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?
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.
I did not make it any further into your post. This is ridiculous. It is overly burdensome on the nursing staff. Keeping PRNs in the Pyxis is fine, but all scheduled meds? Whoever thought of this needs to be taken behind the barn and.....well....
Specializes in Acute Care Cardiac, Education, Prof Practice.
I work in a large hospital on a busy 24 bed med-surg floor and everything but the kitchen sink is in the PIXIS.
We double sign (and show each other religiously!) our insulins.
We double check heparin drips together.
We waste narcs with each other.
We even double check boluses off the PCA's for each other before we give them.
Currently we are having problems with our portable computers, so scanning isn't always an option, so we do often use the old school "two patient identifiers" and your normal 5 rights. However our new system is coming in soon.
The only time I have had any issues with this system is when I get stuck behind one of our slower RT's who takes like 20 mins to pull all her meds, or at 0655 when pharmacy decides to come and fill the PIXIS as I am behind on an end of shift med pass. Then the frustration is minimal, and I get over it.
I actually enjoy pulling meds from the PIXIS, something satisfying to me about the little pop, and the puzzle of getting everything back into the pocket after you pull it out. I appreciate the safety of the checks, and the teamwork involved in getting everyone's meds passed safely.
That's just me!
Tait
PS. And as far as insulin drips, its Q1 hour accuchecks, do the math and then get a double check and sign, every hour.
All I can say is, WOW..I wonder what else they could do to make your job more cumbersome and time consuming..Maybe from now on you all could have to sing the name of each med and what it's for to the pt, then do a little tap dance (ending with jazz hands, of course) before handing them the pill to take..Geez.
PRN meds in the Pyxis? OK.. but all of them? Ridiculous.
Specializes in NICU, PICU, PCVICU and peds oncology.
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).
Thanks for the encouragement! I'm already stressed enough about the e-charting business for lots of other reasons... that just makes it ALL better!:chuckle
Thank you all for your thoughtful responses! They are great, please keep them coming.
I think the "that's just the way it is and that's just the way it's going to be" mindset is almost a dangerous one. Instead of jumping through hoops and "pretending" to double check and triple check meds with another RN and then having her countersign twice in the required two different spots just in case one area of the MAR spontaneously combusts, I think it is important to recognize the difference between what is safe and what is realistic.
I'm not saying that there aren't times when a medication should be double checked, and I'm certainly not against barcode scanning meds upon administration, but I am saying that the solution to the aforementioned problems (pyxis stocking all meds in addition to barcode scanning plus the double checking of coumadin and lmwh) should not be a backdoor work-around or a cheat code or doing a run-by scanning of another rn's badge for all of the meds that need double checked.
Sometimes I think that problems like these might not exist in the first place if we weren't so busy with the acuity of the patients and actually had enough energy to speak up about these changes and how they are negatively impacting patient care. How would a pharmacist or a clinical manager know the best way to pass meds if he has never passed meds on a floor before? Just because I drive a car does not mean I know how to build one, and vice versa! I'm not saying RNs are infallable, or that RNs know the best way to do everything, but I do think that RNs should have more of a voice in these kinds of issues and I encourage everybody reading to stick up for your patients, yourself, and your colleagues when you think that an issue is negatively affecting how you care for your patients. And to the person who replied saying that EVERY med had to be double checked except for tylenol--I am at a loss for words.
We have most of our meds in the accudose. I've been told that the true reason for this is to assist with inventory and charges.
What I do is, the beginning of my shift, I pull out all the meds for the day from the machine and put them in the pt drawer. Each pt still has a drawer for oddball meds that aren't in the accudose.
You can do this quickly, without even looking at the MAR worksheet, by looking at the meds on the pt profile, and there is an indicator whether it's a PRN med, a Q day, BID, QID, or HS. So, I pull them out quickly based on what I see on the pt profile, bam, bam, bam. I get most of them in the drawer, and then I only have to access the machine for PRNs, narcs, or new meds.
This saves time and is efficient. You can also come up with your own timesavers based on the flow of work in your unit and your own system.
Good luck in trying to avert these changes, you'll need it because I'll bet you a million bucks that there is no way you'll be successful in that. It's better to change your approach to your work environment and learn to adapt.
We have most of our meds in the accudose. I've been told that the true reason for this is to assist with inventory and charges.
I'll bet that factors in big time. The thinking is that since the nurse has to chart all of the meds given anyway and since the meds have to be charged for and the inventory accounted for, why not throw a system like Pyxis in there so that the nurse's action is captured and the meds accounted for and the patient account charged all in one fell swoop! Efficiency! On paper, the hospital will save money because the system is supposed to reduce the amount of manpower needed for accounting and inventory management. So instead of having a couple of people responsible for all of that, each nurse does a little of bit it themselves. Cost effectiveness!
Only that's not how it always works. When documentation systems don't integrate, you end up having to double enter everything, something many nurses get frustrated with. Those designing systems think "well, it's just one little extra step, no big deal" but it adds up quickly since nurses work with multiple patients and with multiple systems (eg pharmacy, supplies, dietary, etc). Toss in the fact that in hospital care all systems and the staff working within them are subject to constant interruptions and quick changes of plans and what might be efficient in certain contexts can become unwieldy to the bedside nurse.
What I do is, the beginning of my shift, I pull out all the meds for the day from the machine and put them in the pt drawer. Each pt still has a drawer for oddball meds that aren't in the accudose.
You can do this quickly, without even looking at the MAR worksheet, by looking at the meds on the pt profile, and there is an indicator whether it's a PRN med, a Q day, BID, QID, or HS. So, I pull them out quickly based on what I see on the pt profile, bam, bam, bam. I get most of them in the drawer, and then I only have to access the machine for PRNs, narcs, or new meds.
I would get written up for that. We aren't allowed to pull meds until the time they're due.
This week I saw a nurse put patient labels on a "cheat sheet" that they used to scan instead of the patient ID band. What's the point of having all this new fangled equipment and then bypass the safety features??
I've heard people do that. For us, only the bracelets brought up from admitting will work for scanning. On my unit, no one bypasses the bracelet, unless someone has put it on the bed in the case of someone who can't or won't wear the bracelet.
There was an article in Nursing 2008 about how nurses all over the nation are bypassing the scanning systems. They attributed that to the fact that the programs are user unfriendly to the flow of the workplace and need to be better designed with that in mind.
Real, bedside nursing sometimes means taking shortcuts, otherwise necessary care needed by patients would not be achieved in a timely manner. Most of us, unfortunately, are forced to prioritize how and where we will fudge, since the way the system is currently set up, it's impossible be all things to all people.
We exist in a space/time continuum, something that seems not to have been considered when many of these programs and mandates were put into place by policy makers within the healthcare system.
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?
I work in an inpatient psych facility that uses an Omnicell system (all meds stored in the Omnicell) plus med computer carts and exactly the process you describe, and it works just fine. Of course, we use a "team nursing" system with one med nurse, so we don't have multiple people trying to pull meds from the machine at the same time. I would encourage you to approach the new system with an open mind and positive attitude, and wait to see how things work out. This is the first time I've worked with a med admin system like this, but I really like it. The best thing about it, I think, is that it makes it almost impossible to make a med error -- you have to really work at it. :)
Thanks guys, I have to admit that I am new at this and I am very randomly pressing a "Thanks" button on some posts, although I am not too sure what it does! I hope it sends all of you some money or something (fat chance!)
I think the subject of using a pyxis/omnicell (BTW i am familiar with both :) ) as a type of small satellite pharmacy begs the question, what ever happened to pharmacy techs? what kind of money is a hospital saving when a pyxis stocks all of those meds on every floor? Seriously, there are probably over 1000 pills in these Pyxi (I liked that plural form of Pyxis that somebody else used.) I am sure each pyxis costs some big bucks as well, and I'm not talking about deer..
I should also mention this..somebody had a comment about using a Pyxis scanner or something. While I have noticed a barcode scanner on the pyxis itself, I do not know what that is for. Nursing has never ever used it to my knowledge. I am talking about having Computers on wheels (COWs) and barcode scanning from that. Just clarifying!
When we got the omnicell (aka omnihell) at my last place of employment, the pharmacy techs were working double time trying to iron out all the many kinks. They are still needed with these devices. They are the ones who stock them, and they help get the meds on the profile.
I've worked with all three, Pyxus, Omnicell, and Accudose. I think I like Accudose the best.
Virgo_RN, BSN, RN
3,543 Posts
I did not make it any further into your post. This is ridiculous. It is overly burdensome on the nursing staff. Keeping PRNs in the Pyxis is fine, but all scheduled meds? Whoever thought of this needs to be taken behind the barn and.....well....