When I was in the hospital one thing I noticed nearly all the nurses doing was scrambling to ensure they delivered all medications “on time.” They also seemed terrified to even dream of pulling a PRN medication even a minute early from the accudose. This was one of the many examples I noticed of the nurses robotic behavior and the inability to thing for themselves and make decisions unique to my care. The scripts just don’t allow for that, apparently.
This really confuses me.
In my years of bedside care I often had to go outside of the 30 minute window for timed medications for the benefit of the patient. Most of the times these times are arbitrary anyhow. If a medication is ordered once per day it doesn’t really matter what time of day the patient gets it. It should fit within their normal routine not within what the pharmacy schedules it. I never once received any sort of reprimand for my medication timing. I often had to request the scheduled times for medications be changed by the pharmacy, but many times I had to give the medication at a different time and documented the reason why.
Here’s a great example of a medication where the nurse should have used her judgment rather than fearing the pyxis.
I requested a sleeping pill at 9pm. The nurse refused. She stated it wasn’t scheduled until 10pm and could not give it until then.
“Why?” I asked her.
“Because it will show on the pyxis that I pulled it out earlier and it isn’t ordered until 10pm.”
“Really? Are you sure it isn’t ordered at bedtime?”
“It’s at 10pm on the MAR and I cannot get it to you before then,” the nurse stated.
“That doesn’t make any sense. I want to go to sleep now. What difference does an hour make?” I questioned.
“I’m sorry Mrs. Wilson. The medication is on the MAR at 10pm and I cannot give it to you until then. It will show up that I pulled the medication out early if I do.”
I gave up at that point. It wasn’t worth the argument. But I just didn’t understand the logic of the nurse or rather the inability of the nurse to use logic.
When did we start relying so heavily on the computer screen and not on our own clinical judgement? This goes beyond preventing medication errors.
The EMR is not there to define your nursing practice, it is there to allow you to document the care you provided. It can also assist in helping you ensure that you document all that is required. It’s not meant to tell you exactly how to deliver your nursing care. It’s not meant to dictate a patient’s schedule.
Nurses ,I have to ask you, does your employer audit your medication administration so meticulously that you are frightened to vere even slightly from the MAR’s administration times?
Do you let the electronic medical record dictate how and when you provide your nursing care? Or so you use it as a helping tool?
I have encountered a few nurse managers who want the EMR to police their nurses for them. They want the chart to be locked down so tight that it forces certain behaviors. To which I questioned “isn’t this where their clinical judgement should be used?” I once got the reply that clinical judgment can’t be purchased at walmart.
Fair enough. Clinical judgement cannot be purchased. It is earned and kept sharp with frequent use. So why aren’t we allowing nurses to think for themselves to keep their skills sharp?
Medication administration should be based upon the patient’s schedule, not the MARs. If the patient takes a medication at night, don’t give it to them in the morning. Get the time changed on the MAR and administer it when it is appropriate for them, not the chart!
If hospitals are being so strict as to not allow for changes such as this and for other decisions involving proper use of nursing clinical judgement, then I am very sad and where things are headed.
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Forgot to add…
Yes, many facilities are utilizing the Emar for disciplinary purposes. Reports are ran and nurses are being written up for late PRN re-evaluations, missed meds (I agree, important), and late meds.
Really?
I guess I feel blessed that I never worked in such a strict environment.
Really not conducive to high morale in nursing staff.
I am primarily licensed in Indiana. If you go outside of the 1 hour pre/post administration times you can suffer reprimand up to and including loss of license. It’s law in Indiana. If the MD ordered the med at 8pm you can only give it between 7-10pm.
I agree that it would be ‘nice’ to be able to simply change an administration time….for me however, this is two-fold difficult. #1 it’s much easier to manage med administrations when they are all on a routine schedule. Med admin can be timely with logging into both the computer/emar as well as the pyxis. Not to mention dragging the computer with you to the bedside (if you can find a mobile computer that works or is charged and believe me, this is a HUGE issue in many hospitals).
#2 The time that it takes to get a medication time changed. Some facilities require that a MD authorize the change. Calling the MD at home at 10pm for a simple time change is going to get you’re @1770238d30042ae0cbed792914c2e889:disqus $$ chewed by most docs and Getting in touch with pharmacy on the ‘off’ shifts can sometimes be time consuming and most of the time (from my experience) the pharmacy isn’t highly concerned with the times as they have enough difficulty getting the medications to the floors in time for med pass (inpatient pharmacies are WAY understaffed).
There are certain advantages to having the emar but as a 12 year nurse, I have found an increased level of stress with med admin over the last few years as it’s been instituted in more and more facilities. It now takes so much longer just to pass one simple pill….and each minute that is added to passing meds is taken from direct patient care.
I’m off my rant now….this is a subject that has been much discussed with my fellow colleagues lately.
Your state’s rules are super strict! ack!
Really what are our brains for?
The reason why hospitals are so strict is because they are concerned with the bottom line. It all goes to the flow of pretty green.Most Nurses are passive complainers. And you can’t really blame them. Many hospitals use punishment as a way of keeping the nurses like little puppets. They don’t encourage or foster independent thought.Computers don’t improve anything really. Nurses go about their pt care and put in their documentation to fit the hospitals requirement.Computers are not any more reflective of the actual time dispense of a med than the old handwritten way.In any event, computers will only advance an efficiency comensurate with the time. Kinda like the xerox machine to old handwritten carbon:)
I would argue that computers are much more effective than handwritten patient documentation, in more ways than one. However, that is a post for another day.
I could give you a books worth of information on the improvements to patient care that computers and other technology have yielded.
However, your comment has made me think about whether compensation for medication administration is tied to medication administration.
For medication where timing matters (antibiotics) I could see where this would be done.
I don’t see the need for tying reimbursement to medication administration timing for any other reason, unless it’s for insurers to find reasons not to pay.
Another thing that reminds me that healthcare ins’t broken, health insurance is.
Mars Medication System and Medication administration is there for a purpose, Farmacokinetics is very dinamic , if you are familiar with the mechanisms of farmacodynamics and kinetics then you will understand the purpose of and for the MARS Medication system and you will find it to be an excellent tool
for patient monitoring , safety and timely interventions as well as efficouse documentation..
Hope that these details help to alliviate some frustration or anxiaty percieved towards the Mars Medication Administration System.
Ms Leticia Cruz RN MSN
Letica,
EMARs should be the master decider in how I can deliver patient care.
The hospital that I work in allows us a four hour window (two hours in each direction) in which to administer medications. So, if the computerized MAR tells me that your around-the-clock medication is due at 22:00, I can administer that medication anytime between 20:00 and 24:00.
We have the same rules with our “PRN at HS” meds. Yes, HS means 22:00. But that’s just for a general rule. Obviously there are patients that want to go to sleep earlier or later than that. At the start of a night shift, I usually check to see which patients have PRN Ambien (or whatever other drug) ordered and ask them what time they would like to take it. Some people like it at 21:00 and some like it at 23:00. I remind them that sometimes things outside their room can get a little hectic, and so I encourage them to ring for me 15 minutes beforehand if they’re starting to feel ready for bed, just to remind me. No matter what time the patient wants their sleeping medication, the time that I sign it out and the time that I administer it are two different things. I could sign 6 patients worth of Ambien out at 20:00 and then administer those doses throughout the next 4 hours (patient specific), and it doesn’t matter. The only thing that matter is that all of the Ambien I signed out is accounted for.
Amy,
Thank you for confirming that sanity still exists in bedside care. Thank you also for not being a robot and thinking for yourself and your patients. I sincerely hope that you are the majority.
In the hospital where I work sharing drugs made by observing clinical schedule set by the family doctor
Nursing is a robot as concerns the patient’s clinic
Directed by a physician for each intervention
Drugs are not computerized, simple marked by clinical hours medical clinic card
Depends on the the consciousness of the nurse
I thoroughly disagree with “nursing is a robot”
I am not a robot!
I am dynamic part of the healthcare team to assesses patients needs and performs interventions as needed. I don’t mindlessly complete tasks just because they were “directed by the physician”
I also don’t know what you mean by “Depends on the consciousness of the nurse”
I just really think it’s absurd that nurses are not able to use their judgement on when medications should be administered.
I think waking up patients is ridiculous and if they were going to bed then give the HS med and be done with it, how silly! Common sense has to come into play here. I miss nursing, but not the regimented aspect of it! I have been out of direct patient care since 2004, and now out of nursing completely since 2009. Great to meet another nurse/blogger! Lisa
Can’t believe I missed this comment!
I complete agree that waking someone up for a med is bull.