Let's say a 55 year old patient has an order for MS Contin every 12 hours 8am and 8pm for chronic pain. They also have an order for 2 tabs Vicodin 5/500 every four hours as needed for breakthrough pain. These orders have been in place for 10 days and the patient has been receiving the PRN Vicodin 5 times per day for all 10 days.
On Monday, the patient receives 2 tabs of Vicodin at 6am, 10am, 2pm, and 6pm. The patient requests 2 Vicodin at 10pm from the RN that just came on duty. This nurse typically works on the other side of the unit and has never cared for this patient before. The nurse reviewed the MAR and realized that administering the medication would put the Tylenol over the safe dose of 4000mg/day.
The on-call MD was notified and the nurse went over the patients allergies with him. The on-call MD ordered a lidocaine patch to be applied to the lower back. The nurse applied it, in addition to assisting the patient with other comfort measures. The patient seemed satisfied and verbalized an understanding of why the Vicodin could not be given.
The next day however, the patient complained to the regular MD when he was doing morning rounds, the MD in turn complained to the unit manager. The unit manager approached the RN (next scheduled shift) and asked why the Vicodin was not given. The nurse explained the situation, to which the Unit Manager replied that if it doesn't explicitly state on the MD orders for the patient not to exceed 4000mg/day, there is no reason to hold the dose and it was incorrect for the nurse to not give the medication.
Would you administer a medication that exceeds the safe dose? I am a fairly new nurse and did not feel comfortable giving the medication and I do not feel any better now after hearing the managers response to the situation.
