Written Up

NurseBlaq · Mar 17, 2019

On 3/13/2019 at 12:44 PM, 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.

No ma'am! You do not take your patient's word for anything when narcs are involved. You check the order and if clarification is needed they will wait until they are clarified. Take this as a learning experience and don't hesitate to call a provider. At minimum, I would have asked co-workers and/or a supervisor, as you're now asking us, to prevent this exact situation. We help one another all the time. I'm notorious for asking my co-workers questions. It's always best to err on the side of caution.

jodyangel, RN · Mar 17, 2019

On 3/13/2019 at 12:42 PM, medteleER said:
VSS?????
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.

peachtreednurse, RN · Mar 17, 2019

The order was unclear at the time it was written and should have been flagged for clarification first by the nurse taking the order and then by the Pharmacy. In any case the person administering the medication is the last defense and in this instance due to the hour-the dose for sleep, given and the q 8hr.prn dose requested marked as 'not given' and the reason; that way, the patient may have gotten her needed sleep and the creative nurse would not be losing sleep over an unnecessary error.

llieber4 · Mar 17, 2019

You could give the HS dose 8 hours after the PRN.

nursejduke, BSN · Mar 17, 2019

As a nurse manager, I would hope that my charge nurse would have taken this opportunity to coach and mentor this nurse. Was this the first time this type of error was made or has it happened before? If it was the first time this type of event occurred I would have taken the time to evaluate your critical thinking ability, consider placing you on a remediation track so that you can develop your critical thinking. ALWAYS use your charge nurse as a resource, and don't feel bad for asking questions, any prudent nurse had rather you ask questions than to make an error and potentially harm a patient.

Jory, MSN, APRN, CNM · Mar 17, 2019

You need to be reviewing critical thinking skills.

SpEdtacular, MSN, RN, EMT-P · Mar 17, 2019

The OP's "double dosing" is just a symptom of a bad system and stems from multiple issues. Here's what comes to mind for me:

Benzodiazepines are not the best treatment for insomnia and if used regularly they can cause rebound insomnia and make the patient dependent on the medication in order to fall asleep. Now granted sleeping in a hospital is way different than sleeping at home so some extra help might be needed, but many of the folks in the hospital that need benzos for sleep were already taking them for sleep when they got there.

Technically, the patient saying the doctor prescribed 1mg of Xanax is true and there's a good chance the OP isn't the first (or last) person who did this.

The doctor wrote the duplicative orders for Xanax which were then reviewed by a pharmacist before being profiled on the patient's MAR. Ideally this should have been caught by the doctor or pharmacist and one of the orders should have been canceled.

The hospital should have a policy regarding duplicative orders and educate nurses on how to address them. It's not clear if that's the case here, but orders like the ones referenced by the OP and orders where there are multiple meds prescribed with the same or similar indications get a lot of well meaning nurses in trouble. For example, there's an order for 2mg of morphine for PAIN and 4mg of morphine for CHEST PAIN greater than 5/10. The nurse decides to give the 4mg of morphine because while the chest pain is only 2/10 the patient's leg pain is 10/10. It seems okay on the surface, but it could get a nurse in big trouble. Or maybe a patient has orders for both Tylenol and Motrin for pain and fever q4 hours. How should you give them? How do you know which you should you try first? Do you give both at the same time or rotate between them every 4 hours? What if Tylenol is for both pain and fever but Motrin is only for pain? If I give Tylenol for fever and shorlty after taking it, the patient wants something for pain, can I give Motrin or do I have to wait since the Tylenol has pain as an indication too? Having a clear policy about these types of orders can prevent this confusion and nurses who are aware of the issue are less likely to second guess themselves when deciding whether or not to give a med and/or get clarification from the provider.

When the OP scanned the medications, the EHR should have warned her that it was too soon to give the additional Xanax (it may or may not have done this). Unfortunately, technology bias can lead to an overreliance on the computer to catch mistakes and some nurses (and doctors and pharmacists) assume all is well if the EHR "lets" them do something.

Reporting this as a med error or near miss is appropriate, but I sincerely hope the OP isn't being punished for her actions. That helps no one and negatively impacts safety.

medteleER · Mar 18, 2019

On 3/16/2019 at 9:59 PM, Jory said:
You need to be reviewing critical thinking skills.

this is what bothers me. my rationale was "it's ONLY 1 mg". i've been in similar situations with schedule acetaminophen and prn norco, antibiotics being scheduled incorrectly by pharmacy (receiving a q8, q12, or qday dose too early because patient was a direct admission and received whatever it may be already at other facility), and meds that are synergists of each other, ie; the "seeker" type patients. and i was able intervene.

can anybody else answer below? i need to keep myself out of trouble. any assistance is appreciate it. please and thanks.

On 3/13/2019 at 10:50 PM, medteleER said:
how exactly would you approach this? i am asking, not being contentious. we care of patients like these frequently, with "patient advocates" who somehow manipulate (maybe that isn't the correct word) the MDs into prescribing meds like dilaudid, benedryl, trazodone, xanax, ativan, librium, phenergan, seroquel, gabapentin, amitriptyline, restoril in 1 sitting. most are scheduled and cleverly labeled PRN.
i once questioned some orders being "not safe" and was grilled by the an MD and charge nurse. roughly, "if the vitals are stable, you have no reason to deny a patient their medication." even if i spread medication out an hour apart, some do not metabolize out in an 1 hour. and i'll get terminated for time management issues. any ideas?

NuGuyNurse2b · Mar 18, 2019

I wouldn't have given both doses. We just had this exact situation with morphine for a pt. One of the other nurses asked me to cover her pt, there's an order for Morphine 2mg stat, and then for morphine 2mg Q4hrs (standing, not prn). Well the brilliant system allowed the stat order to be entered into the MAR at the same time to start with the Q4 standing dose. So I'm staring at two tasks for morphine to be given, 4mgs total. I bounced it back to the primary nurse to handle her pt, I wasn't about to get caught up in that one. I don't know whatever came of it, there's no doubt in my mind the Q4 hr standing was to be started 4hrs after the initial dose, but since the MD ordered both at the same time, the system automatically kicked it in like that.

kbrn2002, ADN, RN · Mar 18, 2019

I'm surprised at how many people here are questioning OP's judgement like this was some major error. I'm guessing not many of you work in LTC. Orders like this is where I work are not that uncommon and yes, I would have given both doses concurrently as ordered.

One scenario that nobody has addressed is the mandatory attempted med reductions we go through in the SNF setting. It's entirely possible that the primary MD purposefully wrote the order that way to allow for the 1 mg dose by writing the med as two separate orders. Case in point, one of our long term residents had an order for 2 Norco scheduled at HS that she'd been taking for a long time with good effect. She never used the med any other time of day so those 2 pills were the only dose given. As part of that mandatory med reduction the MD rewrote the order for 1 scheduled Norco at HS for sleep and 1 Norco prn at HS for pain so both pills continued to be administered as usual. The provider worked the system a bit to allow her to continue using the dose she was accustomed to. Though I was a little surprised that writing an order for Norco specifically for sleep went through without a hitch, never heard of that being prescribed as a sleep aid before or since!

There should be some discussion with the prescribing MD to clarify if that was the intent, but as we don't have generally have that prescribing MD available and an on-call not familiar with the resident wouldn't know the rationale behind writing two separate orders for the same med I'd give both doses as the orders allowed and clarify with the prescribing MD during office hours. That is assuming these are established orders and the resident has been on the med for some time. If these were new orders for a med the resident has no history with I'd be more inclined to call an on-call for clarification before giving it.

JKL33 · Mar 18, 2019

7 hours ago, medteleER said:
can anybody else answer below? i need to keep myself out of trouble. any assistance is appreciate it. please and thanks.
On 3/14/2019 at 1:50 AM, medteleER said:
how exactly would you approach this? i am asking, not being contentious. we care of patients like these frequently, with "patient advocates" who somehow manipulate (maybe that isn't the correct word) the MDs into prescribing meds like dilaudid, benedryl, trazodone, xanax, ativan, librium, phenergan, seroquel, gabapentin, amitriptyline, restoril in 1 sitting. most are scheduled and cleverly labeled PRN.
i once questioned some orders being "not safe" and was grilled by the an MD and charge nurse. roughly, "if the vitals are stable, you have no reason to deny a patient their medication." even if i spread medication out an hour apart, some do not metabolize out in an 1 hour. and i'll get terminated for time management issues. any ideas?

1. Don't take orders from the patient. "Orders" meaning all statements about how another nurse always does it or what a physician/provider supposedly wants them to have, or what the patient says is the only thing that works for them. They may be right and I would never disregard their experiences out of hand, but these assertions require independent confirmation, professional nursing judgment, and specific orders if indicated.

2. If you have two different orders for the same medication, generally speaking it is good to take steps to clarify prior to administering the medication to the patient.

These two ideas will keep you out of most trouble in situations like these.

?

Ruby Vee, BSN · Mar 18, 2019

2 hours ago, NuGuyNurse2b said:
I wouldn't have given both doses. We just had this exact situation with morphine for a pt. One of the other nurses asked me to cover her pt, there's an order for Morphine 2mg stat, and then for morphine 2mg Q4hrs (standing, not prn). Well the brilliant system allowed the stat order to be entered into the MAR at the same time to start with the Q4 standing dose. So I'm staring at two tasks for morphine to be given, 4mgs total. I bounced it back to the primary nurse to handle her pt, I wasn't about to get caught up in that one. I don't know whatever came of it, there's no doubt in my mind the Q4 hr standing was to be started 4hrs after the initial dose, but since the MD ordered both at the same time, the system automatically kicked it in like that.

Yeah, that's a problem with our software as well. Most of us have chatted with the prescriber about the order before they wrote it or immediately afterward, so we know what they meant and proceed accordingly. But it has gotten a few new grads whose preceptors weren't paying attention.