of the expertise BUT the pharmacists do not have free reign in a hospital setting. EVER.
When I run codes it may appear to an outside observer that I am ordering and dosing emergency drugs, however, I am actually following well defined, evidenced based protocols which have been approved by several committees. Any material deviation and I am toast.
4) The nurse is always the "last line of defense" in med administration; If you weren't satisfied with pharmacy's explanation, seek guidance/clarification from the provider before hanging the med.
100% Correct. She should have NEVER hung the Vanc without clarification/guidance.
5) All that said, I'm fairly certain that the physician merely "misspoke" when he/she wrote for a Vanco "trough" and that he/she fully expected that a dose would be given at midnight per protocol. It's the pharmacist's responsibility to determine whether or not that late draw will interfere with his dosage calculation.
I honestly don't think the "Physician" misspoke. Whom ever sent the Vanc to the floor should have never done so. The are reason why a Trough is being drawn. In my past experience of Vanc it has been the Pharmacist who wrote the on going orders for the medication and troughs.
6) In any event, when you know you have an issue early in the evening, it's best to resolve it then.
But with all of this said. Who really wrote the order? Was this the 1st order for Vanc? It doesn't seem so. Could it have been the Pharmacist whom wrote the order? Anyways. The Vanc should have not been given until the trough was drawn, not after. That trough is no good and now the patient has a lab charge that is basically bogus.
I personally believe that the OP really should read up on her medications before giving them if she has any questions.
(4 (5 (6 Sure glad I was given 100% on my last 3 points; with only 50% on the first 3, I might have failed and had to repeat the course or something.