Apollo1 Posted March 17, 2022 Share Posted March 17, 2022 Does anyone here deal with this issue, where the nursing staff give the patient a different dose than what you ordered in the EMR (ex. ordered 0.5mg Dilaudid, and nurse gave 1mg)? I imagine this issue, when present, typically occurs in the EM/CCM realms. Some of my colleagues mention that nurses will do "nursing doses" to avoid extra work of wasting etc., but my concern is if I'm ordering a specific dose for a specific reason, my interpretation of the patient's response is based on faulty information which can affect further patient care. Any thoughts on whether this is a topic worth discussing with nursing staff, or should I avoid this hill entirely? Quote Link to comment Share on other sites More sharing options...
CAAdmission Posted March 17, 2022 Share Posted March 17, 2022 I have never heard of a "nursing dose." If its existence is secondary to wanting to avoid extra work, I'd say that's a pretty bad idea. 3 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted March 17, 2022 Share Posted March 17, 2022 I have a great relationship with my nurses. In some cases I will tell them to use their judgement concerning timing or partial doses of meds, usually supplemented with a comment put in the order. That could be a PRN order, or a comment for dosing like 10 mg of geodon, can repeat in 30 min if patient still agitated, etc. I can't think of a time where that went the other way - to a larger dose - than ordered. I have heard the nurses call it a "nursing dose". We also have an understanding that in the rare occasions where I can't get to a patient fast enough, they can do things like breath tx and anti-emetics, until I can get there. I'm also ok when they hold a dose and then ask, especially if the need for the med has gone away, e.g. BP has normalized, patient says their pain is better, etc. 2 Quote Link to comment Share on other sites More sharing options...
iconic Posted March 17, 2022 Share Posted March 17, 2022 Just don't order 0.25 mg Ativan Quote Link to comment Share on other sites More sharing options...
sas5814 Posted March 17, 2022 Share Posted March 17, 2022 There is no such thing as a nursing dose. If they administer anything other than what was ordered its a med error. 1 2 Quote Link to comment Share on other sites More sharing options...
kettle Posted March 17, 2022 Share Posted March 17, 2022 Depends on if you are ordering a medication with a range on it i.e. 0.5-1.0 mg. I often will do this in the ER with 3 doses PRN q1h. If it's busy. In the ICU it gets tricky as if I'm trying to wean a vented patient I'm more specific Quote Link to comment Share on other sites More sharing options...
sas5814 Posted March 17, 2022 Share Posted March 17, 2022 Its fine to give a range and let a nurse give what they feel is appropriate. But if there is no range and do something other than what was ordered..... its a med error. Many moons ago when I was doing inpatient work we used to write orders like "give every 4-6 hours PRN". That became a no-no. If its PRN just say every 4 hours PRN and give parameters. Its the same with dose ranges. That is fine as long as there are parameters. Thats what good nurses do. My read of the question said OP ordered .5 of something and the nurse gave 1. That is a no-no. 3 Quote Link to comment Share on other sites More sharing options...
Reality Check 2 Posted March 17, 2022 Share Posted March 17, 2022 That is a HORRIBLE scenario. That can lead to all kinds of issues. Years ago - we had traveling nurses in the ER. A couple who traveled together. I ordered 50 of Demerol - yep - years ago. My handwriting is good and clear and it was a paper chart. Nurse pulled 400 mg of Demerol out of the Pixus Machine and pocketed the extra. This couple had been doing this for several months inpatient and ER. And on recently discharged patients who were still in the Pixus - and on deceased patients. Charge nurse called me at home right after I fell asleep after an overnight shift and asked if I had really given a patient 400 mg of Demerol. WIDE AWAKE at that point. My written orders were extremely clear and the patient was indeed alright. They investigated further and found ALL the patients these two had touched had more meds than ordered pulled. They had checked out and left town this very morning in question. EMRs and computers may have helped fix this but you can still pocket drugs if you are indeed addicted. I vote NO on this subject unless clearly specified as above in other posts. Give what is ordered. Re-order if needed. Just my crusty old 2 cents. 1 Quote Link to comment Share on other sites More sharing options...
CAAdmission Posted March 17, 2022 Share Posted March 17, 2022 29 minutes ago, Reality Check 2 said: They had checked out and left town this very morning in question. I hope that wasn't the end of the story. Need some jail time, loss of license, etc. Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 17, 2022 Moderator Share Posted March 17, 2022 hard spot you are in A nurse does not have the right to change your orders, hard stop. In reality in a good working team there is some give and take, but INCREASING the dose of an OPI is something I would not allow with any of the nurses I work with, ever.... Yup med error Few ways to handle this 1) report officially as a med error - (this is likely the only choice you have that does not put liability on you) 2) have a quiet conversation with her, supporting he clinical thoughts, but pointing out that you and you alone have the ability to order meds. Politely but firmly state that if it happens again you will report it. But if she is diverting - well you just helped them... 3) talk directly to her supervisor - end run around a nurse never goes well.... I think just apologetically going forward the only way is to have them file a med error report and then you support the nursing staff in every other way. You don't want to own any part of this.... (BTW I have a X-provider as a patient, was diverting meds for her own use. DEA is sending them to FEDERAL PRISON - they are fighting hard to get 3 years of house arrest......) be prepared for the blow back from nursing.... but it is the right thing to do. Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted March 17, 2022 Administrator Share Posted March 17, 2022 I see the words "medication error" used a lot here. It's not. An intentional dispensing of a legend drug (let alone controlled substance) without a valid prescription is a crime. 1 Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 17, 2022 Moderator Share Posted March 17, 2022 2 hours ago, rev ronin said: I see the words "medication error" used a lot here. It's not. An intentional dispensing of a legend drug (let alone controlled substance) without a valid prescription is a crime. Rev you bring up an excellent point. darn I want your job. Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted March 18, 2022 Administrator Share Posted March 18, 2022 1 hour ago, ventana said: darn I want your job. You, too, can be an eclectic weirdo with such a bizarre CV that no one hires you after they see it. Just take ~40 years of Sci Fi reading, every form of gaming, IT hacking, chaos theory, debate, religion/theology, EMS, Fire/rescue/disaster management planning, martial arts of the armed and unarmed varieties, and a hint of ASD tendencies, shake well, sprinkle with various trauma, and let ferment for 10 years while trying to function as a conscientious medical professional. 2 Quote Link to comment Share on other sites More sharing options...
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