What do you think of this Ambien order?

[IowaLPN]

I could I also title this "Did I make a med error?" :)

I have a new skilled res with an Ambien order that reads: Ambien 5 mg po Take 1-2 tabs at HS prn

Twice in the last few weeks, I have given her one Ambien at about 2200 and then have found her still awake at around 2400 so I would give the second Ambien. I would never repeat the dose if she had been sleeping for a few or several hours. I mean how do you know if you need one or two Ambien when you're trying to get to sleep? Anyway, the day nurse threw a fit saying that I'd made a med error and now I"m just waiting to hear what the skilled supervisor thinks. The order is now going to be clarified so that it won't be an issue in the future but I'm interested to hear what you all think of this.... Do you think I made a mistake?

[P_RN, ADN, RN]

scoochy is right on target. Any order giving ambiguous parameters puts us on the hot seat. Orders should be written for ONE drug, One amount and ONE time interval-the Nursing office should back you up on this by making it a rule for us nurses to follow, and they should get after the doctors who don't prescribe correctly.

[LouisVRN, RN]

At the hospital I work at, we have just changed policy so if the order states 1-2 tabs, we must first start with administering one tab, reassess within the designated period of time 1-2 hours for po meds, and then may, if warranted, administer the second. Provided your documentation showed why you gave a second tab I would say . However the second night I would have just given her the 2 tabs since 1 tab was shown to be ineffective previously.

But I don't think it was a med error.

[systoly]

I would ask the day nurse why he/she is so hell bend to pin a med error on the

facility, because if it is reported as a med error it will definitely go against the facility. A much more helpful approach, rather than throwing a fit, would be, as already mentioned, to get the order changed.

[msn10]

Scoochy, we got to talk. I find myself agreeing with you all the time!!:)

Anyways, Scoochy and P RN are right. The laws have changed (even though many docs,nurses, and pharmD's are not aware yet). You have to get an order for the correct amount. No more 1-2 tabs. it had to read "5mg OR 10mg"

No guessing anymore like we use to.

[nursel56]

Thanks for the input! I agree that it is a poorly written order that I should have had clarified from the beginning but I'm relieved to hear that you don't think its an error. This particular day nurse seems to be one who is always trying to catch the overnight nurses doing something wrong (superiority complex maybe?) Anyway, thanks again for the input!

. . . .sigh. . . the personality type that nitpicks to death though not your superior= so annoying! I had one who would say, "if you don't know how to do something you can always ask me errr no thanks I think I'll pass :)

The order is ambiguous but couldn't it hinge on "HS" and not technically be a med error? Though I work in home health so "HS" is like pain, "whatever the patient says it is". The commonly worded way to do it would be "ambien 5mg qHS prn etc may repeat in 2 hours if not effective". I wish I could say this would be the last time the day nurse will find fault, but sadly I cannot.

[mappers]

This is what the KY Practice Advisory says:

"When an order/prescription for medication contains a minimum/maximum dosage range (i.e Demerol, 50 - 75 mg, IM q3-4 hours, prn for pain) the registered nurse, or the licensed practical nurse under the direction of a registered nurse, may determine which dosage to administer."

It was written in 1983, but reviewed this year. So I guess it's OK in KY to write an order like this. It does sound like, however, they would not approve of giving 50 now and 25 more in 1 hour.

[HeartsOpenWide, RN]

This is a PRN order. As long as you did not give more than two or the order specifically said, may take second after 2 hours of unsuccessful sleep then it does not sound like you made an error. IMO

Think of it this way. You tell me I can have 1 or 2 vicodin for pain. I do not normally take vicodin so I want to just take one. An hour later I am still in pain. you say "sorry its only every four hours" I am ticked and say "but it was 1 OR 2 and I only had 1, I want the other one". you say "but I can only give one or the other and then I have to wait 4 hours"...now I am really ticked, and now I am going to take 2 every time just in case.

[rn4ever?]

I personally don’t think it’s a med error. However, this kind of order needs to be clarified. Where I work, this kind of order will most likely look like this:

Ambien 5 mg PO PRN at HS for Insomnia, may give another Ambien 5 mg PO after one hour if ineffective.

[suanna]

Did you administer the med as the doctor expected- sure. Only an anal retentive squirl ball would make a big deal out of a technicallity in your administration. I can see, however, how it could be viewed as a med error. A sensible thing for that nurse to do was say " I don't like the way that PRN is worded- when I talk to the doc later today I'm going to get the order clairified to: Ambien 5mg at hs- may repeat x1 after 1 hour if needed for sleep- do not give after 2am. Is that how you see it as intended?" Working together is so much more fun than filling incident reports.

[HamsterRN, ADN, RN]

Our practice council recently went over this topic and couldn't find any new laws or regulations that says nurses can no longer titrate based on range orders, so I'm curious to hear what the new laws that are being referred to in this thread.

[prinsessa]

We still have orders at our facility that read like that so I am also curious about the new laws. If we are breaking some kind of law I definitely want to know so I can make sure the MDs don't write orders like this.

[cherrybreeze, ADN, RN]

The way the order is written is not an acceptable order in the state where I work. It must be written as "Ambien 5 mgm po qhs prn. May repeat x1 before 1 a.m. (or may repeat in 1 hour)." By giving the patient Ambien 10 mgm upfront (if you had done so), you are, in, essence, outside the scope of nursing practice because you have arbitrarily made the decision of how much Ambien to give. Therefore, you are considered to be "prescribing" medication. When you repeat the medication after giving the 1st dose, you have made this decision based on your nursing assessment. Don't forget to document your assessment!

Years ago, it was standard practice to have orders such as this: Morphine 5-8 mgm sc q 3 hrs prn pain. Now the order has to be written using the pain scale:

Morphine 5 mgm pain 4-5, etc.. It is not within the scope of nursing practice to decide the dosage arbitrarily. This has been mandated by the state Dept. of Public Health and the Nursing Board of Examiners.

I'm sorry, I disagree with this. If the order states 1 or 2, you are not prescribing by giving 2. It is not outside of our scope of practice to give 2, either, if the order states that we can. I think it's a HUGE stretch to call following an order "prescribing." Especially since, after the first time, it's not "arbitrarily" deciding that she needs two....one has proven not to work for this patient, so it only makes sense to go to the higher end of the prescribed range.

As far as the OP is concerned, this is at least twice now that the patient did not benefit from taking one tablet. To me, that's more than enough cause to give two right off the bat the next night, and not continue to give one and then one later. I think it's ok to do that once, because if it's a new med for them, you don't know how it will work. Now you know that one tab isn't enough, and you go to two on subsequent nights. If the patient prefers one at HS and one a little later, get the order changed to "1 tab at hs, may repeat x 1."