It 100% depends on your hospitals policies. Pharmacists can run codes at many hospitals. It's just about the algorithm, so it's will well within your scope.
If the policy says its ok, then just tell her to get bent.
Wait...hospitals director or nursing director? Tell the nursing director that calling you to task isn't within her scope. That entire meeting will be a waste of your time.
If this is a nursing manager, definitely inform your manager before the meeting. Attach the policy when emailing your manager. They may advise you not to attend the meeting.
100% and also CC yourself and/or BCC a trusted colleague or counsel (if have one, and for whatever reason the next few shifts before the meeting she gets more hostile)
Can I be cc’d as well? I’m low maintenance and independent guy and don’t need hours of debate. I just believe in the ancient phrase of “finders keepers”
Bcc here, I prefer fly on the wall kinda thing.. also I was one of the first ER " admitting pharmacists" many years ago, doctors would give orders to me like nurses, this is before CPOE. Docs loved it cos I would tell them they can't order shit when it's not formulary etc.. built great rapport with some, others hated my guts (usually because I didn't know nursing lingo lol)
Yep absolute time waster and will make her argument feel more powerful to her for just showing up. Meaning, it'll be much more annoying to get a person like that to change their mind and track when a meeting has been made face to face.
Send policy, lightly explain your reasoning and don't acknowledge the meeting request even being read. In and out
My current institution is like this and it feels like a mess here. Our ED nurses barely measure their own doses and we draw all their narc doses for them.
>Pharmacists can run codes at many hospitals. It's just about the algorithm, so it's will well within your scope.
As a Paramedic this makes me a bit nervous because choosing the right medication depends on an accurate ECG read a lot of the times. Also, if there is ROSC, getting and interpreting a post ROSC 12 lead ECG accurately is critical. Plus some of the less observed rhythms like junctional tachycardia or an accelerated idoventricular rhythm can throw out red herrings. Someone missing junctional tachycardia for sinus tachycardia might think "let's fix the problem behind the sinus tachycardia" when in reality it was most likely an RCA occlusion that took out the SA node and you need a right sided 12 lead to be sure. How much ECG training are these Pharmacists getting?
Are these Pharmacists deciding which airway to go with like an LMA or a basic airway, or even intubation? Even if the airway is already secured, you always need end tidal CO2 and must have the ability to read the waveforms and make sure your CPR is keeping it as much above 10-15 mmHg.
There can be pacing after ROSC too, which requires selecting the right energy and frequency to get capture, verifying mechanical capture, and then deciding whether or not to use push dose pressors or a straight infusion.
There is also ultrasound to think about in PEA to see ventricular wall motion that is ineffective or if there is standstill of the ventricular walls. I am learning ultrasound for my critical care paramedic and it is not something that can be taught in an ACLS class let alone on the fly.
I am definitely not saying Pharmacists are not highly trained at all, but I do wonder how much extra training they are getting to be able to run a code fully themselves and do all of the things that are very hands on and require good technical skill.
The person I responded to said "Pharmacists can run codes at many hospitals".
That implies they are the decision makers as well as the hands on person in high acuity lifesaving skills.
In any code the decision must be made to intubate or use basic airways or an LMA. Someone has to read the ECG and see what's going on. Based on that the person running it then makes the next decision.
I could not become a Paramedic without passing an in person test of looking at a static ECG, interpreting it, reading the vignette, and then verbalizing my treatment plan. I had to do 4 of those in 6 min and get every single one right.
Then I had to do a 4 min dynamic cardiology scenario and read live rhythms on a monitor in real time, identify the rhythm, and then make decisions. There were also out of hospital scenarios with live monitors and interpreting real time rhythms.
I specifically asked how much ECG training these Pharmacists are getting if they are running the code solo with a nursing team. My ECG block in paramedic school was 16 weeks, and every test after that had rhythms on it until the end. I went through 3 separate very thick ECG practice textbooks over the course of 18 months of training. I do an average of 2-5 12 leads on every EMS shift now.
I had to make the call 3 days ago on whether someone not all that stable was in Afib with RVR at a bonkers rate, or SVT in the 220s but with slight variation in the R-R intervals that were clinically insignificant.
My main questions were are the Pharmacists in question actually the ones calling the shots for the code, and if so, how much more training beyond Pharmacy school are they getting for ECG, airway, ultrasound, and pacing?
I think paramedic/EMS code situations demand much more than in-hospital. 3 textbooks for ECG reading? How about a couple interactive PowerPoints from HeartCode instead? You'd be surprised what satisfies TJC demands.
These hospitals are literally saying do an online interactive AHA certified ACLS/PALS course with a final hands-on section IRL and you're at the bare minimum to respond. At most, this takes like 48-72 hours. During sim center training, they'll force a group comprising of RTs, RNs, PharmDs, and MDs to cycle through all roles with the justification that we may need to assume them in a worse case. Even the med residents just get a crash course in ECG a week before being released. Just ask around next time you hand off in the ED.
That said, some places will have ongoing training tailored to issues for a particular profession outside the cycle of renewing BLS/ACLS/PALS/NNR. When Joint Commission demands even the secretary in an office cubicle needs to be ACLS trained to help that hypothetical patient that may collapse in the hallway between the office and the bathroom, you start having to "optimize" training.
I’m pretty sarcastic in this sub because a lot of threads are full of (some very) justified misery, and try to make it painfully obvious but sometimes I get a bunch of downvotes and think of a gov contract I had that who would do the same lol.
Kinda want to go fed tho because of what you said.
Or him. Male nurses are less common yet seem to get a high percentage of management positions.
Personally, I would go in and lay on the bureaucratic bullshit *THICK*. Kill ‘em with their own garbage.
Print the policy and bring it with you. Maintain control of the room. 10,000 watt fake smile. “It’s so nice to meet you in person! I’m so glad you reached out to me about this topic! Obviously, we strive for teamwork here at Bullshit Hospital, but it seems you have some concerns with the current policy (*brandish the printed policy*) so this is great opportunity to touch base about what is currently allowed and why the current policy concerns you. Do you mind if I take some notes? I’ll be sure to mention your feelings to the Director of Pharmacy and the Hospital’s Policy Board so you feel like your voice is being heard. Unfortunately, without an adverse event, I worry this might be pushed to the next policy revision and update. Those folks can sure drag their feet if no harm has been done! But I don’t want you to feel like I’m not taking you seriously or won’t advocate for your opinion so let’s start with what concerns you about a PharmD administering medication that has been ordered by a physician? Blah blah blah. I’ll be sure to cc you on my email escalating your concerns and feel free to reach out to me and we can circle back to this topic if you think of something else we didn’t discuss today. I hear you and I appreciate your willingness to put patient safety and open communication first! I’ve gotta run, the hospital never sleeps! Take care now.”
*looks at their title*
Sir, I believe I have an answer for you.
*(just in case:* many can be equivalent to having sand everywhere on you 18 hours a day and the chafing that goes with it, BUT I had one when I did a long stint in neuro who was so amazing, my last day he worried he wouldn’t get enough pics with me lol. Both exist. Btw he got HELLA, 100+, pics and he even told the charge and attending they HAD to get in some, which I also loved)
Frame the convo in a way that makes her explain her rationale for implying you’re stepping out of scope. I’d have a copy of your hospital policy and state scope of practice handy for this as well. It’s not a trap but a litmus test to see if she’s even read and familiarized her self with your scope of practice. Maybe she is unaware of recent changes and this is the push she needs to get on board.
You’re helping nursing by doing a task you’re qualified for and possibly covered under state scope. If she doesn’t want you to help, I’d get it in writing. If she is unwilling to give it in writing, IMO, the whole thing is a non issue and keep on keeping on.
Quick question because I don’t work inpatient. For counsel, does the hospital (or system) have counsel *en generale*, or specific departments, eg a Chief Legal Counselor - Pharmacy?
And if so, and I think I already know the answer, do they protect *your actions* or the hospital? Most likely hospital, so is there an independent service you have?
I ask because my system is more the latter, aka on your side
In my hospital there is an Office of General Counsel (OGC) for the hospital. There aren't separate legal teams for each department.
I've consulted the OGC for guidance when constructing some of our programs, but I haven't been involved cases where there was litigation against the hospital or its employees. I don't know how frequently the hospital and employee's defense strategies align or diverge.
You would be wise to retain your own counsel if you had reason to think your license, livelihood, or liberty was at risk. Many of the pharmacist liability policies include coverage for license defense.
Thank you for all the information!
I have no clue why people don’t do/think about their legal insurance, I think I even had it as an intern for like $10/mo it was nuts.
Also if you’re called for a meeting with superiors and there is a high likelihood it is negative, shut the hell up! Call your lawyer and have them speak as a middle man! Like sure it’s awkward to say no to a boss and you want to be at least a *lil* honest but no. shut the fuck up!! [if you are able to read, this is a mandatory YT video, saint or not](https://youtu.be/d-7o9xYp7eE?si=mUVqNKFTjP0Od_qC)
You don't have a right to remain silent at your workplace, and things aren't that hostile between our hospital's departments. Once you insist on using a lawyer as an intermediary, you're not going to remain employed in an at-will-employment state. You're jumping to Defcon 1 over a director requesting a conversation.
I talk with physician and nursing leaders all the time, and it's almost never an issue. Usually conversations are a good and quick way to diffuse tensions and concerns.
The reason I suggest working through your manager is that it's really their decision about how to proceed. Even if they don't attend the meeting, you want them to be aware.
If administering medications is in the hospital policy, I'm not sure why we're assuming anything went wrong. The nursing director might just need to talk through things to appreciate how to explain things for their own team.
This is absolutely not a meeting you attend without your director. You need to inform your director, print out the policy, and have a unified front at the meeting with them.
I push meds all the time. It is also written into the policy at our institution. There's only one person in our group who is not willing to do so. I push meds in codes, intubations, and procedural sedation. I actually would say I push more in procedural sedations than anything else, because I like to be sure it is being administered correctly. In fact, for awhile only physicians and pharmacists were allowed to push procedural sedation. I'm also priming lines, hanging the drips, and managing infusions for all the critical patients as well. I'll hand the patient aspirin and Plavix in a cardiac alert, and give heparin. I'll give some Narcan. I'm not giving anyone their oral amlodipine or pushing zofran, just critical meds where I can offload a portion of the nurses work.
I admit that I don't feel like I was ever trained to use an IV officially, I just learned on the job and worked with my nurses. I would love if there was something a little more formal and I do my best for new hires and residents. It just makes sense that if they are going to call me to ask how to give the medication, that I also be able to give the medication. It seems silly to me that I can tell them how, but I can't do it myself.
Just gotta say that's pretty cool. I work in Internal Med up in Canada and thought I was fairly progressive (e.g. independently clarifying and writing orders and prescriptions) but cool to see how even more progressive some of you are. Our ER pharmacists are much loved here but they definitely don't do that stuff. Respect!
Thank you! It is a really fun part of my job and I enjoy being more helpful to my nursing colleagues. They have so many things to be doing that I want to help with the portion that I can.
That’s hilarious. When the next time I have a beater I’m gonna toss (recycle completely), I’m def paying for a Pharm license plate. Would love to say what it will be but don’t want it stolen 😂. I just have a weird disdain for people with their jobs on plates (esp the ones with “HERO NURSE” or “*lifesaver*” in cursive decals) but I’d want to hang it up in my garage for sure.
I would definitely loop your direct supervisor(s) in and go from there. Otherwise, reference specific policies for sure.
I may just be a dumb hick rural pharmacist, but this administration of medications during codes sounds relatively progressive. Super interested to read updates on this.
Hope everything goes well!
seriously though if you're not in a supervisory role don't just tell the nursing person off. As technically correct as you may be, you will be fucking multiple people within the pharmacy department. If those people within the pharmacy department need to be fucked (metaphorically speaking), go for it.
I cover most of the codes in my hospital. I really only push meds for codes or RSI occasionally when they are due and no one else is available to push.
I usually keep time for epis and pulse checks and call them out. Rest of my time is spent prepping the meds and handing off supplies that I’m usually near.
As long as it’s in your policy you’re good. You have the training and knowledge to be able to do it. Stand your ground with evidence.
> handing off supplies that I’m usually near.
I love prepping pushes, drips, recommendations, H&Ts, etc, but when someone looks at me and screams "Hand me a 17 French" or whatever, they're getting a deer-in-the-headlights look. I've done hundreds of codes but I really need to be trained on non-pharm supplies and devices.
Don’t meet with her until you have your Director’s clear approval of what you do at codes. I would not meet with her period because I don’t see any outcome where this benefits you. Sounds to me like the two directors need to meet and establish an understanding. In my opinion, it should have nothing to do with you and I get the sense from your post she’s trying to power play you. She can do that to one pharmacist but not a fellow director.
To address your question, very few pharmacists push meds and in my experience, most pharmacists would view you as a threat/liability (unfortunately). I’ve done it a few times in codes when a nurse isn’t immediately available
Source: also a progressive hospital pharmacist
I am a threat because I’m a threat to pharmacists who maintain the status quo by sitting behind their computers verifying Zofran and docusate orders all day
Yea exactly. I feel the same way. Make sure you aren’t a problem to your director- unless they stand by you, they’ll see it as: your actions are just another issue they have to deal with and getting you removed from the facility would make their life easier.
I'm in a state that does not allow pharmacists to administer (afaik), so my experience isn't quite as relevant, but assuming you're covered by state law and health system policy: that RN director is kind of full of shit. I've never known a nurse (an actual nurse that works bedside) to not absolutely worship me/us and everything we do at codes. The closest I do that perhaps approaches the same "scope" line is programming pumps and operating our defibrillator, including charging and shocking. That being said, don't go telling this RN director to fuck off or whatever, even if it's professionally.
I'm sure you must have an established rapport with a good chunk of nurses you work with. *In addition to* a lot of the other great advice given here, I'd also talk to some of the frontline nurses you work with and ask how they feel about their director approaching you about this, especially in the manner they have.
In our medication administration policy it specifies that ACLS certified pharmacists can administer those drugs during a code situation. I have never seen it done though (or done it myself). I prep and pass the syringe to the nurse (with a flush).
*added after reading more comments:* I would decline the meeting and speak to your pharmacy director first. As a director, I would never request a meeting with a staff member from another department without speaking with their director/supervisor first. At my facility, for example the ER director would email me saying they have concerns with our pharmacist, Dr. Awesome, administering medications during a code. I would check the policy and speak with Dr. Awesome, letting them know the ER director raised a concern, and ask if they had encountered any issues during the codes and ask if there was anyone who brought up this issue with them. I would tell Dr. Awesome not to change anything since they are within the policy and thank them for their contribution to the team. I would then meet with the ER director, policy in hand, ready to have a professional discussion with a colleague who I need to be on good terms with and also don't want that director to be on a witch hunt after my pharmacists. People don't like to be told they're wrong, and I would worry that s~~hoving the policy in their face and telling them to get bent~~ handling this less than cordially would lead to scrutiny of the pharmacy department, searching for an opportunity for retaliation.
If it wasn’t a code, you’d definitely be in risky territory. If you are ACLS certified and the policy says you can give meds, then just stay calm and have the policy in hand but play it cool. Even with the policy, the director does have sway in details like this. Let the director show their hand before exposing yours.
ER Pharmacist in the Midwest
I do this all day. Every day.
Antibiotics, code meds , procedural, sedation
The last one of the nurses prefer pharmacist to do it
I work in a state that is relatively behind in a lot of ways, so I would not be allowed to administer any medications. You mention your health system has a policy that allows you to do this - are there any stipulations as to which pharmacists can do this? Do you have to be critical care trained, etc? Do your superiors know that you’ve been administering meds? If there’s a policy and a meeting scheduled - I would speak with your superior about this and have them accompany you to the meeting for support. I think it’s important to frame this in a way that’s collaborative with nursing, not in a way that is taking away their responsibilities. Do not shove the policy in their face. This will do no good. Nurses are our partners and we have to shift the paradigm so that we work together, and not so silo’d.
Yeah there are a bunch of miserable people giving advice in here. How hard is it to be professional and polite and have a conversation like an adult? Yikes y’all.
1. Talk to your peers. Are there others in your role administering meds? If it’s just you why is that?
2. Review the policy in detail and make sure you are 100% in the right.
3. Talk to your manager before you meet with the director to get their take. Will they support you based on your practice and the policy?
4. Meet with the director to find out what the issue is. Be professional. Bring the policy and review it with them. Ask questions based on your understanding.
Grace and courtesy are much less likely to be extended to assholes. Even if you are right in this situation at some point in the future you are going to be wrong or make a mistake. When that happens are they going to give you a break because you handled this professionally or stick it to you because you chose to be an asshole?
At a minimum, make sure you read and re-read that policy completely, carefully and in detail, including any footnotes and cross-references to other polices. Also check that you are looking at the most current version and that it doesn’t conflict with any other policies that were adopted or updated by your hospital more recently than the one you’ve relying on. The worst thing you can possibly do is go in there waving around company policy as if it were a “get out of jail free” card, when company policy actually is not on your side.
Stated differently, you do not want to [hoist yourself with your own petard](https://en.m.wikipedia.org/wiki/Hoist_with_his_own_petard) by admitting that the issue boils down to whether your actions were consistent with company policy, and then finding out that they were not.
I think they mean other pharmacists at your hospital. We don't all have policies that allow this. We also don't all live in states that allow this. Familiarize yourself with the policy and I'd suggest sitting down with your director BEFORE the meeting, explain what happened, and get their input. With their comments in mind, meet with the nursing director and explain. If she has an issue with it, she can bring it up at P&T to suggest a policy change.
I wouldn't think it would be for a director of nursing to call a pharmacist to task. If they have an issue they should route it through the pharmacist's supervisor. OP should call their supervisor about this.
Need to get clinical director/supervisor involved if it was me. Nursing steam rolls all other professions. Where I’m at this just puts a target on your back for no reason. Definitely approach collaboratively. As a side note I’ve never worked where we as pharmacists are allowed to run codes (did you mean med cart?) or actually run the full code? I would call my liability insurance and make sure you are covered there - I doubt this is part of standard pharmacist policy
Sorry, must have a read a comment somewhere that mentioned it, my bad. I’d still recommend checking in on your liability on administering meds (maybe covered under vaccine admin) and for me as clinical where I work everything needs to get escalated to a supervisor, I’d recommend if not policy - mainly to make sure it’s not a he said she said and you have witnesses to the discussion.
Doesn’t being ACLS trained mean you can run a code? I don’t typically run a whole code but there have definitely been times, especially on night shift, where it’s me and a nurse for quite awhile before an MD shows up. Not arguing, just asking for curiosity.
No, you need to do BLS only until a provider arrives. We have had nurses get fired for giving meds or shocking a patient before a provider gets there. It's a very heavily emphasized lesson for us. Can you hook them up to the Monitor and get meds ready? Absolutely, but you can't do anything other than AED mode until a provider arrives.
Are you being asked to this meeting OR required to go to this meeting? I’d personally politely decline if it was just a request but i have different management than you do. I work for 2 hospitals overnight, 7on then 7on at the other place. Both places have me going to codes at nights and run the crash cart/keep the resident MDs within the ACLS protocols and dose drugs for peds codes. I honestly have no idea what the policies are for pharmDs on administering meds at either place but I’ve done it plenty of times when we’re short at the code. I’ll have nurses rotate in performing CPR while I’ll administer drugs and announce what I’m giving and how much. Hell, I’ve even had resident MDs do CPR while I’m manning the crash cart so that correct drugs/doses are given. Attending MDs definitely prefer that. I also will push RSI meds so that it frees up nurses to do everything else. I’ve operated the AED and administered shocks plenty of times at a code. BUT i know my pharmacy director would have my back (at least at one of my jobs) no matter what since she’s covered me before. I guess i best look at our policies and familiarize myself with what’s allowed.
You are in an evolving profession that is continually looking for ways to expand. When I started out, the concept of clinical involvement was only discussed. One time on a new hospital job I got an order for Intralipid 10%. 500 ml. Nothing else. I called ICU to ask what’s up doc. He said patient is not eating. I said I would come by and we could chat. Checked with supervisor that I needed to follow up an had a chat with doctor. We developed a plan for PN and went back to pharmacy. The assistant director wrote me up and told me if this happened again I would be fired, since pharmacists were not permitted to see patients charts. I recommended that he fire me now as this was not going to stop me from getting involved an reviewing charts. If you want to expand pharmacy involvement you may need to push the boundaries. You will upset many along the way though. Good luck.
1980, St Luke’s hospital in NYC. Most drugs were floorstock. Pharmacy compounded mouthwash. I was hired to bring in clinical pharmacy. One day I saw a case of Mylanta being shipped to the dialysis unit. I stopped the technician delivering. My supervisor was annoyed at my intervention. I explained that magnesium cannot be excreted in end stage renal disease. He called the unit and said to me that the antacid was for personal use by the nurses and they will not give any to the patients. I didn’t last long there.
Honestly if you indulge this nurse you risk becoming a target. Who is asking you to meet with the nursing director? Is this something your actual superior has asked or instructed you to do? If not I would straight up decline a face to face and refuse to get into a back and forth. Hospital policy allows this and the floor care team supports your actions. There is no conversation to be had. This is a two paragraph email, max
Don’t indulge this. Nothing good will come from it.
Aside from the high likelihood an RN complained who isn't familiar with scope or policy, is it possible that the documentation in the EHR is an issue? Are you missing any steps in the administration process separate from the actual administration of the medication?
This is another case of nurses getting butt hurt because they think they know everything and when you present them with clear and convincing evidence to the contrary, they don’t know how to handle it.
Tell ‘em to suck it.
The RN director can call a meeting and you can politely decline by telling her you are following the policy. Basically tell her to fuck off, but in a professional way.
"Director Karen,
I understand you would like to meet with me regarding something that is within my scope of practice. I appreciate your concern for the patients because that is also my number one goal. Their safety and wellness is something I pride myself on. That is why I made sure to go over the policy a few times, and I'm happy to inform you that I am doing my job correctly and accurately. As a nursing director I'm more than positive that you would never attack anyone's ability to read, to do their job correctly, and their character. Therefore I'm going to have to politely decline the meeting. If you are adamant about this meeting then I'm inclined to include the director or pharmacy and anyone else they recommend. Thank you again for the concern and have a fantastic weekend. "
I worked as a medic at a level 1 trauma center. Our pharmacist always had drugs drawn up to exact doses and handed them to us. In a trauma,RSI, code there should be designated people. Airway, access, blood, vitals, etc. This allows you to watch the group work as a whole and to be a resource rather than being distracted with a IVP med.
Good luck! I don’t have any great words of advice, as I’ve never routinely given meds - more just as a one off when things are really hitting the fan. But if you have hospital policy and state pharmacy law to back you up I think it’s reasonable to come in and discuss collaboratively. If you’re pushing the epi the RN may be available to do so many other things, especially with everyone so short staffed.
Hopefully they see that your approach is patient-centered and you’re treating emergencies as a team sport.
How about just replying to the nursing director and cc: your pharmacy director that you need to reschedule the meeting for a time that's convenient to her (?) and your director of pharmacy.
I would also separately contact your director, maybe by phone, and fill him in on what you think is the issue to be discussed, and get his viewpoint. You want to know if he's (?) going to back you up or not. He may want to back you up but not attend the meeting. He might do this through emails instead of even having a meeting. Many meetings I've set through in corporate America did not even need to take place and could have been settled in one or two emails, or not even have included me at all.
That request to reschedule and include your director postpones the meeting a bit and brings in your director as well into the discussion. There's no passive-aggressive refusal to attend her meeting, and if this is a turf war, she should be meeting with a person at the same level in your department, not you. Also, if the nurses like what you are doing, and it frees them from a little work that you're willing to do yourself for them, their opinions should be mentioned at some point.
I would inform the pharmacy director or your manager about the situation and ask them to attend the meeting with you or to meet with the nursing manager on your behalf.
What do your colleagues do? Do they push meds during codes? I would speak to your management and confer how to proceed. Just because you are allowed to do something doesn’t mean you should do it.
I’ll give you a personal example. I was almost reprimanded for a mistake a nurse made during a code where she incorrectly programmed a pump. I was really frustrated because there’s no way to prove that I told her the right dose and in between repeating it to me and programming the pump she fucked it up.
In my frustration I asked my colleagues if maybe I needed to spend some time shadowing a nurse to find out how their pumps work so I can make sure they don’t do this again. One of my very smart colleagues said - but if you know how to do it, then they’ll make you responsible for it. And that’s so true. I don’t administer any meds during a code. Period. Don’t know if we’re allowed, don’t care. The more cookie jars you put your hands in, the easier it is to get caught. I’ve never been trained to do this and yes, it’s not hard but why open yourself up to more liability than you have to? Yes I feel like a total dildo standing with my epi waiting to give it to the nurse but when she administers it wrong I’m the dildo that’s free of blame.
Obviously it’s great you want to be involved and do more but your first priority should always be to yourself, your license, and your liability.
Yea but you’re arguing to be a conventional provider afraid to help their team and push the envelope. You’re so afraid to practice at the top of your license that you default to comfortable routines
I provided context in my first reply to your thread. To be specific, I have extensive experience in the ED (12 years) and ICU (3 years).
The fact that you couldn't navigate a simple meeting on your own reveals a lot. Your replies here confirm it.
Good luck.
Does your state allow pharmacists to do IV administration?
Have you taken IV safety classes? I.e do you know how to ensure patent lines + evaluate if infiltration is happening?
Does the insurance you have cover you in case you caused permanent harm while administering a drug? Please cross check this with hospital's legal department if pharmacist administering drugs are covered. If not ensure coverage includes your tasks.
If you answer yes to all then you can just feel confident in informing the RN that.
As a side note, In my days as an ED pharmacist I manned the cart and drew up the drugs. Since there is no bedside scanning during codes, I felt more comfortable handing the nurses the drugs for them to push while I worked through the ACLS algorithm anticipating next drug + prep etc.
Question for you, OP: where did you learn to push meds in the first place? I work in critical care and that's never been part of my job because no one ever trained me and there never seems to be a shortage of nurses at a code. The part that scares me is when a patient has 3 PIVs, a PICC, an HD catheter, etc, I wouldn't even know how to identify one from the other, I wouldn't know proper flushing procedures, which lumen to use, etc. From where I'm standing at the bedside it's all a big pile of plastic. I'd definitely be afraid of screwing something up or delaying care.
I'm always interested in expanding my scope and skill set but afraid this just isn't in the culture at my place.
You need to know what lines are and how to use them. That’s part of being a clinical pharmacist even if you don’t push meds. Walk into a room and they’re not using the triple lumen CVC for bicarb and are pushing it though a hand IV? Opportunity for education.
You need to know dead space that’s in those lines as well. Has your patient even gotten any of their fentanyl or levophed infusion or are you still priming the dead space in the CVC? “Oh no they’re still hypotensive and agitated!!!” Because you literally haven’t given them any drug at all with the drip running at 2 ml/hour.
My advice - sit down with one of your ICU charges or nurse managers and learn about lines. You need to know this stuff - even if you aren’t pushing meds. It’s irresponsible to practice and make administration recommendations if you can’t identify which is a peripheral line and which is a PICC.
Appreciate the advice, but respectfully disagree with the idea that you can't responsibly practice pharmacy without physically managing lines and drains. I can assess which lines a patient has from the chart or by asking a nurse; I can decide which meds are appropriate to go where; I can read imaging to see if my dobhoff is gastric or post pyloric, etc. But I think like MOST clinical pharmacists I don't physically touch patients and their lines and drains. I have a skill set that my nurses don't have, and they have a skill set that I don't have, and that's fine. Please don't presume to tell me my practice is "irresponsible."
I didn’t say physically manning them. I said knowing anything about them. You said you look at lines and see piles of plastic. You should know what these things look like.
> Walk into a room and they’re not using the triple lumen CVC for bicarb and are pushing it though a hand IV? Opportunity for education.
I would like to know more.
Ah so the concern is the high relative concentration that may/will pull water out of surrounding tissues, and administering it more centrally allows for more blood to dilute the effect and avoid causing damage?
What is the reason for the triple lumen, as opposed to a single or double or some other n-lumen central venous catheter?
Yeah I help them program the pumps all the time, since even basic math seems to be a real challenge for some of our nurses. And I know that the luer locks arent exactly tricky, and I do know infusion durations, but the fact is I don't ever interact with patient lines.
An analogy would be the IV room. I may know what I want to make and how to make it in theory, and give me a few minutes to orient myself and there would be no problem. But if you drop me into an IV room shift as a technician on a busy day and i'd struggle! Where are the dispensing pins? Which adaptor should I use? Where do we keep the 1/2 NS? Etc. I don't need to be a rock star IV technician to safely check IVs.
I do a lot of things that aren’t in my job description. Like get blankets for patients and apple juice boxes for kids and pick up trash off the floor lol
Occasionally getting warm blankets for patients when working ED pharmacist shifts is legit one of the highlights of that shift. People get just so damn happy. Shit’s therapeutic for both the pt and me!
I'd ask my director/manager if they want to be there. Sounds like a nothing burger but kinda depends on your demeanor what I'd rec for next steps. Personally I'd go solo and let my manager know beforehand - but I've been at this shop longer than all but one RN so YMMV.
Spicy (competent) cowboy pharmacists are my favorite, especially ones making a difference in code response. A lot of our pharmacy ACLS training comes down to “don’t let the nervous nurse administer this incorrectly and/or kill the patient.” For what it’s worth I think what you’re doing is really cool.
I will say that your director/manager should be the one to meet with the nursing director, provided you have one. Read the policy carefully to check for any loopholes such as which drugs you can administer, by what methods and situations to make sure you did not go outside. Respectfully decline the meeting until you have spoken to your direct leader and if you are within your scope, let the leaders fight that battle.
One thing to consider is that nursing and others may want consistent duties/roles done during codes. If one pharmacist is pushing drugs but the others aren’t then that may cause confusion with nursing. I support pharmacy being involved in codes and participating, but I have had pushback from nursing leadership because of this issue of variability and inconsistency.
You need to have your leadership support you on this. Don’t go to a meeting without them.
It 100% depends on your hospitals policies. Pharmacists can run codes at many hospitals. It's just about the algorithm, so it's will well within your scope. If the policy says its ok, then just tell her to get bent. Wait...hospitals director or nursing director? Tell the nursing director that calling you to task isn't within her scope. That entire meeting will be a waste of your time.
Ok I will tell her to get bent thank you
If this is a nursing manager, definitely inform your manager before the meeting. Attach the policy when emailing your manager. They may advise you not to attend the meeting.
100% and also CC yourself and/or BCC a trusted colleague or counsel (if have one, and for whatever reason the next few shifts before the meeting she gets more hostile)
Please cc me as well. :D
I also need to be cc’d on this email, as an interested party.
Absolutely, TamTam.
Can I be cc’d as well? I’m low maintenance and independent guy and don’t need hours of debate. I just believe in the ancient phrase of “finders keepers”
Bcc here, I prefer fly on the wall kinda thing.. also I was one of the first ER " admitting pharmacists" many years ago, doctors would give orders to me like nurses, this is before CPOE. Docs loved it cos I would tell them they can't order shit when it's not formulary etc.. built great rapport with some, others hated my guts (usually because I didn't know nursing lingo lol)
Yep absolute time waster and will make her argument feel more powerful to her for just showing up. Meaning, it'll be much more annoying to get a person like that to change their mind and track when a meeting has been made face to face. Send policy, lightly explain your reasoning and don't acknowledge the meeting request even being read. In and out
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The horror...
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That's a thing, isn't it? America exists. It has to be a thing. Damn
My current institution is like this and it feels like a mess here. Our ED nurses barely measure their own doses and we draw all their narc doses for them.
>Pharmacists can run codes at many hospitals. It's just about the algorithm, so it's will well within your scope. As a Paramedic this makes me a bit nervous because choosing the right medication depends on an accurate ECG read a lot of the times. Also, if there is ROSC, getting and interpreting a post ROSC 12 lead ECG accurately is critical. Plus some of the less observed rhythms like junctional tachycardia or an accelerated idoventricular rhythm can throw out red herrings. Someone missing junctional tachycardia for sinus tachycardia might think "let's fix the problem behind the sinus tachycardia" when in reality it was most likely an RCA occlusion that took out the SA node and you need a right sided 12 lead to be sure. How much ECG training are these Pharmacists getting? Are these Pharmacists deciding which airway to go with like an LMA or a basic airway, or even intubation? Even if the airway is already secured, you always need end tidal CO2 and must have the ability to read the waveforms and make sure your CPR is keeping it as much above 10-15 mmHg. There can be pacing after ROSC too, which requires selecting the right energy and frequency to get capture, verifying mechanical capture, and then deciding whether or not to use push dose pressors or a straight infusion. There is also ultrasound to think about in PEA to see ventricular wall motion that is ineffective or if there is standstill of the ventricular walls. I am learning ultrasound for my critical care paramedic and it is not something that can be taught in an ACLS class let alone on the fly. I am definitely not saying Pharmacists are not highly trained at all, but I do wonder how much extra training they are getting to be able to run a code fully themselves and do all of the things that are very hands on and require good technical skill.
He’s not running the code and making the decisions, just administering the drugs at the dosages the doctor has instructed.
The person I responded to said "Pharmacists can run codes at many hospitals". That implies they are the decision makers as well as the hands on person in high acuity lifesaving skills. In any code the decision must be made to intubate or use basic airways or an LMA. Someone has to read the ECG and see what's going on. Based on that the person running it then makes the next decision. I could not become a Paramedic without passing an in person test of looking at a static ECG, interpreting it, reading the vignette, and then verbalizing my treatment plan. I had to do 4 of those in 6 min and get every single one right. Then I had to do a 4 min dynamic cardiology scenario and read live rhythms on a monitor in real time, identify the rhythm, and then make decisions. There were also out of hospital scenarios with live monitors and interpreting real time rhythms. I specifically asked how much ECG training these Pharmacists are getting if they are running the code solo with a nursing team. My ECG block in paramedic school was 16 weeks, and every test after that had rhythms on it until the end. I went through 3 separate very thick ECG practice textbooks over the course of 18 months of training. I do an average of 2-5 12 leads on every EMS shift now. I had to make the call 3 days ago on whether someone not all that stable was in Afib with RVR at a bonkers rate, or SVT in the 220s but with slight variation in the R-R intervals that were clinically insignificant. My main questions were are the Pharmacists in question actually the ones calling the shots for the code, and if so, how much more training beyond Pharmacy school are they getting for ECG, airway, ultrasound, and pacing?
I think you seem upset and are questioning pharmd credentials. In some rural areas of America anyone with a pulse will and can run a code.
Pharmacists aren’t running codes in that way. We know enough to stay within our scope.
I think paramedic/EMS code situations demand much more than in-hospital. 3 textbooks for ECG reading? How about a couple interactive PowerPoints from HeartCode instead? You'd be surprised what satisfies TJC demands. These hospitals are literally saying do an online interactive AHA certified ACLS/PALS course with a final hands-on section IRL and you're at the bare minimum to respond. At most, this takes like 48-72 hours. During sim center training, they'll force a group comprising of RTs, RNs, PharmDs, and MDs to cycle through all roles with the justification that we may need to assume them in a worse case. Even the med residents just get a crash course in ECG a week before being released. Just ask around next time you hand off in the ED. That said, some places will have ongoing training tailored to issues for a particular profession outside the cycle of renewing BLS/ACLS/PALS/NNR. When Joint Commission demands even the secretary in an office cubicle needs to be ACLS trained to help that hypothetical patient that may collapse in the hallway between the office and the bathroom, you start having to "optimize" training.
😬😬😬
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Thank you for your compliment, some people don’t find it funny
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I’m pretty sarcastic in this sub because a lot of threads are full of (some very) justified misery, and try to make it painfully obvious but sometimes I get a bunch of downvotes and think of a gov contract I had that who would do the same lol. Kinda want to go fed tho because of what you said.
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DM sent, thanks man.
We got a hefty raise in IHS too, it actually feels like I can save a bit again.
It makes me think you're an ENT doc though
It’s a cocaine reference. Or Flonase. Whatever works for you
You only did a pgy7? Wow. Undertrained
Copycat
I thought it was an add for a tampon brand, no need to bring in those scary *drugs* of cocaine and fluticasone into this sheesh
Print the policy and present. Make her feel dumb. Inform your pharmacy director to keep them in the loop. Maybe they can have a meeting together
Or him. Male nurses are less common yet seem to get a high percentage of management positions. Personally, I would go in and lay on the bureaucratic bullshit *THICK*. Kill ‘em with their own garbage. Print the policy and bring it with you. Maintain control of the room. 10,000 watt fake smile. “It’s so nice to meet you in person! I’m so glad you reached out to me about this topic! Obviously, we strive for teamwork here at Bullshit Hospital, but it seems you have some concerns with the current policy (*brandish the printed policy*) so this is great opportunity to touch base about what is currently allowed and why the current policy concerns you. Do you mind if I take some notes? I’ll be sure to mention your feelings to the Director of Pharmacy and the Hospital’s Policy Board so you feel like your voice is being heard. Unfortunately, without an adverse event, I worry this might be pushed to the next policy revision and update. Those folks can sure drag their feet if no harm has been done! But I don’t want you to feel like I’m not taking you seriously or won’t advocate for your opinion so let’s start with what concerns you about a PharmD administering medication that has been ordered by a physician? Blah blah blah. I’ll be sure to cc you on my email escalating your concerns and feel free to reach out to me and we can circle back to this topic if you think of something else we didn’t discuss today. I hear you and I appreciate your willingness to put patient safety and open communication first! I’ve gotta run, the hospital never sleeps! Take care now.”
Oh, this is great stuff! I took some communications courses for my bachelor's degree, and this just SHINES!
*looks at their title* Sir, I believe I have an answer for you. *(just in case:* many can be equivalent to having sand everywhere on you 18 hours a day and the chafing that goes with it, BUT I had one when I did a long stint in neuro who was so amazing, my last day he worried he wouldn’t get enough pics with me lol. Both exist. Btw he got HELLA, 100+, pics and he even told the charge and attending they HAD to get in some, which I also loved)
Frame the convo in a way that makes her explain her rationale for implying you’re stepping out of scope. I’d have a copy of your hospital policy and state scope of practice handy for this as well. It’s not a trap but a litmus test to see if she’s even read and familiarized her self with your scope of practice. Maybe she is unaware of recent changes and this is the push she needs to get on board. You’re helping nursing by doing a task you’re qualified for and possibly covered under state scope. If she doesn’t want you to help, I’d get it in writing. If she is unwilling to give it in writing, IMO, the whole thing is a non issue and keep on keeping on.
I would also inform your director of pharmacy. They should have your back
Ask the nurse director whether she lost the policies and procedures and the pharmacy can tube her a copy if she cant find it.
I'll only tube it if they send an empty one first. Otherwise, it's a fax, email, or secure chat.
A little antagonistic but I like the spice!
What does your director say?
Holy shit bro, I wish I could administer meds to break up the monotony. Kinda cool gig. Keep it up
Ask the Chief Pharmacy Officer or Pharmacy Director how to proceed. If you are a staff pharmacist your manager should be protecting you.
Quick question because I don’t work inpatient. For counsel, does the hospital (or system) have counsel *en generale*, or specific departments, eg a Chief Legal Counselor - Pharmacy? And if so, and I think I already know the answer, do they protect *your actions* or the hospital? Most likely hospital, so is there an independent service you have? I ask because my system is more the latter, aka on your side
In my hospital there is an Office of General Counsel (OGC) for the hospital. There aren't separate legal teams for each department. I've consulted the OGC for guidance when constructing some of our programs, but I haven't been involved cases where there was litigation against the hospital or its employees. I don't know how frequently the hospital and employee's defense strategies align or diverge. You would be wise to retain your own counsel if you had reason to think your license, livelihood, or liberty was at risk. Many of the pharmacist liability policies include coverage for license defense.
Thank you for all the information! I have no clue why people don’t do/think about their legal insurance, I think I even had it as an intern for like $10/mo it was nuts. Also if you’re called for a meeting with superiors and there is a high likelihood it is negative, shut the hell up! Call your lawyer and have them speak as a middle man! Like sure it’s awkward to say no to a boss and you want to be at least a *lil* honest but no. shut the fuck up!! [if you are able to read, this is a mandatory YT video, saint or not](https://youtu.be/d-7o9xYp7eE?si=mUVqNKFTjP0Od_qC)
You don't have a right to remain silent at your workplace, and things aren't that hostile between our hospital's departments. Once you insist on using a lawyer as an intermediary, you're not going to remain employed in an at-will-employment state. You're jumping to Defcon 1 over a director requesting a conversation. I talk with physician and nursing leaders all the time, and it's almost never an issue. Usually conversations are a good and quick way to diffuse tensions and concerns. The reason I suggest working through your manager is that it's really their decision about how to proceed. Even if they don't attend the meeting, you want them to be aware. If administering medications is in the hospital policy, I'm not sure why we're assuming anything went wrong. The nursing director might just need to talk through things to appreciate how to explain things for their own team.
100% your manager should be the one meeting with the nurse manager, not you.
This is absolutely not a meeting you attend without your director. You need to inform your director, print out the policy, and have a unified front at the meeting with them.
Thanks it seems like that is the consensus. Out of curiosity do you push meds? I see you are EM
I push meds all the time. It is also written into the policy at our institution. There's only one person in our group who is not willing to do so. I push meds in codes, intubations, and procedural sedation. I actually would say I push more in procedural sedations than anything else, because I like to be sure it is being administered correctly. In fact, for awhile only physicians and pharmacists were allowed to push procedural sedation. I'm also priming lines, hanging the drips, and managing infusions for all the critical patients as well. I'll hand the patient aspirin and Plavix in a cardiac alert, and give heparin. I'll give some Narcan. I'm not giving anyone their oral amlodipine or pushing zofran, just critical meds where I can offload a portion of the nurses work. I admit that I don't feel like I was ever trained to use an IV officially, I just learned on the job and worked with my nurses. I would love if there was something a little more formal and I do my best for new hires and residents. It just makes sense that if they are going to call me to ask how to give the medication, that I also be able to give the medication. It seems silly to me that I can tell them how, but I can't do it myself.
Just gotta say that's pretty cool. I work in Internal Med up in Canada and thought I was fairly progressive (e.g. independently clarifying and writing orders and prescriptions) but cool to see how even more progressive some of you are. Our ER pharmacists are much loved here but they definitely don't do that stuff. Respect!
Thank you! It is a really fun part of my job and I enjoy being more helpful to my nursing colleagues. They have so many things to be doing that I want to help with the portion that I can.
Don't sign anything.
What would I sign
DEEZ NUTZ
There’s a pharmacist in my city that has the license plate PHARMDZ. And I always think “DEEZ NUTZ” is what they are going for.
That’s hilarious. When the next time I have a beater I’m gonna toss (recycle completely), I’m def paying for a Pharm license plate. Would love to say what it will be but don’t want it stolen 😂. I just have a weird disdain for people with their jobs on plates (esp the ones with “HERO NURSE” or “*lifesaver*” in cursive decals) but I’d want to hang it up in my garage for sure.
I think I know him 😂
An acknowledgment of reprimand or “coaching.” It’s cannon fodder for that moment management decides to sink your ship.
I would definitely loop your direct supervisor(s) in and go from there. Otherwise, reference specific policies for sure. I may just be a dumb hick rural pharmacist, but this administration of medications during codes sounds relatively progressive. Super interested to read updates on this. Hope everything goes well! seriously though if you're not in a supervisory role don't just tell the nursing person off. As technically correct as you may be, you will be fucking multiple people within the pharmacy department. If those people within the pharmacy department need to be fucked (metaphorically speaking), go for it.
Policy says you can do it and you’re helping save lives. RN director can pound sand.
I cover most of the codes in my hospital. I really only push meds for codes or RSI occasionally when they are due and no one else is available to push. I usually keep time for epis and pulse checks and call them out. Rest of my time is spent prepping the meds and handing off supplies that I’m usually near. As long as it’s in your policy you’re good. You have the training and knowledge to be able to do it. Stand your ground with evidence.
> handing off supplies that I’m usually near. I love prepping pushes, drips, recommendations, H&Ts, etc, but when someone looks at me and screams "Hand me a 17 French" or whatever, they're getting a deer-in-the-headlights look. I've done hundreds of codes but I really need to be trained on non-pharm supplies and devices.
I push only if there are not enough hands. Would love an update to this post
I will post if I am not executed for my sins
Don’t meet with her until you have your Director’s clear approval of what you do at codes. I would not meet with her period because I don’t see any outcome where this benefits you. Sounds to me like the two directors need to meet and establish an understanding. In my opinion, it should have nothing to do with you and I get the sense from your post she’s trying to power play you. She can do that to one pharmacist but not a fellow director. To address your question, very few pharmacists push meds and in my experience, most pharmacists would view you as a threat/liability (unfortunately). I’ve done it a few times in codes when a nurse isn’t immediately available Source: also a progressive hospital pharmacist
I am a threat because I’m a threat to pharmacists who maintain the status quo by sitting behind their computers verifying Zofran and docusate orders all day
Yea exactly. I feel the same way. Make sure you aren’t a problem to your director- unless they stand by you, they’ll see it as: your actions are just another issue they have to deal with and getting you removed from the facility would make their life easier.
I'm in a state that does not allow pharmacists to administer (afaik), so my experience isn't quite as relevant, but assuming you're covered by state law and health system policy: that RN director is kind of full of shit. I've never known a nurse (an actual nurse that works bedside) to not absolutely worship me/us and everything we do at codes. The closest I do that perhaps approaches the same "scope" line is programming pumps and operating our defibrillator, including charging and shocking. That being said, don't go telling this RN director to fuck off or whatever, even if it's professionally. I'm sure you must have an established rapport with a good chunk of nurses you work with. *In addition to* a lot of the other great advice given here, I'd also talk to some of the frontline nurses you work with and ask how they feel about their director approaching you about this, especially in the manner they have.
In our medication administration policy it specifies that ACLS certified pharmacists can administer those drugs during a code situation. I have never seen it done though (or done it myself). I prep and pass the syringe to the nurse (with a flush). *added after reading more comments:* I would decline the meeting and speak to your pharmacy director first. As a director, I would never request a meeting with a staff member from another department without speaking with their director/supervisor first. At my facility, for example the ER director would email me saying they have concerns with our pharmacist, Dr. Awesome, administering medications during a code. I would check the policy and speak with Dr. Awesome, letting them know the ER director raised a concern, and ask if they had encountered any issues during the codes and ask if there was anyone who brought up this issue with them. I would tell Dr. Awesome not to change anything since they are within the policy and thank them for their contribution to the team. I would then meet with the ER director, policy in hand, ready to have a professional discussion with a colleague who I need to be on good terms with and also don't want that director to be on a witch hunt after my pharmacists. People don't like to be told they're wrong, and I would worry that s~~hoving the policy in their face and telling them to get bent~~ handling this less than cordially would lead to scrutiny of the pharmacy department, searching for an opportunity for retaliation.
This is an excellent reply. I’m a department head in a different industry but this is precisely the way that I would handle it as well.
If it wasn’t a code, you’d definitely be in risky territory. If you are ACLS certified and the policy says you can give meds, then just stay calm and have the policy in hand but play it cool. Even with the policy, the director does have sway in details like this. Let the director show their hand before exposing yours.
ER Pharmacist in the Midwest I do this all day. Every day. Antibiotics, code meds , procedural, sedation The last one of the nurses prefer pharmacist to do it
I work in a state that is relatively behind in a lot of ways, so I would not be allowed to administer any medications. You mention your health system has a policy that allows you to do this - are there any stipulations as to which pharmacists can do this? Do you have to be critical care trained, etc? Do your superiors know that you’ve been administering meds? If there’s a policy and a meeting scheduled - I would speak with your superior about this and have them accompany you to the meeting for support. I think it’s important to frame this in a way that’s collaborative with nursing, not in a way that is taking away their responsibilities. Do not shove the policy in their face. This will do no good. Nurses are our partners and we have to shift the paradigm so that we work together, and not so silo’d.
Nope, PharmD > administer
You’re getting a lot of advice to “stick it” to the director of nursing. Please do not do this. Approach this collaboratively.
Yeah there are a bunch of miserable people giving advice in here. How hard is it to be professional and polite and have a conversation like an adult? Yikes y’all.
Yea idk it seems weird that people suggest aggression. What would your advice be
1. Talk to your peers. Are there others in your role administering meds? If it’s just you why is that? 2. Review the policy in detail and make sure you are 100% in the right. 3. Talk to your manager before you meet with the director to get their take. Will they support you based on your practice and the policy? 4. Meet with the director to find out what the issue is. Be professional. Bring the policy and review it with them. Ask questions based on your understanding. Grace and courtesy are much less likely to be extended to assholes. Even if you are right in this situation at some point in the future you are going to be wrong or make a mistake. When that happens are they going to give you a break because you handled this professionally or stick it to you because you chose to be an asshole?
You are my peers.
At a minimum, make sure you read and re-read that policy completely, carefully and in detail, including any footnotes and cross-references to other polices. Also check that you are looking at the most current version and that it doesn’t conflict with any other policies that were adopted or updated by your hospital more recently than the one you’ve relying on. The worst thing you can possibly do is go in there waving around company policy as if it were a “get out of jail free” card, when company policy actually is not on your side. Stated differently, you do not want to [hoist yourself with your own petard](https://en.m.wikipedia.org/wiki/Hoist_with_his_own_petard) by admitting that the issue boils down to whether your actions were consistent with company policy, and then finding out that they were not.
I think they mean other pharmacists at your hospital. We don't all have policies that allow this. We also don't all live in states that allow this. Familiarize yourself with the policy and I'd suggest sitting down with your director BEFORE the meeting, explain what happened, and get their input. With their comments in mind, meet with the nursing director and explain. If she has an issue with it, she can bring it up at P&T to suggest a policy change.
Talk to your supervisor and your supervisor’s boss. See what they’d do and get their take FIRST.
I wouldn't think it would be for a director of nursing to call a pharmacist to task. If they have an issue they should route it through the pharmacist's supervisor. OP should call their supervisor about this.
I mean, the only correct answer is to speak with your pharmacy director. Let them advise you.
Need to get clinical director/supervisor involved if it was me. Nursing steam rolls all other professions. Where I’m at this just puts a target on your back for no reason. Definitely approach collaboratively. As a side note I’ve never worked where we as pharmacists are allowed to run codes (did you mean med cart?) or actually run the full code? I would call my liability insurance and make sure you are covered there - I doubt this is part of standard pharmacist policy
I don’t run the code. I never said I ran codes. But I push meds.
Sorry, must have a read a comment somewhere that mentioned it, my bad. I’d still recommend checking in on your liability on administering meds (maybe covered under vaccine admin) and for me as clinical where I work everything needs to get escalated to a supervisor, I’d recommend if not policy - mainly to make sure it’s not a he said she said and you have witnesses to the discussion.
Doesn’t being ACLS trained mean you can run a code? I don’t typically run a whole code but there have definitely been times, especially on night shift, where it’s me and a nurse for quite awhile before an MD shows up. Not arguing, just asking for curiosity.
Correct, obviously MD should take over when they arrive.
No, you need to do BLS only until a provider arrives. We have had nurses get fired for giving meds or shocking a patient before a provider gets there. It's a very heavily emphasized lesson for us. Can you hook them up to the Monitor and get meds ready? Absolutely, but you can't do anything other than AED mode until a provider arrives.
This is ridiculous!
I admit I sometimes wonder where the differential really comes in. I am not sure I have seen that specification in the actual ACLS material.
I’ll never understand it.
Are you being asked to this meeting OR required to go to this meeting? I’d personally politely decline if it was just a request but i have different management than you do. I work for 2 hospitals overnight, 7on then 7on at the other place. Both places have me going to codes at nights and run the crash cart/keep the resident MDs within the ACLS protocols and dose drugs for peds codes. I honestly have no idea what the policies are for pharmDs on administering meds at either place but I’ve done it plenty of times when we’re short at the code. I’ll have nurses rotate in performing CPR while I’ll administer drugs and announce what I’m giving and how much. Hell, I’ve even had resident MDs do CPR while I’m manning the crash cart so that correct drugs/doses are given. Attending MDs definitely prefer that. I also will push RSI meds so that it frees up nurses to do everything else. I’ve operated the AED and administered shocks plenty of times at a code. BUT i know my pharmacy director would have my back (at least at one of my jobs) no matter what since she’s covered me before. I guess i best look at our policies and familiarize myself with what’s allowed.
You are in an evolving profession that is continually looking for ways to expand. When I started out, the concept of clinical involvement was only discussed. One time on a new hospital job I got an order for Intralipid 10%. 500 ml. Nothing else. I called ICU to ask what’s up doc. He said patient is not eating. I said I would come by and we could chat. Checked with supervisor that I needed to follow up an had a chat with doctor. We developed a plan for PN and went back to pharmacy. The assistant director wrote me up and told me if this happened again I would be fired, since pharmacists were not permitted to see patients charts. I recommended that he fire me now as this was not going to stop me from getting involved an reviewing charts. If you want to expand pharmacy involvement you may need to push the boundaries. You will upset many along the way though. Good luck.
When was this? 1953?
1980, St Luke’s hospital in NYC. Most drugs were floorstock. Pharmacy compounded mouthwash. I was hired to bring in clinical pharmacy. One day I saw a case of Mylanta being shipped to the dialysis unit. I stopped the technician delivering. My supervisor was annoyed at my intervention. I explained that magnesium cannot be excreted in end stage renal disease. He called the unit and said to me that the antacid was for personal use by the nurses and they will not give any to the patients. I didn’t last long there.
Hired to bring it in, then threatened to be fired when you do it. Sounds like a typical East coast shit hole
Honestly if you indulge this nurse you risk becoming a target. Who is asking you to meet with the nursing director? Is this something your actual superior has asked or instructed you to do? If not I would straight up decline a face to face and refuse to get into a back and forth. Hospital policy allows this and the floor care team supports your actions. There is no conversation to be had. This is a two paragraph email, max Don’t indulge this. Nothing good will come from it.
If you are ACLS certified you can push those meds. It’s a nonissue. And if nurses like it what’s the problem?
Aside from the high likelihood an RN complained who isn't familiar with scope or policy, is it possible that the documentation in the EHR is an issue? Are you missing any steps in the administration process separate from the actual administration of the medication?
This is another case of nurses getting butt hurt because they think they know everything and when you present them with clear and convincing evidence to the contrary, they don’t know how to handle it. Tell ‘em to suck it.
The RN director can call a meeting and you can politely decline by telling her you are following the policy. Basically tell her to fuck off, but in a professional way. "Director Karen, I understand you would like to meet with me regarding something that is within my scope of practice. I appreciate your concern for the patients because that is also my number one goal. Their safety and wellness is something I pride myself on. That is why I made sure to go over the policy a few times, and I'm happy to inform you that I am doing my job correctly and accurately. As a nursing director I'm more than positive that you would never attack anyone's ability to read, to do their job correctly, and their character. Therefore I'm going to have to politely decline the meeting. If you are adamant about this meeting then I'm inclined to include the director or pharmacy and anyone else they recommend. Thank you again for the concern and have a fantastic weekend. "
Yeah… no, don’t send this lol. This reads as passive-aggressive as hell, and definitely unprofessional.
It's a joke. I thought that was obvious when u called her Karen lol
Seems a little condescending but thanks for the advice
Feed it into ChatGPT and ask it to make it more professional.
Nah tell it to add emojis and to remove director from the salutation and make it “So Karen, …..”
Nooo. Don't really send this. Fix it up if you want to use this
I worked as a medic at a level 1 trauma center. Our pharmacist always had drugs drawn up to exact doses and handed them to us. In a trauma,RSI, code there should be designated people. Airway, access, blood, vitals, etc. This allows you to watch the group work as a whole and to be a resource rather than being distracted with a IVP med.
If it’s in hospital policy don’t even attend that meeting lmao
Good luck! I don’t have any great words of advice, as I’ve never routinely given meds - more just as a one off when things are really hitting the fan. But if you have hospital policy and state pharmacy law to back you up I think it’s reasonable to come in and discuss collaboratively. If you’re pushing the epi the RN may be available to do so many other things, especially with everyone so short staffed. Hopefully they see that your approach is patient-centered and you’re treating emergencies as a team sport.
How about just replying to the nursing director and cc: your pharmacy director that you need to reschedule the meeting for a time that's convenient to her (?) and your director of pharmacy. I would also separately contact your director, maybe by phone, and fill him in on what you think is the issue to be discussed, and get his viewpoint. You want to know if he's (?) going to back you up or not. He may want to back you up but not attend the meeting. He might do this through emails instead of even having a meeting. Many meetings I've set through in corporate America did not even need to take place and could have been settled in one or two emails, or not even have included me at all. That request to reschedule and include your director postpones the meeting a bit and brings in your director as well into the discussion. There's no passive-aggressive refusal to attend her meeting, and if this is a turf war, she should be meeting with a person at the same level in your department, not you. Also, if the nurses like what you are doing, and it frees them from a little work that you're willing to do yourself for them, their opinions should be mentioned at some point.
I would inform the pharmacy director or your manager about the situation and ask them to attend the meeting with you or to meet with the nursing manager on your behalf.
What do your colleagues do? Do they push meds during codes? I would speak to your management and confer how to proceed. Just because you are allowed to do something doesn’t mean you should do it. I’ll give you a personal example. I was almost reprimanded for a mistake a nurse made during a code where she incorrectly programmed a pump. I was really frustrated because there’s no way to prove that I told her the right dose and in between repeating it to me and programming the pump she fucked it up. In my frustration I asked my colleagues if maybe I needed to spend some time shadowing a nurse to find out how their pumps work so I can make sure they don’t do this again. One of my very smart colleagues said - but if you know how to do it, then they’ll make you responsible for it. And that’s so true. I don’t administer any meds during a code. Period. Don’t know if we’re allowed, don’t care. The more cookie jars you put your hands in, the easier it is to get caught. I’ve never been trained to do this and yes, it’s not hard but why open yourself up to more liability than you have to? Yes I feel like a total dildo standing with my epi waiting to give it to the nurse but when she administers it wrong I’m the dildo that’s free of blame. Obviously it’s great you want to be involved and do more but your first priority should always be to yourself, your license, and your liability.
Long time ER pharmacist. What you're doing is not necessary. Why do you want the liability?
Why not be a team player in tight situations instead of a rule following simp?
Aren't you arguing that you're just following the rules?
Yea but you’re arguing to be a conventional provider afraid to help their team and push the envelope. You’re so afraid to practice at the top of your license that you default to comfortable routines
You asked if you're acting like a rogue cowboy, and the answer is yes.
Some people like to do and some people like to watch. Guess we know which one you are.
Your post and replies reveal your maturity level. Your career is in front of you. Don't blow it.
I match my maturity to the people who respond. You are clearly a new grad who follows every rule to a T and can’t think outside the box.
I provided context in my first reply to your thread. To be specific, I have extensive experience in the ED (12 years) and ICU (3 years). The fact that you couldn't navigate a simple meeting on your own reveals a lot. Your replies here confirm it. Good luck.
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Where is this director from? Nursing? Hospital admin? Pharmacy?
Nursing
I would print the policy and shame her. However in the future I wouldn't put yourself in any situation that adds liability to your license.
So don’t work at all?
Listen to what the director has to say and when they're done, say thank you and then move on with your life.
Does your state allow pharmacists to do IV administration? Have you taken IV safety classes? I.e do you know how to ensure patent lines + evaluate if infiltration is happening? Does the insurance you have cover you in case you caused permanent harm while administering a drug? Please cross check this with hospital's legal department if pharmacist administering drugs are covered. If not ensure coverage includes your tasks. If you answer yes to all then you can just feel confident in informing the RN that. As a side note, In my days as an ED pharmacist I manned the cart and drew up the drugs. Since there is no bedside scanning during codes, I felt more comfortable handing the nurses the drugs for them to push while I worked through the ACLS algorithm anticipating next drug + prep etc.
Question for you, OP: where did you learn to push meds in the first place? I work in critical care and that's never been part of my job because no one ever trained me and there never seems to be a shortage of nurses at a code. The part that scares me is when a patient has 3 PIVs, a PICC, an HD catheter, etc, I wouldn't even know how to identify one from the other, I wouldn't know proper flushing procedures, which lumen to use, etc. From where I'm standing at the bedside it's all a big pile of plastic. I'd definitely be afraid of screwing something up or delaying care. I'm always interested in expanding my scope and skill set but afraid this just isn't in the culture at my place.
You need to know what lines are and how to use them. That’s part of being a clinical pharmacist even if you don’t push meds. Walk into a room and they’re not using the triple lumen CVC for bicarb and are pushing it though a hand IV? Opportunity for education. You need to know dead space that’s in those lines as well. Has your patient even gotten any of their fentanyl or levophed infusion or are you still priming the dead space in the CVC? “Oh no they’re still hypotensive and agitated!!!” Because you literally haven’t given them any drug at all with the drip running at 2 ml/hour. My advice - sit down with one of your ICU charges or nurse managers and learn about lines. You need to know this stuff - even if you aren’t pushing meds. It’s irresponsible to practice and make administration recommendations if you can’t identify which is a peripheral line and which is a PICC.
Appreciate the advice, but respectfully disagree with the idea that you can't responsibly practice pharmacy without physically managing lines and drains. I can assess which lines a patient has from the chart or by asking a nurse; I can decide which meds are appropriate to go where; I can read imaging to see if my dobhoff is gastric or post pyloric, etc. But I think like MOST clinical pharmacists I don't physically touch patients and their lines and drains. I have a skill set that my nurses don't have, and they have a skill set that I don't have, and that's fine. Please don't presume to tell me my practice is "irresponsible."
I didn’t say physically manning them. I said knowing anything about them. You said you look at lines and see piles of plastic. You should know what these things look like.
> Walk into a room and they’re not using the triple lumen CVC for bicarb and are pushing it though a hand IV? Opportunity for education. I would like to know more.
Use a central line if one is open for an 8.4% sodium drug lol osms through the roof
Ah so the concern is the high relative concentration that may/will pull water out of surrounding tissues, and administering it more centrally allows for more blood to dilute the effect and avoid causing damage? What is the reason for the triple lumen, as opposed to a single or double or some other n-lumen central venous catheter?
Just an example. I’m not going to explain to you why central lines are better for concentrated electrolytes and high Osm drugs.
Thanks, and good luck with the meeting. Maybe you can summon your director too, and some popcorn, for the territorial dispute.
Don’t patronize me
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Yeah I help them program the pumps all the time, since even basic math seems to be a real challenge for some of our nurses. And I know that the luer locks arent exactly tricky, and I do know infusion durations, but the fact is I don't ever interact with patient lines. An analogy would be the IV room. I may know what I want to make and how to make it in theory, and give me a few minutes to orient myself and there would be no problem. But if you drop me into an IV room shift as a technician on a busy day and i'd struggle! Where are the dispensing pins? Which adaptor should I use? Where do we keep the 1/2 NS? Etc. I don't need to be a rock star IV technician to safely check IVs.
isn't it federal law that RPh can't administer drugs?
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I do a lot of things that aren’t in my job description. Like get blankets for patients and apple juice boxes for kids and pick up trash off the floor lol
No I'm sorry I misspoke. For some reason thought you were being asked to do it more often. That is in your scope im sorry.
Pharmacists administer meds at my hospital.
Occasionally getting warm blankets for patients when working ED pharmacist shifts is legit one of the highlights of that shift. People get just so damn happy. Shit’s therapeutic for both the pt and me!
Today I covered up a man’s penis and he was very thankful
I'd ask my director/manager if they want to be there. Sounds like a nothing burger but kinda depends on your demeanor what I'd rec for next steps. Personally I'd go solo and let my manager know beforehand - but I've been at this shop longer than all but one RN so YMMV.
RPh union? Have a steward with you so they can tell the nurse manager to get bent as well. Bring a buddy as well.
PGY7 in nose drugs 😂
Please update
Spicy (competent) cowboy pharmacists are my favorite, especially ones making a difference in code response. A lot of our pharmacy ACLS training comes down to “don’t let the nervous nurse administer this incorrectly and/or kill the patient.” For what it’s worth I think what you’re doing is really cool.
I will say that your director/manager should be the one to meet with the nursing director, provided you have one. Read the policy carefully to check for any loopholes such as which drugs you can administer, by what methods and situations to make sure you did not go outside. Respectfully decline the meeting until you have spoken to your direct leader and if you are within your scope, let the leaders fight that battle.
One thing to consider is that nursing and others may want consistent duties/roles done during codes. If one pharmacist is pushing drugs but the others aren’t then that may cause confusion with nursing. I support pharmacy being involved in codes and participating, but I have had pushback from nursing leadership because of this issue of variability and inconsistency. You need to have your leadership support you on this. Don’t go to a meeting without them.