Pulling Meds for Multiple Patients

[trustsupplyguy]

In order to save time, I will often pull meds from the Pyxis for more than one patient. For example, I'll get patient #1's meds, put them in a little zip-lock bag, put the Pyxis receipt with the patient's name into the bag and them zip it shut. Then I'll do the same for patient #2. So ultimately I have 2 or 3 ziplock bags containing meds and the related Pyxis receipt.

Several nurses have told me this is "bad" and not to do it. But I don't get what the problem is. When I get to the patient's room, I pull his ziplock and check everything against the MAR before giving the meds. The receipt is in the bag so anyone can see whose meds these are and what meds were taken from the Pyxis.

Will the meds from bag #1 jump into bag #2 by magic and change what's written on the Pyxis receipt? Seriously, am I missing something (I am pretty new)? Is there a Joint Commission ruling on this? I have never had a problem doing this, and it does save time.

[elthia]

If an error occurs and you weren't following policy, you're screwed.

Our pyxis does not give a receipt, btw. I haven't used one yet that does. I guess that must be something set up by each individual hospital.

I'm curious as to why those who pull for multiple patients at once won't pull narcs too. If the practice is kosher, what difference would it make?

I don't pull narcs because because even though I can lock my med cart, every employee on the floor knows the code to the med cart. That is why are computers are set up as mini med carts with lockable drawers

In the days of unit dosing when everything was in the real med cart, and you didn't have to log in to the pyxis to get po zantac and po lopressor was the pt's scheduled morphine kept in the med cart???

I really don't see the difference from pushing my med cart from room to room, and locking it between pt's with how meds are administered at a long term care facility.

My nurse director and my nurse manager are well aware that this is how I and many other nurses on the floors administer our meds, that is why they advocated for the mini med carts with lockable drawers to upper management.

I do not "pop" my pills out of their packaging before scanning and telling the pt what they are, I do not draw up meds out of vials before scanning them at the doorway, I do not spike IV bags before scanning. And I always compare the label to the MAR regardless of what the barcode scanner says, the barcode scanner has been wrong before.

Some people are saying this is against JCAHO, but I've been searching their website for the past half hour, and haven't found anything about pulling meds from the pyxis on multiple patients at once and then locking them in a med cart in separate drawers being unsafe practice.

http://www.macoalition.org/documents/Best_Practice_Medication_Errors.pdf

I followed this link from JCAHO's website, it mentions unit dose machines, but doesn't mention pulling meds for multiple pt's.

http://www.jcipatientsafety.org/fpdf/psp/PatientSafetyArticles/S4-PS-02-03.pdf

This definitely mentions reconciling meds against the MAR and securing meds safely by locking them up.

http://www.jcipatientsafety.org/22818/

and heres a link to JCAHO's long list of links of med error stuff if you have the time.

[Spidey's mom, ADN, BSN, RN]

Every nurse was taught in school never to pull meds for more than one pt at a time. In reality, things just do not, and often can not, work the way we were taught.

I think the OP's system is a good idea. I would not tell mgmt about it, though. They most certainly will tell her she can't do it.

Boy, I just have to say it .. .it is not a good idea to lie to your employer .

steph

[leslie :-D]

Boy, I just have to say it .. .it is not a good idea to lie to your employer .

steph

you don't have to tell me twice.

already, this is the beginnings of a very, slippery slope.

leslie

[RN1989]

I am wondering if the "time saving" that many people are talking about is related to many nurse's inherent "me first" attitude when it comes to taking turns at the med cart. Every facility that I have worked at has had several people on each shift/floor that is SOOOOO slow getting their meds out of the machine that they cause others to be behind. So then the staff feels like they need to be hogging the machine to get all the pt's meds out at once because they don't like waiting around for the slow pokes. I've seen nurses literally stand for 20 minutes waiting for their chance at the med machine instead of finding something else to do like charting, checking labs, etc. So maybe they feel like if they get all the meds out at once, that is where they are saving time instead of using their time wisely in the first place. I've even had to chew nurse's butts on this matter because meds for pain and urgent issues take priority and I've had nurses try to tell me to "wait till I'm finished" and then want to spend another 10 minutes getting meds out. I don't put up with that stuff whether I am working as staff or management. But I think I am more than a little concerned about having unsecured meds, narcs or not, being pulled out with the possibility of someone taking stuff from your baggies to use on their pts or the possible contamination by taking them from room to room. Guess that just shows I'm old school.

[EmmaG, RN]

I don't pull narcs because because even though I can lock my med cart, every employee on the floor knows the code to the med cart. That is why are computers are set up as mini med carts with lockable drawers

That is different than what is described in the OP.

[Agnus]

First as far as Joint Commission goes they do not post was is not the standard of care. Instead they list what is standard of care. Any nurse at my hospital can tell you Joint Commission will cite you the state will cite you. We are in serious danger of loosing our acreditation. Believe me we know.

Lets think this Pyxis thing through. Why do we even have Pyxis and why is set up so that you can only pull meds for one pt at a time. There is a reason. Just as one poster suggested there is a reason management would tell you not to do as you are doing.

Before Pyxis we locked meds up on the floor. Now some of us have Pyxis. which locks and despenses meds one pt at a time. A very expensive system.

We turned to this expensive system not because hospitals love to spend $ or love to make nurses' jobs harder.

We have pyxis because there were inherent dangers in the old system. Pyxis provides certain safe guards that were not present in the old system.

Yes it is very illegal to have the meds on you or to be carrying meds for more than one pt into a room. You are not likely to find this on Joint Commission's site or your state's site either but I can assure you it is illegal. If you dispute that then Contact your state's surveyers and ask them specifically.

Let me tell you about a system that was even older. One that most (maybe all of you never saw let alone heard of because it is now so old.

We used to do this. We had these little cards with pt name and meds listed on it. We would lay out the cards for all the pts on the floor. Place a little med cup on top of each card with the meds poured (we did not have blister packs in those days).

So now you have all these little cups of pills that you can no longer ID positively because they are out of their packages, laying in seperate open little cups with the only thing to identify them or the pt they belong to is a little card sitting under the cup. Now you carry the whole mess down the hall on a tray and distribute them to the patients.

Why to I mention this antiquated system. Because it is what we did at the time and we found a safer way.

Namely pour and give meds to only one pt at a time, use individually pkted meds and do not open them until you are at the bedside, take MAR to bedside etc.

Pyxis takes these things even farther.

First it is illegal to have meds on your person. So if you are carrying around a lot of ziplock bags you are just asking for trouble. If you lock them where are you doing it? Has it been approved for meds.

If you are locking them on the floor don't you think the pyxis might be a waste? Or maybe the locked area is a waste? We have duplication here. Unlock from Pyxis and lock some place else. Something is very wrong with this picture.

If you are afraid to tell management then just maybe there is some thing wrong with what you are doing. If you are doing nothing wrong you have nothing to fear. What is wrong with this is you are short circuiting safty measures. Just because you do not under stand the safty measure does not mean it is not existant. Yes there are flaws in pyxis there are flaws in every system. But it certainly is better than what we had.

[james_lankford]

i'm not a nurse, i'm actually a computer programmer whose job is to track pyxis pulls, medication usage, wastes and general tracking of drug use.

the problem with pulling multiple patients and doing ziplock bags is the "unexpected sidetrack"

you pull drugs for 8 patients, after giving drugs to 4 patients you have to go to the bathroom, then there's a patient emergency or the nurse gets stuck in a room teaching a patient's family something

now, the nurse has all these drugs for patients 5-8 that were withdrawn 40 - 60 minutes ago, but haven't been administrered yet; my job is to red flag those long unexplained times between withdrawl and administration, make a report and give it to the nurse manager

then of course there are statistics, this unit has an average time difference of 5 minutes between withdrawl and administering, this unit has an average of 20 minutes, ... why ? because of multiple withdrawls

now, what if patient 2 just doesn't feel like taking their tylenol or whatever, maybe they're naseaus (i know i spelled that wrong), if the nurse had been doing single withdrawl, then she could return that packet to the pyxis and get the next patient's drugs, but because she's doing multiple, all at once, she will not return the drug to pyxis but will continue on with patients 3-8

now the nurse could get realy busy and it could be hours before that drug is returned and you can bet that will raise red flags

[BeachBayNurse]

As someone who used to work days, I saw pre-pulling happen often. It may be my imagination, but it seemed to be in result of a few "slower" nurses taking an excessive amount of time to pull up just one patients medications. Instead of taking their medication sheet printed up from the computer, they would fire up the computer next to the pyxis and have to log in, pull up the individual patient, and as you could imagine weren't the most computer savvy :angryfire. However, working nights, with a different group of nurses that seem to be quicker at the pyxis, I have yet to see someone pull up multiple patients medications.

Assuming it is legal to pull up multiple patients medications at one time, and assuming the nurse takes all steps(plastic bags, labels, rechecking in the room), I see no problem with this, and it may be the solution to making sure patients get their medications on time.

[RNLaborNurse4U]

I work on L&D, and I will pull delivery meds for two patients at one time - it simply saves me time, and it's the exact same meds: 1000 cc LR with 20 units pitocin, erythromycin eye ointment, 1% lidocaine for laceration repair. Pretty simple, I'd say.

[jessica1983]

We don't have a pixis where I work. Instead we have the old fashioned med carts with a drawer for each patient with all their meds in it. I don't see how a nurse pulling meds from a pixis and putting them in baggies is any different from a pharmacist pulling meds from the pharmacy and putting them in patients drawers. I don't see how it's unsafe if you check the meds again AT THE BEDSIDE against the MAR. If you picked up the wrong baggie or the wrong meds or anything, you'd be able to catch it right there before the patient took the meds. I've walked into patients rooms before with meds for other patients, usually a patient also in the room. I only do this rarely when I'm crunched for time where all my patients simultaneously want all their 10p meds right away with sleeping pills and pain meds so they can go to sleep. So I go in the room with say, pain med or whatever for one patient in one pocket, and the other roomates meds in the other pocket and check against my kardex before giving. Hasn't resulted in any errors.

[Spidey's mom, ADN, BSN, RN]

i'm not a nurse, i'm actually a computer programmer whose job is to track pyxis pulls, medication usage, wastes and general tracking of drug use.

the problem with pulling multiple patients and doing ziplock bags is the "unexpected sidetrack"

you pull drugs for 8 patients, after giving drugs to 4 patients you have to go to the bathroom, then there's a patient emergency or the nurse gets stuck in a room teaching a patient's family something

now, the nurse has all these drugs for patients 5-8 that were withdrawn 40 - 60 minutes ago, but haven't been administrered yet; my job is to red flag those long unexplained times between withdrawl and administration, make a report and give it to the nurse manager

then of course there are statistics, this unit has an average time difference of 5 minutes between withdrawl and administering, this unit has an average of 20 minutes, ... why ? because of multiple withdrawls

now, what if patient 2 just doesn't feel like taking their tylenol or whatever, maybe they're naseaus (i know i spelled that wrong), if the nurse had been doing single withdrawl, then she could return that packet to the pyxis and get the next patient's drugs, but because she's doing multiple, all at once, she will not return the drug to pyxis but will continue on with patients 3-8

now the nurse could get realy busy and it could be hours before that drug is returned and you can bet that will raise red flags

Thanks for this.

I do not understand why professional nurses put up with unsafe or just disorganized patient care. The fact that it has always been done this way is simply wrong.

The buck stops with us.

steph

[brainynurse]

I have been a nurse for many years and remember when we pushed a big, heavy medicine cart down the hall. I have seen a lot of changes in nursing. I to pull my meds for each of our pt and place in individual zip top bags. It is totally unrealistic to pull one pt meds at a time due to the large area in our unit and only one pyxis for all the nurses. We also are using the scan barcodes before administering meds, fouht it at first but now almost panic when technology goes down for a while.