Written Up

[medteleER]

The oncoming shift charge nurse got on me about "double dosing" a patient. MD had (2) specific orders PRN:

1) xanax 0.5 mg for sleep

2) xanax 0.5 mg q8h for anxiety

I gave BOTH of them because the patient claimed being anxious and wanted something to sleep. My charge nurse pulled me to the side afterward and stated she was going to write it up. The patient was VSS in the morning. I'm not sure how I should be feeling about this.

[Tenebrae, BSN, RN]

2 minutes ago, RNNPICU said:

Technically yes, you did double dose the patient if you gave both at the same time. The order should have been clarified as was the sleep dose only at night? Likely they need both orders for daytime and night time. The medication is the same regardless.

I would have questioned the order. Even if I gave the patient a dose at let's say the dose for sleep was due at 8pm. I gave a patient a dose for anxiety at 6pm. Since this med needs 8 hours spaced apart, I would question the MD.

A quick search online reveals that a single dose is 0.25 - 0.5mg Q 8, you gave your patient 1mg in a single dose.

But its two seperate orders.

Order 1 is to be given for sleep

Order 2 can only be given q8

Nothing mentioned that order 1 and order 2 have to be given 8 hours aparrt

[pixierose, BSN, RN]

Just to add to this discussion ... you see orders like this all the time on psych units. 1mg lorazepam scheduled at HS and 0.5mg lorazepam PRN q4 for anxiety ... zyprexa for increased agitation and then a scheduled order ...

Best judgment with the call to the on call is always the best move. I work with a lot of older patients with comorbities and all I think of is respiratory depression with some of them ... in your case, I would have given one PRN and re-assessed, call to the doc if needed.

[KatieMI, BSN, MSN, RN]

Write up? Probably not.

Stern talk about poor clinical judgement and critical thinking? Oh, yes.

BTW, this is what happens when we providers are bombarded with calls about something for this symptom and something for that complain and nobody consciously reviewing the already existing orders. And BOTH sides need to do that every day for every patient.

And, yes, 0.5 of Xanax doesn't seem to be a lot, but if patient also was on Norco 10 q4h PRN, dilaudid 1 q2h PRN, on loading Amio PO and new Cardizem drip for afib/RVR (both inhibitors of CYP3A4, which metabolizes benzos), then the benzos-naive patient could experience respiratory depression.

[medteleER]

all i wanted to do was help my patient sleep and not wig out. the patient told me "the MD ordered 1mg of xanax for me", but the orders didn't reflect this. so i took their word for it and got creative. i figured 0.5mg+0.5mg = 1mg, so let's try that. since 1 was for sleep, and 1 was for anxiety, it would be OK, i thought. i did take into consideration 1mg of xanax isn't going to kill the person. but now i'm not so sure. i actually feel bad about this.

[Daisy4RN]

Although I am not sure I agree with the write up, I would have clarified the order with the MD. If it was written exactly as you say here then the order does not even say how often for sleep, every night etc. Pt could ask to sleep at 1400. Also, usually an order like this will say something like "do not give more than 0.5mg within 8 hrs" (on both Xanax orders). I would question the write up but just take it as a learning experience and not dwell on it either, we all make mistakes.

[0.9%NormalSarah, BSN, RN]

3 hours ago, medteleER said:

all i wanted to do was help my patient sleep and not wig out. the patient told me "the MD ordered 1mg of xanax for me", but the orders didn't reflect this. so i took their word for it and got creative. i figured 0.5mg+0.5mg = 1mg, so let's try that. since 1 was for sleep, and 1 was for anxiety, it would be OK, i thought. i did take into consideration 1mg of xanax isn't going to kill the person. but now i'm not so sure. i actually feel bad about this.

I have actually seen a lot of these orders in the hospital where I did most of my clinicals. Like another poster said the pharmacy requires each PRN reason to have its own order, even for the same Med. If I were giving the same Med from two different orders at the same time, it would make me stop and wonder why or want to clarify, but I can definitely see your rationale and I’m grateful you shared this scenario. It’s a great learning opportunity and hopefully the one write up isn’t too bad on your record there.

Edit: Sounds like this patient also got over on you a little bit. I can be naive to this too, but that’s why my preceptor told me never to take “orders” from the patient lol!

[FolksBtrippin, BSN, RN]

I do not think this warranted a write up, nor do I think it was poor nursing judgment. 1 mg of xanax is a small amount. If the patient is taking 0.5 for anxiety, they are generally taking 1 mg for sleep. Sleep requires a higher dose. I would have read the order, and understood the doc to have written it that way instead of 0.5 mg prn anxiety and 1 mg prn sleep so that the patient did not wind up getting more than 1 mg at night.

I would want to know if the doc complained, because if not, your NM is micromanaging you.

To support your case further, the patient was asking for a full 1 mg dose. This is obviously not a benzo- naive patient. Unless there were many other respiratory depressants on board as another OP suggested, I can't see why you are in the wrong here.

[Davey Do]

A rule of thumb I use with any controlled meds when the order is unclear: Separate by an hour.

Patients will come in on different controlled substances and say, "I take them all at once at home!" I say, "I don't know you and I will always error on the side of safety, so make a choice: Are you feeling more anxiety or pain (benzodiazepine or narcotic analgesic)?"

[Workitinurfava, BSN, RN]

You always have to question giving double of anything. The order could explain more but the way I see it is, if you give the med for sleep the patient won't need the other dose. Ativan can be given in so many different ways but typically I have given it every 4 hours. This med was a regularly used in a psych facility I worked in. In fact we often gave cocktails because using it alone was not enough.

[klone, MSN, RN]

You say "write up" but was it an incident report? I am assuming that's what you meant (like Midas or Quantros or whatever incident reporting system your facility uses). That is not necessarily meant to be punitive, but to look at the process. I definitely think something like that deserves an incident report - not to place blame on any individual, but look at flaws in the system, such as how these orders are written, and to improve the process.

[Workitinurfava, BSN, RN]

I am wondering why no other meds were considered to help this patient sleep? Ativan is not normally the first choice an MD goes with to help a patient sleep and not only that it can become addictive especially when being used for sleep. The other thing is if this med is stopped abruptly it can lead to rebound insomnia.

[klone, MSN, RN]

7 minutes ago, Workitinurfava said:

I am wondering why no other meds were considered to help this patient sleep? Ativan is not normally the first choice an MD goes with to help a patient sleep and not only that it can become addictive especially when being used for sleep. The other thing is if this med is stopped abruptly it can lead to rebound insomnia.

I would guess it's because it's what the patient takes at home.