Pulling meds early?

[snizzlenort]

I work in PACU, and frequently have been pulling meds before or very shortly after a patient lands. Generally, I pull oxycodone, acetaminophen, dilaudid, fentanyl, and zofran for almost every patient. If it's ordered or I think I'm likely to need it, I'll also pull reglan, scopalomine, and / or toradol. I find that having these meds at the bedside makes it much easier to immediately respond to patient reports of pain or nausea, and it doesn't violate any policies. I know a lot of Endoscopy and procedure nurses pull up meds they expect to use during as case, but I wonder if anyone in recovery uses a similar method to streamline care.

edit, to address some of the comments: I have an order for the drugs, and I find that I use at least a portion (25 - 50 mcg fentanyl and 0.2 - 0.4 mg dilaudid in most patients) of the narcotics in 95% of the cases. We don't need a witness to return zofran, so that isn't an issue. Oxycodone and APAP are the typical discharge prescriptions, and we frequently start those right before the patients leave. The policies don't prohibit this; I've read them multiple times.

[joanna73, BSN, RN]

Most facilities have written policies that discourage pre-pouring or pulling meds early. Some nurses do this regularly, but it isn't safe practice.

Have you reviewed your facility policy?

[sallyrnrrt, ADN, RN]

Please don't pull meds you do not yet have an order for...please

[Rose_Queen, BSN, MSN, RN]

Don't you need a witness to return unused narcotics? My facility does. I think it's taking a bit of a risk and adding a burden to your coworkers if they need to witness a return.

[ProgressiveActivist, BSN, RN]

Don't your anesthesiologists give odansetron and morphine at the end of the case?

Do your patients consistently come from OR awake, hypertensive and in pain?

If so, something is off.

[Anna Flaxis, BSN, RN]

I don't work in recovery, but I think that so long as you are pulling meds in advance for one patient at a time, you have orders for the meds, this practice is not prohibited by facility policy, and you are following the six rights and three checks, then it's fine.

[snizzlenort]

They do give analgesics and anti emetics, but patients sometimes have pain or PONV regardless. Hypertension is rarely an issue, and generally speaking, our anesthesia department does a great job. Some patients have a history of chronic pain, so they need more opioids, and sometimes no matter how good the anesthesiologist/CRNA is, people wake up in pain from surgeries. My goal is to be proactive and efficient in treating whatever complaints they have.

[~PedsRN~, BSN, RN]

I do not work in PACU, so maybe this doesn't even apply to me -- but I do not pull meds early unless I am going to give them early. When caring for multiple patients, you are just increasing your chances for a med error by having a million meds bouncing around in your pockets.

[HouTx, BSN, MSN, EdD]

Aside from the highest priority of patient safety, what are the financial implications for this practice? Are patients accurately credited for any returned/unused meds? If not, this can easily give rise to pervasive overcharging/inaccurate bills -> accusations of fraud -> CMS audits, and so on. If this happens, any individual practitioners who were complicit with the practice can end up on the OIG (do not hire... ever) list.

Just sayin'

[RainMom]

Is this phase I or phase II? In phase I, we don't usually have time to predict which pt is coming out next. Even if we do think we know, it turns out differently or multiple pts come out together & you don't get the pt you thought you might get.

If this is phase II, maybe pulling the oral meds typically given at discharge wouldn't be a problem, but I don't think pulling the IV meds are a good idea without knowing what the pt has already received in surgery/phase I.

Seems like you may be spending as much time returning meds as you're taking them out. Having a significantly higher percentage of meds pulled/returned compared to the rest of the staff may also be a red flag to pharmacy...and eventually you will probably make a mistake & not return something and/or misplace a med.

[Mavrick, BSN, RN]

Is this phase I or phase II? In phase I, we don't usually have time to predict which pt is coming out next. Even if we do think we know, it turns out differently or multiple pts come out together & you don't get the pt you thought you might get.

If this is phase II, maybe pulling the oral meds typically given at discharge wouldn't be a problem, but I don't think pulling the IV meds are a good idea without knowing what the pt has already received in surgery/phase I.

Seems like you may be spending as much time returning meds as you're taking them out. Having a significantly higher percentage of meds pulled/returned compared to the rest of the staff may also be a red flag to pharmacy...and eventually you will probably make a mistake & not return something and/or misplace a med.

I also pre-pull meds but don't open them so I can credit the patient back the medication if I don't use them. Especially useful for patients in isolation and you're trapped in a room without ready access to the Pyxis.

Problem is the ole last minute switcheroo when you don't get the patient you think you're gonna get and it can be confusing when you're tempted to use the drug on the patient you do get but forget to credit the patient you don't get. Get it?

[NOADLS]

I work in LTC and don't normally have to administer meds. I do watch the floor nurses and on some occasions I get stuck doing it and I don't see any issue with pulling out meds early. Pre-pouring is another issue which depends on an individual's level of comfort.

Policies are based on the lowest common denominator for liability purposes. Pre-pouring is dangerous when some nurses do it, but perfectly safe practice for other nurses. I would personally never pre-pour, but I am not opposed to others doing it.