When to enter meds on MAR

At our facility, the med order goes on the MAR at the time the order is noted. Meds are taken from the Emergency drug box on each unit for the doses that will be due before the nightly pharmacy delivery. If the order is for a med not readily available in the Emergency drug box then either there has to be an emergency delivery by the pharmacy or one of the Unit managers has to go to a local pharmacy to pick up the doses that will be due before our facility pharmacy delivers. This requires communication between our local pharmacy and the facility pharmacy, however and we avoid having to do this. Sometimes, the MD or NP will give the order for the med to start when delivered from the pharmacy. We are not ever allowed to write med unavailable on the MAR, and we most certainly cannot just leave holes! Nor or we able to show a lag time between the time the order is noted and the time it goes on the MAR. That's a tag for sure for not following MD orders.

We try to get all MD orders in to the pharmacy before 3:00 p.m. to ensure that the meds will be delivered that day, however sometimes that isn't possible especially in the case of new admits and readmits, so these are called in to the pharmacy as soon as the orders are verified and they will usually be delivered with that night's delivery. Every nurse in the facility has a list of drugs available in the Emergency drug boxes and Emergency narcotic boxes and if the order is for a drug unavailable it is the noting nurses responsibility to alert the MD that we do not have this med on hand and get further instruction. I'm not saying this always happens, but this is facility protocol. Sometimes, nurses are just lazy and they "borrow" a med from another resident, which everybody knows is a big no no. But yet still it happens a lot. Then, when the pharmacy consultant catches that "now" orders were not taken from the e-box, the offending nurse gets all defensive when HER error is brought to her attention. It never ceases to amaze me, the indignance you see in some people who are being held accountable for imporoperly doing their jobs.

Medication errors of this sort are a topic of discussion at EVERY nurses meeting we have. I, for one, get tired of having to listen to the same gripe at every meeting we have and wish that all nurses would just note orders and carry them out properly, ALL the time. This is one of the easier "problems" that we as LTC nurses face. I just don't understand why it is one of the hardest to get the nurses to correct.

The first is proper, the second covers their butts.

"It is the responsibility of the facility to obtain the meds, but for a nurse to withhold posting of it on the MAR to suit the facility is actually not legal.

This is one way to lose a license. And the facility will not back one up on this. You need to cover your license."

Thank you for your information, precisely what I thought.

Thanks,

OK...than I have a question.

Where I used to work nurses would do their med pass and then sit down at the nurses station and flip through and initial everything... I thought that was wrong to do that. Is it ok to wait until the end of the med pass to initial everything in one sitting?

I have been reading several posts about this and I think I might be doing it wrong because I didn't think the way I mentioned it above was correct. How I do it is I use the MAR and pop out the medication. I then would flip through the MAR(again) and initial as I re-confirmed that I truly have that medication in my cup to have the patient take. They take the meds and I move on. If they don't take the med, then I circle my initials, which at my facility means the patient refused.

Now I am confused... trust me it doesn't take much to do that.

Well state did show up. They followed a very experienced nurse. I was looking at her MAR and said…what are these dots where you would initial? She said it was her way to check that she has the med but she is not to sign until after giving them. She then initialed over the dots.

I didn’t think it was a good idea to wait until a med pass to initial the MARs all at once. I figured it was too easy to forget something. I am very thankful I came across this post and now I will change how I do that part of the pass.

Now to go back on topic:

Whenever I get an order for medication. I place it on the MAR before the med shows up. Regardless if the med shows up, it is still an order.

If we get the order after 1700, we ask the doctor to order that it can be initiated the next day...if it needs to be initiated right away, we call the pharmacist at home. It doesn't look good if we have to chart that a medication is unavailable, but it is much better than not putting something on the MAR right away.

We all know that it is inappropriate to sign the MAR before the med is given...it is also inappropriate to wait and sign everything at the end of the shift. I will never understand why we don't just try to do things right all the time so we aren't fumbling to do things right when state is there.

I've worked at several places with several different pharmacies and they all say there are two correct ways of doing the med pass: Pour, Give, Chart OR Pour, Chart, Give. As long as you are consistent you're okay. I used to pop the pills into the cup,initial as I popped, then give the meds. If the person refused, I'd circle the initial and write the reason for refusal on the back. If some of the meds had parameters, I'd pop them in a separate cup. I've seen nurses initial everything after the pass was done and I've seen them initial everything before they started the pass....yikes.

As for writing the meds on the MAR, we write them when we get the order. If we know it's an unusual medication we'll add "start when available" to the order.