Routine Tylenol #3 and PRN administration

Pat_Pat RN · Oct 10, 2009

I wouldn't call that a med error either.

nurse_clown · Oct 10, 2009

Thanks. I have since quit that job. More abuse and harassment from that place. I'm in the process of launching a wrongful dismissal and intolerable work environment lawsuit against this place. Also looking for a new job.

Thanks for the supportive responses.

Much appreciated.

KAYBDT6, BSN, RN · Oct 11, 2009

I mean Tylenol #3 which is consider a narcotic, is that consider a med error?

SunnyAndrsn · Oct 11, 2009

I checked my drug book, and the max dose is limited by the tylenol--4000mg per day, and 360mg of codeine. Tylenol #3 has 30mg of codeine per tab, and 325mg of tylenol per tab. According to the med book, doses above 60mg do NOT have a significantly improved analgesic effect. This gives a MAX safe dosage of 12 tabs per day.

It sounds like this pt. is not getting adequate pain relief, and perhaps a different medication is needed. That being said, it sounds like either he needs something later than 1700. I would think that scheduling could be adjusted as well. Right now, the scheduling has him getting this medication 6 hours after the first day's dose, and then 5 hours after that, with what, like 10 hours again until the next dose?

Suggest an 8 hour spread of the scheduled dose: 0800, 1600, and midnight, and perhaps suggest to the MD to increase the dose to two tabs at a time, with either a different PRN to help with breakthrough pain, or a different medication all together. OR, if the MD feels this is too much for the pt to take two at a time, have the MD clarify the PRN. IE, if the 0600 dose is give, do you have to wait 4 hours to give a PRN? Then would you have to hold the noon dose? IMO, no, but this is the kind of crazy nit picking that I've seen some of my co-workers do and it's ridiculous. This is where critical thinking comes into play and you have to know your pt's status as well as the the safe dosing parameters of the medication.

I do not think this should have been written up as a medication error, based on the fact that it is within safe dosing and within the written parameters of the orders. I do think the MD should be updated that the pt. is requiring quite a few PRN doses, that some nurses have had to give two tabs at a time, and that he is waking up in excruciating pain, and suggest the stuff above.

Finally, your co-workers are jerks, and if you have to sign anything, sign that you do not agree, why you don't agree, and that you are signing under duress.

nurse_clown said:

A patient is ordered Tylenol #3 1 tab, po, TID. and 1 tab Q 4-6h PRN
I know I should know this. I am ashamed for even asking but,

If the patient gets one Tylenol #3 at 0600, 1200 and 1700. The patient wakes up in horrible pain at 0600 and is asking for another tab of Tylenol #3 at 0600 on top of his routine Tylenol #3.

What could I suggest to him?

Could I give him another PRN Tylenol #3 at 0600 in addition to his "routine" dose?

I read in the MAR on one shift I happened to be filling in for another nurse, he had received a PRN Tylenol #3 one day at 1200 in addition to his 1200 routine dose. On another shift, he received a PRN Tylenol #3 at 1700 in addition to his 1700 routine dose. He had also received a PRN Tylenol #3 in addition to his 0600 routine dose.

So, one morning, I gave him another Tylenol #3 in addition to his 0600. I was the one and only one who was written up for a medication error.

I haven't filled in the med error incident report yet. I don't know what to write in. Did I make a mistake in medication administration? I feel stupid for following suit like a lemming. The patient said he was in horrible pain at six in the morning and the other nurses were giving him two Tylenol #3's at a time. Should I also be asking if the other nurses will be written up for the same med errors?

I have officially decided that it is not in my best interest to take any extra shifts at this nursing home. I'm not well liked by the day shift staff (three full time RPN's) and the Director of Resident Care. They all hang out together and are personal friends. They gossip openly about me for the residents and staff to hear. I work very well with the staff and the residents really like me. I have been the subject of workplace harrassment and bullying and I'm currently in touch with the union head office because our union steward is one who is involved in bullying me.

I am trying to think of myself here. There are plenty of nursing homes around in my area and I could easily get another job. But, I know that the day staff are gathering every little piece of evidence to make me look incompetent. I can't even ask for any reasonable amount of help for fear of being ridiculed and the RPN's and the DOC voicing how incompetent I am. I haven't taken a break in four days so that I ensure that I do not miss anything. If I don't stalk the med cart, they complain and tell the PSW's that I don't pull my weight. I was threatened physical harm by a resident and those day shift Registered staff openly voiced to the staff and residents that I brought that on myself.

Anyway, I have to head to work now. I'm scared of going to work because I am under the microscope. I want to call in sick because I'm having these bad anxiety attacks and I'm finishing up ten shifts in a row to cover another RN's holiday. No one else likes taking the night shift.

I'm so stressed out. I can't stop crying and I want them all to just stop and leave me be to just do my job.

Your help with how to deal with the medication error situation would be immensly appreciated.

SunnyAndrsn · Oct 11, 2009

KAYBDT6 said:

If a nurse missed a schedule dose of Tylenol for a pt, Is that count as a med error?

yes, of course.

SunnyAndrsn · Oct 11, 2009

OP also stated that other nurses had administered two tabs at a time, which may indicate why the pt. was asking for the PRN on top of the scheduled dose.

MoopleRN said:

The OP stated that the patient woke up at 0600 in horrible pain...the pain meds were due at 0600.
The patient ASKED for the dose to be doubled..

Correct. He was asking for his PRN along with his scheduled. He was asking for his PRN even before the scheduled had a chance to work. If the clock said he could have his PRN, he was entitled to it and covered by the PRN unless the PRN order had some kind of parameters which I've already mentioned.

The pain medication was on a schedule, along with additional doses PRN.

The OP gave the patient a double dose of the pain meds at the scheduled time, which was 0600.

That is a med error.

She did give a double dose at 0600 but it's NOT a med error if the clock says he could've have his PRN/he was asking for it/the PRN order didn't have parameters.

You cannot justify that the pain was not controlled, when you have not given the scheduled pain med and then assessed the pain before and after the administration of the scheduled dose.

Pain is subjective as you well know. Again, it was PRN (without parameters) and if the clock said OK, then she was covered, obligated/justified even, to give that PRN because the patient requested it. As I said in my original post in this thread, I would've encouraged the scheduled to have a chance to work and then reassess his pain. I agree with you on that. I don't agree that it was a med error, however, for the reasons I've stated.

She also would have had ammunition, based on assessment, administration, and response, to the physician to either increase the pain medication dosage, a shorter interval between dosages, or something stronger.

She still had that "ammunition" based on assessment/response even though she gave the PRN he was entitled to have along with his scheduled. It was getting documented how often he was getting his PRN along with his scheduled. Hopefully, a subjective/objective assessment of his pain (as well as a f/u) was documented as well. There was no med error that I can see based on the information given. What there appears to be is a failure to inform the doctor of the pain issue.

I totally see your point that the scheduled should've had a chance to work before giving the PRN but again, if the clock said he could have it, he was asking for it, there weren't any parameters on the PRN order, she was totally covered/"justified" in giving that PRN.

suanna · Oct 11, 2009

I don't see your error! the programmed TID med was to provide a basal pain relief- like the set rate on a PCA pump.If that is enough for the patient- fine, but if the pain is at a higher level than he has previously complained of- the dose you gave is well within the safe range for this drug and was ordered by the physician. That is what PRN means! I didn't see any limiting parameters other than your judgement and safe dosage level for this medication. How long were you supposed to wait to see if the basal dose pain med was going to be more effective than it was last dose? It's not just the degree of pain relief but the duration of comfort that is important. If the patient got pain relief in 30 min but it only lasted 2 1/2 hrs you are better off giving a larger dose and trying to mantain the pain relief until the next programmed dose- why rollercoster the patients pain relief? If another nurse dosen't agree with your judgement- even if they are the boss, that dosn't make a med error. That is what I would document on any incident report.