Pyxis as the problem? You decide.

[vicarious]

I am looking for opinions on the following situation. Right now an entire hospital is using the Pyxis for the storage of all medications. For example, each unit has one large Pyxis for all meds for all patients. In other words, pharmacy does not come up with bags or drawers for each patient. The nurse must pull all meds from the Pyxis for all of her patients one by one. Respiratory therapists also use the Pyxis as many of the respiratory meds (except for inhalers) are kept in the Pyxis as well. I felt the need to clarify in detail because I have told others this situation and they have been thoroughly confused.

This hospital also is about to go to the electronic medication administration, including the scanning of meds and the patient. The practice of "double checking" all anticoagulants, including Coumadin and any subcutaneous, e.g. Lovenox, is also about to begin.

My question, I guess, is whether or not this system is reasonable, from an outside perspective.

Here's my two cents--In theory the Pyxis system for storage of all meds seems like a good one. MANY meds are kept in the Pyxis and if a patient is put on a new med and it is stocked in the Pyxis, or if you have a new admission, you don't have to wait for the meds to arrive from pharmacy. There are a lot of negative things about the Pyxis system though, IMHO. When the acuity is high, one RN may not have time to stand at the Pyxis for that long fighting with the drawers and waiting for them to open. There is an option to assign yourself patients and remove meds by time, and this does make it somewhat helpful. Also, I should mention that this Pyxis system is rigged with a very large refrigerator-looking section with bins inside. So instead of the medication being spit out or a drawer and compartment opening, sometimes you have to sort through many bins and medications looking for the right one. There is also the inherent problem with the Pyxis--when you are forced to stand in line with the other RNs, RTs, and pharmacy techs if it needs filled, waiting to get out that one pill. Another annoyance about this system is that the Pyxis is monitored by the pharmacy, and there is a minimum bin level where the pharmacy is supposed to come and re-fill. The reality is that this rarely happens and the pharmacy is always getting calls to send more meds. Oh, and the extra narcs? Yeah, they are still kept in the old narc drawer--requiring a daily narc count and taking away any of the aforementioned convenience of said Pyxis system.

Now that each med has been painstakingly removed from the Pyxis, the idea is that each patient will be scanned. Then each med is scanned. Is this redundant? My exact thoughts on this matter are.."Are you serious? One or the other, Pyxis or the barcodes on all these meds! I am already taking one out at a time from the Pyxis!" That being said, back in the day when Pyxis was used for mainly narcs, I could see myself being ok with doing double duty and removing from Pyxis AND scanning..it is only the pain med afterall, that takes considerably less time removing and scanning that one PRN rather than removing and scanning every scheduled med.

THEN Coumadin and lovenox are supposed to be double checked and will require a witnessing RN to swipe her card at the time of administration. I understand the necessity to have IV Heparin and I will accept the fact that insulin needs double checked as well. But Coumadin and lovenox? Is this just to look good for the Joint Commission? Why don't we double check every med while we are at it? Oxycontin can be given with one RN, but Fragmin is suddenly so dangerous that it requires a witness. I understand the need for patient safety, but where is the line drawn? People have died taking aspirin too--will that need a double check? Is an RN no longer competent enough to administer meds? How long before three nurses need to check insulin? Or until 2 RNs must assess together? Sure this is all great in theory, sure it would be great if the doctor and pharmacist could come to the floor and scan their badges too, but there is no time for all of this, ESPECIALLY with the advent of the E-MAR and the documentation of the exact time of administration. There are not enough nurses and there is not enough time in a day for all of these requirements.

So let me take you through the process if your patient is on Lovenox or Coumadin..

Sign onto Pyxis, remove all meds, take meds to patient room, sign onto E-MAR, scan patient nameband, scan all meds, have another RN swipe to witness, and give the meds.

I am all for correct patient identification and I will concede that scanning every med is actually a good (albeit time consuming) thing. I am all about correctly identifying the patient and what meds he/she will be receiving..essentially, patient safety. But removing the meds from the Pyxis (although it was implemented first in this change to the E-MAR) seems like whoever thought of this "ingenious" system has never once administered a medication on the floor, and is inadvertently and unknowingly putting patient care/safety on the backburner. It is taking time and wasting it--and while it is meant to increase patient safety, it actually works against it. The burdens of this Pyxis system outweigh its benefit. What say you?

[blinks14]

We do not have Pyxis per se at my hospital but we do have something similar, it's called Omnicell. Anyways not every single med is stored in our Omnicell. We keep IV fluids, all narcs, additional emergency meds and other various things in the Omnicell. When a new pt comes to the floor pharmacy sends the required meds to the floor and they are placed in the Omnicell for us to get out. Also new daily meds are brought up between 2100 and 2200 and placed in the Omnicell for us to get out and distribute into locked drawers in each pt's room.

We also have a computerized med administration system. We have had it for almost 10 years, a LONG time. The computerized system that we have does not require you to scan the patient and then each med, you scan all the meds you are giving at that time then you scan the patient at which time you can administer the meds. It's actually a very nice system. I really like it to be honest.

We also require a cosignature from another RN on various meds, IV heparin, cardizem and other various meds. The other RN has to type in their SSN when the med is given.

I do understand your frustration with the new changes but there is always frustration with any new change and there's always a learning curve. Various kinks will need to be worked out as well.

[NeoNurseTX, RN]

we have several pyxi (pyxises?) on our unit but most of the meds are in the med cabinet or fridge. narcs are in the pyxis and it's annoying to have to get someone to witness counts of them when they're such tiny doses...but i guess someone could take ALL of them. except the PO ativan...why anyone would want to put that stuff in their mouth is beyond me!

[FireStarterRN, BSN, RN]

We are using the accudose machine, along with a hand held scanning device. Once you get used to it, it goes just as quickly as the previous method. Most nurses do use shortcuts. For instance, if you scan the patient with our device, it will show the meds due, so it's like carrying around a MAR of sorts. Then I'll run to get the meds and go right back to the room. Technically you are supposed to do the whole operation at the bedside, but I'm not so braindead that I don't remember what patient I was just visiting. On scanning for heparin and insulin, truthfully, we just scan one another. We don't have time to go through all that, so we just hold out our badges and scan one another and that's that.

If you don't fight the system and learn to use it, you can make it work for you. You just have to change the way you work.

[RNperdiem, RN]

I am not familiar with the scanning function of the PYXIS, but I prefer it to the med drawers stocked by pharmacy.

There would almost always be a missing med when I was ready for my med rounds. That would mean having to send a missing med request to pharmacy in the pharmacy message slot(no tube system), then the med would be delivered on the next round of pharmacy delivery. It could take a couple of hours to get a missing med.

Occasionally something is out in the PYXIS, but this is rare.

I don't miss counting narcotics and handing over the keys at change of shift either.

[RNKPCE]

First off where I work we have been double checking coumadin, heparin, levanox for years and insulin. We check with another RN at a computer looking at INR or Platelets. We will go to bar coding in the future not sure if that check will have to be at the bedside or the way we have been doing it already.

We initially had only narc and other frequently stolen drugs in the pyxis. At one point before Zantac went otc we had someone stealing those so they got put in Pyxis. Now almost all drugs are in the pyxis and this has been going on for at least 8 years. Sometimes par levels run low and we have to call pharmacy. I will often call pharmacy when I know we will run out of drugs that one particular patient may be using a lot like Dilaudid.

We have one pyxis for a 30 bed unit and at times you do have to wait behind other nurses or RT's to get the meds. The worse times are 9am, 5pm, and 9pm. If it is urgent, crisis situation the people a head of you will always let you in. We don't need a witness for every narc we take out, only if we are going to override or waste or return.

Because our system was developed gradually it didn't seem that bad. First double checking drugs, then pyxis arrived for just narcotics( so much better than a narc sheet), then all meds in pyxis. If it all happened at once I am sure there would have been anarchy.

[RNKPCE]

Also I don't think using pyxis and bar coding is being redundent. You can take a drug out of pyxis an administer it to the wrong patient. That is the point of bar code scanning. Right drug, right patient, right time, right dose, etc.

[sjt9721, BSN, RN]

...On scanning for heparin and insulin, truthfully, we just scan one another. We don't have time to go through all that, so we just hold out our badges and scan one another and that's that.

If you don't fight the system and learn to use it, you can make it work for you. You just have to change the way you work.

These comments make me a little nervous. We are notorious for our "work-arounds" and I'm just as guilty as the next. But it can be a blessing as well as a curse.

Scanning/countersigning for someone is documenting that your colleague pulled the right med & dose for the right patient. God forbid something bad happens...you're on the hook for (at the least) falsifying documentation. Not just your employer, but also your BON will frown upon that. And whether it's right or not, that's the way it is.

I hope my comments aren't taken as judging or lecturing, but like I said: Been there, done that. The fly-by holding up an insulin syringe saying, "Here's 5 units of Regular, okay?".....and the response, while barely glancing up is, "Yep, looks great. Bring me the chart when you're done."

[RochesterRN-BSN, BSN, RN]

I think a lot of the feeligs of weather this is realistic or not vary from unit to unit.....A LOT depends on how many patients you are having to get meds for.

I know when I left inpatient psych they were going to be getting this set up and all the nurses felt there was just no way-- on a 30 bed unit with 3 nurses pulling meds for 10 patients is time ocnsuming enough! Also they wanted the nurses to wheel around this COW--Computer on Wheels--and do the scanning at the bedside. Well yeah that is a safety issue haivng that cart and computer in an area that gets violent a lot. Then there are the really paranoid patients--yeah!! lol I can see that not going well. God knows what they would think about this all in there room. lol

I am in an ER now--psych ER-- and only have routine med pass for the one or two EOB patients I have and other then that it is random passing. The thought of going back top inpatient with 10 patients and having to use this new system is too much!! And the fact that is polices your time frame of med pass and frankly would make me so anxious as there are so many things that come up during a med pass that can set you behind.

[NotReady4PrimeTime, RN]

I work in a 19 bed PICU where most of the patients are cardiovascular post-ops. The only meds we don't keep in the Pyxis are a small number of personal meds. Everything else is in there. All of our potassium is kept in a locked cupboard that requires signing the key out of Pyxis and then locking it back up when we're done. We've had problems in the past with failure to document narc wastage (and there is a LOT of narc wastage in a peds unit) that has been addressed a number of times. There are definitely bottlenecks both literal and figurative (because of the location of our machine). We double check and double sign every med given except for Tylenol and vitamins. We're still using paper MARs so we aren't scanning meds, but we've also just begun the process of converting to electronic charting, so I expect that to follow. I think I would prefer that to having to wander around the unit, meds and MAR in hand to find a second person to look at my captopril.

[FireStarterRN, BSN, RN]

Double signing for insulin and heparin are hardly universal practices, and in many ways they are cultural traditions of hospitals. It is mostly a silly waste of time. Do we require it for much more critical meds? No.

I've had patients in DKA on an insulin drip which I could adjust per protocol without a sign off, yet if I was giving SQ insulin, I was required to double sign.

I did an agency shift at a highly regarded hospital, Swedish Medical Center, and they don't double sign for insulin. It's not a part of the nurse practice act or any standardized practice.

[*ac*]

I work in a 19 bed PICU where most of the patients are cardiovascular post-ops. The only meds we don't keep in the Pyxis are a small number of personal meds. Everything else is in there. All of our potassium is kept in a locked cupboard that requires signing the key out of Pyxis and then locking it back up when we're done. We've had problems in the past with failure to document narc wastage (and there is a LOT of narc wastage in a peds unit) that has been addressed a number of times. There are definitely bottlenecks both literal and figurative (because of the location of our machine). We double check and double sign every med given except for Tylenol and vitamins. We're still using paper MARs so we aren't scanning meds, but we've also just begun the process of converting to electronic charting, so I expect that to follow. I think I would prefer that to having to wander around the unit, meds and MAR in hand to find a second person to look at my captopril.

With E-Mar, you'll still wander around with the med trying to find that person, but then you have to drag them back to a computer to look at the order. Then you have to find them later and remind them to countersign ('cause they can't until you've signed it off as given, which of course you do not do until AFTER you give it).