Omnicell & Behaviors
What is required for a narcotic cycle count, and how often do you check for discrepancies?
Do you need a RN witness when you waste or return narcotic medication?
Yes, you always need to have an RN to witness any waste or return any narcotic medication.
A patient recovering from knee surgery experiences escalating pain despite his charted medications. His primary RN repositions him and assures him that the pain medication should be working. A secondary nurse reviews the patient’s chart and notices that the primary RN has increased documentation of opioid wasted doses, and that the patients pain levels are reported high, contradicting the effectiveness of the administered pain medication that is documented. Concerned, the secondary nurse notified leadership. After investigation, it was found that the primary RN had been diverting prescribed medications, replacing them with saline solution, falsely documenting the administration and waste. How does this impact patient care? Select ALL that apply:
A. Inadequate pain relief
B. Potential for infection
C. Compromised Quality of Care
D. Erosion of Trust
ALL OF THE ABOVE:
A. Patient suffered unnecessarily due to not receiving the full dose of the pain medication
B. Contamination of needles can lead to infections C. Nurse under the influence, impairs judgement, leading to medication errors and providing substandard care
D. Trust in the healthcare system and realizing that the patients nurse tampered with his medication.
A patient needs a narcotic that isn’t stocked in the Omnicell, you go to pharmacy, pick up the medication and pharmacy dispenses the medication with the Administration and Delivery form (yellow form). After administering the medication, what are the three requirements that must be documented on the form?
Dose given, dose wasted if applicable, Primary RN that administered medication and RN that wasted medication signatures.
Patient is rating her pain 7/10. She is concerned about taking the narcotic pain medication that was ordered for a pain rating between 7-10 per the pain scale. She has requested a non-narcotic medication instead. She does have an order for Tylenol 975mg PO with a pain scale of 1-3. Can this medication be administered per her request, and how should it be documented?
YES! (For PRN doses, a patient may receive a medication ordered for a lower-than-reported pain scale, if requested by the patient.) This statement will be located with the product instructions in the MAR. She can take the Tylenol in lieu of the narcotic. When documenting Pain Assessment: Less Potent Pain Medication Administration (Patient Preference) will be acknowledged by the RN.
You apply a 12mcg Fentanyl patch on your patient. On day 2, patient is being discharged, and medication is not being continued. What are your next actions and how do you document?
Note:
Order is for 72 hours
Patch was pulled from Omnicell (no CDS sheet)
Remove patch → go to Omnicell with RN witness → select Waste Meds → document 8mcg given, 4mcg wasted
A patient needs PRN Morphine 1 mg IV. The Omnicell only has 2 mg syringes, which require wasting. You can’t find another RN, so you give the patient 1 mg, then waste the other 1 mg later with a second RN. Is this correct?
NO: NO. Wasting must be done in real time with a second RN before giving the medication. If no RN is available, notify leadership. If unable to find a second RN ask leadership.
Night RN is assessing her patient and finds a medicine cup at the bedside with 1 Oxycodone. Nurse inquires with the patient, and he states, “I didn’t think I needed 2 Oxycodone, so I was saving it for later.” Nurse reviews the MAR and it is charted that the patient received 2 Oxycodone at 1800. What are the nurse’s next step?
1. Educate the patient that all medication should be taken at the time of administration with the RN observing.
2. Remove the Oxycodone from the bedside.
3. Notify the Charge nurse.
4. Contact Pharmacy of the incident, Pharmacy will issue a CDS Form to properly document the waste of the medication.
5. Complete the CDS form with second RN, waste medication in RX Destroyer and return CDS form to Pharmacy.
6. Report via Origami.
In report the nurse was told that patient in room 2 calls for their PRN Dilauidid every two hours when it is due. The nurse is preparing medications for 1000 AM med pass and pulling medications from the Omnicell. In anticipation of the patient requesting their PRN dose, the nurse pulls the PRN Dilauidid. Is this appropriate practice?
NO! Doses must not be removed in advance or in “anticipation of use or need.” PRN controlled substances will be removed only upon patient need after an assessment has been performed.
The RN received a patient with 2 orders for pain medication within a 7-10 pain rating parameter. One order is for 0.5mg Dilaudid IVP, the other is for 10mg Roxicodone PO. How does the RN determine which medication to administer?
The nurse should not administer either medication. Clarification must be obtained from the MD. It is out of their nursing scope of practice to decide which medication takes precedence.
A new patient is admitted to your floor. During your skin assessment, you find that the patient has a 75mcg Fentanyl patch on his left upper arm. It is not dated, and the patient doesn’t recall when it was placed. MD orders to place Fentanyl patch 75mcg on patient. What is your next step?
Remove the “home” patch.
Go to Omnicell → choose “Fentanyl Home Patch Waste” → enter 75mcg for strength of patch and discard patch in the RX Destroyer with a witness → comment “not applied at AHS” for waste reason.
Then place the newly ordered 75mcg Fentanyl patch on the patient with date/time/initials.
You are preparing to administer a PRN IV Dilaudid 0.25 mg for a patient in pain. After scanning the medication into the MAR as "given," the syringe slips from your hand and most of the medication spills onto the counter and floor. What is the correct action to take?
A. Pull another dose without fixing the MAR or wasting the dose in Omnicell
B. Document in the MAR that the medication was dropped, then pull another dose without wasting the first one.
C. Waste the dropped medication in Rx destroyer with another RN, document in the MAR that it was not given, then pull a new dose and waste the old dose properly with a witness in the Omnicell.
C. Waste the dropped medication in Rx destroyer with another RN, document in the MAR that it was not given, then pull a new dose and waste the old dose properly with a witness in the Omnicell.
At 2100, a patient calls for pain medication for 6/10 pain. The patient has Tramadol ordered for moderate 4-6 pain Q6 hours and last had Tramadol at 1500. The RN administers Tramadol at 2115. At 2200, the patient is sleeping. At 0000, the patient calls to report 8/10 pain. The patient has PO Oxycodone ordered for severe 7-10 pain Q4 hours and IV Dilaudid 0.5 mg Q2 hours ordered for breakthrough pain, if patient is intolerant of PO meds. Which medication should the RN administer?
The RN should administer the PO Oxycodone. This is the appropriate medication for the pain scale the patient is reporting. The nurse does not need to wait 4 or 6 hours between Tramadol and oxycodone – the nurse must give doses of Tramadol 6 hours apart, or doses of Oxycodone 4 hours apart.
It would be inappropriate to give the IV medication since the patient is not intolerant of PO medication and since not all PO PRN options have been exhausted prior to resorting to breakthrough.
The patient requested their PRN Morphine. The RN pulls the medication from the Omnicell and when the nurse returns to the bedside the patient states they are no longer in pain and wants to wait a few more hours for the Morphine. The nurse gets called to another patient’s room to assist a patient to the bathroom. What should the nurse do next?
Promptly returns the medication to the Omnicell and gets another nurse to Witness the return.
A post-surgical patient has orders for PO Oxycodone for 7-10 pain, and for IV Morphine for breakthrough pain. At midnight, the patient calls for pain medicine for severe 7/10 pain. One hour earlier, the RN gave scheduled Tylenol to the patient. A little after midnight, the RN gives the IV Morphine thinking the patient is experiencing breakthrough pain. Was this appropriate?
NO! A breakthrough medication cannot be given following administration of a scheduled pain medication. The nurse should have given the PO Oxycodone for severe pain first. If upon reassessment of pain after oxycodone administration, the patient’s pain did not improve, then the nurse could have administered the IV Morphine for breakthrough pain.
Your patient with a Morphine PCA has an order to discontinue it. There is a yellow Narcotic sheet, what do you do with it?
Go to Med room and waste medication in RX Destroyer with Witness. Fill out the Discontinued portion of the sheet; with date/time, primary RN, witness RN and waste amount. Tube the completed Narcotic sheet to Pharmacy.
Your patient has an order for a fentanyl 50mcg patch Q72 hours. The patch was delivered by a pharmacist to you with a CDS sheet. You document on the CDS when you apply the patch.
The next day the patient is being discharged to rehab with no order to continue the fentanyl patch on discharge. What do you do?
A. Remove patch → put in RX Destroyer.
B. Remove patch → RX Destroyer → document “1 patch off” on CDS → RN witness signs.
C. Remove patch → RX Destroyer → document “16.7 mcg given / 33.3 mcg wasted” on CDS → primary RN signs → return to pharmacy.
D. Remove patch → RX Destroyer with 2 RN witnesses → document “16.7 mcg given / 33.3 mcg wasted” on CDS → both RNs sign → return to pharmacy.
D. Remove patch → RX Destroyer with 2 RN witnesses → document “16.7 mcg given / 33.3 mcg wasted” on CDS → both RNs sign → return to pharmacy.
Pharmacy tech came to refill Ativan 0.5mg drawer and found discrepancy in the count (1 less). Charge nurse made aware and when the nurse who had access to drawer prior stated they took out 2 tabs because pt was initially ordered Ativan 0.5 mg but spoke with doctor and wanted pt to receive 1mg but did not enter order in yet and have not given medication to pt yet. The nurse is a travel nurse and stated he was waiting for order and was preparing ahead of time. As charge nurse you are unsure this was drug diversion. What would you say to the team member? Would you say anything to the RN? What would be your next steps of escalation?
YES! The Charge nurse should review with the nurse that that practice does not align with medication administration policy as well as report to immediate Supervisor or Manager of suspected issue. RN to complete origami.
Anesthesiologist approaches the nurse asking for assistance with a narcotic waste. The RN notices the drug was given the day before and is uncomfortable witnessing the waste. The RN did not work on that shift and would only be taking their word. What would you do?
The RN should NOT witness the waste. They should notify their charge nurse and the anesthesiologist in charge that worked the prior day to handle the waste.
It is 4 am and the RN is rounding on patients. The nurse enters a patient’s room and notes that the patient is sleeping. While measuring the urine output, the patient wakes up and tells the RN that they are in 10/10 pain and would like pain medication. The RN completes the rest of the pain assessment and goes to retrieve Oxycodone for 10/10 pain. When the RN returns to the patient’s room, the RN finds that the patient is lethargic and hypotensive with blood pressure of 80/50. The patient is arousable and still asks for pain medicine but promptly falls back asleep. Should the RN administer the narcotic?
NO! Upon assessment, the RN finds the patient to be lethargic and hemodynamically unstable. In this instance, it is within the nursing scope of practice to withhold the medication because it would not be safe to administer to the patient. The RN should promptly return the medication if unopened, or waste if opened, and alert the provider to the patient’s status.
Day RN documents 10 mg of Oxycodone administered every 4 hours during shift. Patient states to Night RN that pain is not controlled, requesting pain medication. RN reviews MAR and informs patient that they are not due. Patient is grimacing. Patient and family states that they never received any pain medication all day. What are the Nurses next step?
Night RN should notify the Nursing Supervisor (AD) and complete an Origami. If this was discovered on Day shift, the Day RN should notify the ANM/Manager and complete an Origami.
You have an order for Xanax 0.125 mg PRN. You pull a 0.25 mg tablet from the Omnicell, waste half with your charge nurse, and keep 0.125 mg to give. When you go to the room, the patient refuses the dose. Besides marking “not given” in the MAR, what do you do with the remaining half tablet?
With a witness, you would go back to the Omnicell - “Waste Meds”. Make sure to select the correct pt and medication administration with your name as the user.
Be sure to put “0” for the administration amount and the “Waste Reason” as “patient refused”. Put the remaining half of the pill in the RX destroyer.
The nurse is caring for a patient who delivered via C-section post-op day 1. The nurse goes into the room to assess pain and the patient reports 8/10 pain. You review the MAR and there’s orders for Tylenol 975 mg for pain (1-3), Oxycodone 5 mg for pain (4-6), and Oxycodone 10 mg for pain (7-10). The nurse notices, on the previous shift it was documented that the patient received oxycodone 10 mg for a pain score of 7/10. You explain to the patient according to the providers orders for severe pain they will receive 10 mg of Oxycodone which is two tablets total. The patient reports overnight that she only received 1 tablet. You are concerned of drug diversion. What steps would you take next for escalation?
RN would report to their immediate Supervisor or Manager of the suspected issue. The RN must complete a report via origami (may choose anonymously).
The nurse is caring for a patient who delivered vaginally <12 hours ago with a second-degree laceration. During your assessment, she rates her pain as 4/10. You review the MAR, and her current orders read: Tylenol 975 mg PO for pain (1-3), Ibuprofen 600 mg PO for pain (4-6), and Toradol 30 mg IV for pain (7-10). The patient states, “my OB told me to take Toradol IV for my pain” and is refusing Ibuprofen which she is currently due for. What is the most appropriate action? Should the Nurse administer Toradol 30 mg IV to relieve her pain of 4/10 and document pain of 7/10?
The nurse should reassess the patient’s pain quality, intensity, location, then notify the Provider that the patient is requesting Toradol 30 mg IV for pain of 4/10 and that the order parameter’s specify pain of 7/10. The nurse should never document an incorrect pain level to administer a higher dose of medication.
The RN is caring for a confused patient who has orders for PRN pain medication for mild, moderate, and severe pain. The patient cannot state a mutually agreed upon pain score. The patient’s family member at bedside requests that the nurse medicate the patient for pain every 2 hours, even if the patient is sleeping, since the patient is confused and cannot properly articulate their pain. Does the RN comply with this request?
NO! The nurse must assess the patient’s pain using a nonverbal pain scale, such as FACES, the Critical Care Pain Observation tool, or PAINAD. The nurse educates the family member that it is not appropriate to wake up a patient who is sleeping to assess pain; the assessment of a patient who is sleeping is that there is not a need for pain medication. The nurse assures the family member that they will round frequently to ensure the patient is not uncomfortable.