Which Medication to Give First

EllaBella1, BSN · Feb 25, 2017

I would say the same, give them in order of frequency to help preserve the timing to an extent. But I would also start a second IV so that some meds can be run at the same time. If my patient is getting that many meds that frequently, I would want to have more than one IV for sure. You could also call pharmacy and see if we can get some of the meds retimed so that they aren't all due at the same time.

Here.I.Stand, BSN, RN · Feb 25, 2017

There's no single answer... although I would be retiming them so they're not all due at the same time. Lots of times if the MD orders several drugs at once, the pharmacy just puts them all as due as soon as they're verified, and then at the facility's default times.

I recently had a pt who was on 2 IV antibiotics that each ran over 30 minutes, and then a big dose of Vanco which was to run over 2.5 hrs. In that case I gave the Vanco 3rd just because that would hold up the other two by a significant amount of time. What organism(s) are you treating? If one med is specific to the organism, say it's a fungal pneumonia and antibiotics are ordered empirically, I might give the Flagyl first. Or if the culture and sensitivity is not back yet, I might start with a broad spectrum atb. Or I'll look at the MAR and look at 6/12 hrs, 8/16 hrs out, and see if any of them would conflict with other drugs if I started one of them now.

It's probably best to clarify it with the provider, though: "I saw the new orders for these 3 atb's; do you have a preference which the pt should have first?"

Sweetheart2005, ASN · Feb 25, 2017

I agree with that order and retiming if possible. Also, I don't know if these meds are compatible or not. If two are compatible you could put one directly to

the saline lock and the other you could do at the y site and run together.

kchester3 · Feb 25, 2017

Thank you for everyones insight. It makes sense I appreciate the critical thinking with your thoughts!

Kuriin, BSN, RN · Feb 25, 2017

I give the medication with the shortest infusion time first or else you run the risk of being incredibly delayed. If you're that concerned, start a second line and run both infusions.

KelRN215, BSN, RN · Feb 25, 2017

I'd give the cefazolin first because it can be given over 3-5 minutes, followed by the Flagyl which I've always given IV over 30 minutes then the erithromycin last because it takes the longest to infuse. I've never actually seen IV erithromycin ordered but the website globalrph.com tells me that 1g needs to be infused over 2 hours.

AliNajaCat · Feb 25, 2017

If this were my patient I'd reschedule them so they didn't conflict (time-wise). I konw some hospitals won't let you do that.

There's an organization called the Institute for Safe Medication Practices (google them) that addresses timeliness of medications vis-a-vis their frequency.

"Establish guidelines for time-critical medications

Establish guidelines that facilitate administration of the hospital-identified, time-critical

scheduled medications at the exact time indicated when necessary or within

30 minutes before or 30 minutes after the scheduled time (or more exwhen indicated, as with rapid-, short-, and ultra-short-acting insulins). MAR entries for

hospital-identified time-critical scheduled medications should be designated to

remind staff that these drugs require meticulous attention to timely administration.

Establish guidelines for daily, weekly, or monthly medications

Administer these medications within 2 hours before or after the scheduled time.

Although it is generally safe to administer daily/weekly/monthly medications within a

timeframe that exceeds 2 hours, ISMP recommends keeping the timeframe to 2 hours

before or after the scheduled time to prevent accidental omission of doses that might be

more easily forgotten if delayed more than 2 hours.

Medications administered more frequently than daily but not more

frequently than every 4 hours (e.g., BID, TID, q4h, q6h)

Administer these medications within 1 hour before or after the scheduled time.

Current information technology associated with medication use may require vendor

updates to: accommodate more than a single time interval to trigger an alert for delayed

and early doses with bar-coding technology; change the appearance of a medication

entry for delayed doses in electronic medication administration records (eMARs); and

set different time limits for the removal of scheduled medications from automated dispensing

cabinets. Challenges also exist with highlighting time-critical scheduled medications

on eMARs and differentiating between first doses and subsequent scheduled doses

when using these technologies. ISMP is aware of these limitations and has been encouraging

vendors to address them in updated versions of their technology."

I hope this table reproduces here:

Table 1. Acute Care Guidelines for Timely Administration of

Scheduled Medications

Type of Scheduled Medication Goals for Timely Administration

Time-Critical Scheduled Medications

Hospital-defined time-critical

medications*

*Limited number of drugs where delayed or

early administration of more than 30 minutes

may cause harm or sub-therapeutic effect

Includes but not limited to:

Medications with a dosing schedule more frequent

than every 4 hours

Administer at the exact time indicated

when necessary (e.g., rapid-acting

insulin), otherwise, within 30 minutes

before or after the scheduled time

Non-Time-Critical Scheduled Medications

Daily, weekly, monthly medications

Within 2 hours

before or after the scheduled time

Medications prescribed more

frequently than daily, but no

more frequently than every 4

hours

Within 1 hour

before or after the scheduled time

Kuriin, BSN, RN · Feb 26, 2017

We have to request from the MD to reschedule medications. Sometimes the pharmacy will reschedule the medications if the drug requires a trough first.