Weird meeting with manager

[amzyRN]

I work in a busy ER and am constantly giving pain medications. We have an error-prone system where it's easy to pull a narcotic on the wrong patient and administer it to a different patient. This has happened numerous times to people on my unit. They are also very particular about timing of narcotic medications, if you are over 15 minutes late in giving the med, they write you up. My last ER job, narcotics couldn't be pulled without a physician order being verified and you couldn't override narcotic meds. This made it easy to avoid these stupid errors. There was one incident where I forgot to chart a narcotic. The patient was writhing in pain and I gave the med and probably forgot to scan it. I feel bad about these things and feel like an idiot. Not only that I was interrogated by my manager who in the course of the meeting the way she spoke to me made me feel like she thought I was stealing medications, which no one has ever accused me of. I have never every stolen anything in my life.

Not only do I feel like an idiot but now feel so weird, like they think I'm a narc diverter at work and don't trust me. I also worry if I make another mistake I will be fired. I have never ever given narcs so much at this hospital and the system they have makes it easier to pull the meds on the wrong patient. I might make a mistake again because of the frequency of giving the meds. I will try very hard to be careful, but now I feel so bad about my job, nursing in general, like the hard work I do is unrecognized and the mistakes are all that stands out.

[NuGuyNurse2b]

I hate the pain scores. Majority of the time we get dinged on the "timeliness" because the patient simply wasn't due. I actually had Dilaudid ordered Q1hr on a patient. Asked why the patient didn't just get a PCA, because if we timed it so that he could push it Q1 hr, it would send a flag to pharmacy...and then paperwork to explain it...which nobody wanted to do.

[Orca, ADN, ASN, RN]

Are there other options for employment in your area? This sounds like a punitive work environment that blatantly overlooks system errors and/or your manager is not supportive in creating and maintaining a safer work environment.

This was my first thought. I look for system problems first whenever things like this happen. It sounds like this place has a crappy med system that is prone to generating errors, and they apparently aren't shy about blaming staff when the system fails.

[Medic/Nurse, BSN, RN]

Post deleted by me. Sorry.

[audreysmagic, RN]

You are taking this far too personally, and it appears that you know nothing about drug diversion.

I was actually talking about this with a MHW (mental health worker) on my shift the other day...she was saying he thought the amount of nurses in TV shows and movies who divert drugs was unrealistic because "there's so many safeguards." Obviously, I didn't give her a how-to primer, but I did mention it's way more common than people want to think, and often it's not feeding that particular person's addiction.

[blondy2061h, MSN, RN]

Requiring an active order for narcotics is great until you have someone in status epilepticus and need benzos now, have someone with cardiac chest pain and want morphine and pharmacy is way behind verifying orders, or have someone come on with their leg broken in 12 spots when the EMR is down.

[Lunah, MSN, RN]

Requiring an active order for narcotics is great until you have someone in status epilepticus and need benzos now, have someone with cardiac chest pain and want morphine and pharmacy is way behind verifying orders, or have someone come on with their leg broken in 12 spots when the EMR is down.

Truly, I prefer a procedural Pyxis where I can pull what I need for each patient, especially given situations that you describe. Our trauma rooms have a procedural Pyxis for expediency. But I can understand the safety of profiling meds. It's helpful if you have a clinical pharmacist in the ER, I love those people!!

[Ruby Vee, BSN]

Whether the ED has a procedural Pyxis or a profile Pyxis, the OP needs to be mindful of the "Five Rights" when pulling medications. If it's a procedural Pyxis, she needs to be MORE vigilent, lot less.

[Graduatenurse14]

They tell us that the HCAPPS are low because of pain management. They tell us that we need to advocate better pain control for patients and that we are falling behind and that the nurse being the patient advocate needs to speak up. Pain is the 5th Vital sign. In fact a pain crisis will bump acuity up in the ED and management of it becomes the greatest priority second only to life-saving intervention. We are reminded of our low scores at least once a week. Our charts are monitored if someone is above a 4 on the pain scale, they will ask us why we have not treated the pain.

I am shocked that they are pushing you to give pain meds >4 when so many hospitals-including mine- are cutting down due to the opioid epidemic.

I DO NOT mean to imply that individual RNs are at any fault for the liberal policies in place. They are just trying to follow the said policies to keep their livelihood secure as we all are.

I see a lot of post op patients and the docs have really cut back on what are available on the MAR for us to give and even then there are now instructions written next to ones that are there such as "Do not use IV Morphine first. Use PO medication and IV Morphine for breakthrough" or something to that effect.

We rarely hear about our scores and they just post them as they come out. They should probably be more concerned as they are generally not that great.

[Kooky Korky, BSN, RN]

We do and I think many ED's "attract" drug seekers. Narcs are prescribed far too often. I'm starting to think that people should hardly ever get them unless they are in the hospital having surgery or something or have cancer, severe chronic back pain, or some similar condition.

How about pancreatitis,trauma,some chestpain, and many, many other very painful conditions?Walk a mile in your patients' shoes. I agree your boss sounds like she was offbase. Good luck.

[sevensonnets]

Ruby is correct. You must always follow the 5 rights of administering meds that you were taught in nursing school. If you follow them diligently you can't go wrong. And by the way there is no pain so great that it will be instantly relieved by pain medication. You have time to go through your 5 rights checklist and do it right.

[sideshowstarlet, BSN, RN]

First of all, the fact that administration of pain medications seems to be based entirely upon the patient's numerical rating (not symptoms like vs changes, nonverbal behaviors, etc) is just asking to have an ER that caters to drug seekers. I know OP really can't do much about the patient satisfaction policy. But really! Don't people have better things to do than audit charts for that?

Secondly, pulling an employee into a meeting and, according to the OP, insinuating that the manager suspected them of diverting drugs and not simply requiring a drug test as a matter of course (if multiple similar errors are made by multiple nurses throughout the unit and they cause the manager to suspect drug diversion) seems silly. What if one of the nurses was diverting narcotics? Would the manager simply call them into a meeting, chatter on about how boss suspects nurse of drug diversion, NOT drug test said nurse, and send the nurse off to care for patients, leaving the manager to their all-important duty of auditing charts for a self-reported pain of 5/10? From what I've been able to understand of this situation, the hospital is way off base in how they have been dealing with this issue. I think in this instance, drug tests should be given as a matter of course to cover the hospital legally. It wouldn't be personal; the manager wouldn't tell the nurse they suspect him/her of diversion, but simply have the drug test as part of policy. The test would be administered, and, depending on the results, everyone would go from there.

I think it's a good idea to keep patient stickers for patients you treated with narcs to ensure you remember to document and don't have to go through this again. Good luck! I've never worked ER, and I admire nurses who can. I think this pain relief/patient satisfaction policy degrades the work ER nurses do everyday.

[gettingbsn2msn, MSN, RN]

I would find another job stat! Our entire unit was written up and drug tested because too much Dilaudid was pulled on a shift. Too much BS. I left the hospital scene over all this mess. All they talked about were press gainey scores. When push comes to shove they will turn you in to the BON. Btw, everyone on the floor that shift tested negative for drugs. But we felt like criminals.