Agency head warned staff not to pre-pour meds at jail

Pittsburgh Post-Gazette - - Front page - By Shelly Brad­bury

The pres­i­dent of a staffing agency that pro­vides nurses to the Al­legheny County Jail warned his em­ploy­ees not to par­tic­i­pate in the jail’s prac­tice of pre-pour­ing med­i­ca­tions, cit­ing eth­i­cal and safety con­cerns, ac­cord­ing to a let­ter ob­tained by the Pitts­burgh Post-Gazette.

Jeffrey Leonatti, pres­i­dent of Re­liant Staffing, con­demned the prac­tice as “un­eth­i­cal and against all nurs­ing med­i­ca­tion dis­tri­bu­tion stan­dards” in a June 1 let­ter ad­dressed to staff. He also warned that em­ploy­ees who pre­pour med­i­ca­tions at the jail could face civil and crim­i­nal li­a­bil­ity.

Pre-pour­ing is a method of dis­tribut­ing med­i­ca­tion in which a nurse or other med­i­cal pro­fes­sional re­moves in­di­vid­ual doses of med­i­ca­tion from their orig­i­nal con­tain­ers and sets the doses aside to be given to pa­tients later. It some­times in­volves drop­ping pills into cups or en­velopes.

Other pro­fes­sion­als agree that the prac­tice has its risks but can be nec­es­sary.

“It’s a process that is fraught with er­ror and has a lack of ac­count­abil­ity,” said Cather­ine Knox, a reg­is­tered nurse and con­sul­tant who spe­cial­izes in cor­rec­tional health care. “There are some sit­u­a­tions where pre-pour­ing is ap­pro­pri­ate — like in a riot — but for ev­ery­day prac­tice, pre­pour­ing is con­sid­ered a very un­safe prac­tice.”

The best prac­tice is to re­move a dose from the orig­i­nal la­beled container in front of the pa­tient and im­me­di­ately give the dose to the pa­tient, Ms. Knox said. That al­lows the nurse to dou­ble check the med­i­ca­tion, dosage and pa­tient’s name, she said.

Those checks are typ­i­cally not pos­si­ble when the med­i­ca­tion is pre-poured, Ms. Knox said, and pre-pour­ing also pre­vents pa­tients from check­ing for them­selves whether they’re get­ting the right med­i­ca­tion.

“The worst sce­nario is that the nurse could give the wrong med­i­ca­tion to an in­mate be­cause they made an er­ror tak­ing it out of the pack­age and putting it into the

cup,” Ms. Knox said.

Mr. Leonatti did not re­turn re­quests for com­ment about the let­ter, which for­bids Re­liant em­ploy­ees from pre-pour­ing and urges them to re­port it if they feel pres­sured into the prac­tice.

“Re­liant staffing is aware that pre-pour­ing med­i­ca­tions has been adopted as a per­mis­si­ble act by ACJ man­age­ment when deemed nec­es­sary,” the let­ter reads. “It is Re­liant’s opin­ion that this is oc­cur­ring due to a lack of staff. Lack of staffing is not an ac­cept­able rea­son to pre­pour med­i­ca­tions.”

War­den Or­lando Harper said in a state­ment Fri­day that the jail pre-pours med­i­ca­tions only in “emer­gency or nec­es­sary sit­u­a­tions, typ­i­cally based on chal­lenges due to fa­cil­ity and se­cu­rity pro­ce­dures.”

“There is no ab­so­lute,” the jail’s health ser­vices ad­min­is­tra­tor, Aloy­sius Joseph, said in re­sponse to ques­tions about whether the jail pre-pours med­i­ca­tion due to staffing is­sues.

“Whether a pre-pour is nec­es­sary would be de­ter­mined in con­sul­ta­tion with the su­per­vi­sor,” he said.

“Pre-pour­ing med­i­ca­tions, in gen­eral, is not en­cour­aged be­cause it dis­rupts the process of med­i­ca­tion ad­min­is­tra­tion,” War­den Harper’s state­ment reads. “Ev­ery health care fa­cil­ity adopts theirown pro­cesses and prac­tices to en­sure the safe de­liv­eryof med­i­ca­tions.”

Marc Stern, a physi­cian and fac­ulty mem­ber at the Univer­sity of Wash­ing­ton School of Health who re­views jail health care sys­tems, said it’s hard to say how many jails pre-pour med­i­ca­tions, but added, “it is a prac­tice, it will be found, it’s not rare.”

Pre-pour­ing med­i­ca­tion typ­i­cally speeds up the dis­tri­bu­tion process and it can be done safely in some sce­nar­ios, he said, al­though it re­quires strict safety mea­sures to re­duce risk.

The nurse who pre-pours the med­i­ca­tion should be the same nurse who dis­trib­utes it, he said, and that nurse should have con­trol of the pre-poured med­i­ca­tions from the mo­ment the pills are re­moved from their con­tain­ers through when the pa­tient takes them. Ad­di­tion­ally, he said, the med­i­ca­tions ought to be listed on the container the pre-poured pills are put into, along with the pa­tient’s iden­ti­fy­ing in­for­ma­tion.

“It’s nu­anced and it’s very site- spe­cific,” he said. “There are a lot of dif­fer­ent ways you can do it and make it safer.”

War­den Harper’s state­ment said jail pol­icy re­quires that the same nurse pre-pour and ad­min­is­ter the med­i­ca­tions. It also says nurses put the med­i­ca­tions into an en­ve­lope la­beled with the in­mate’s name.

Betsy Snook, CEO of the Penn­syl­va­nia State Nurses As­so­ci­a­tion, said pre-pour­ing med­i­ca­tions is un­safe and no cir­cum­stance war­rants the prac­tice.

“That I know [of], if it is not il­le­gal to pre-pour med­i­ca­tions; how­ever it is not best prac­tice and it is very risky,” she said. “It does place RNs’, LPNs’ li­censes at risk should this prac­tice re­sult in harm to a pa­tient.”

The Penn­syl­va­nia State Board of Nurs­ing doesn’t give “ad­vi­sory opin­ions” or pre-ap­prove par­tic­u­lar con­duct, Ellen Lyon, spokes­woman for the Depart­ment of State, said about the prac­tice of pre-pour­ing.

But in fa­cil­i­ties gov­erned by the Penn­syl­va­nia Depart­ment of Health, the nurse who pre­pares a dose must be the same nurse to ad­min­is­ter it, she said. The Depart­ment of Health does not reg­u­late county jails.

Mr. Leonatti’s let­ter said he had ad­dressed his con­cerns with jail man­age­ment “at a va­ri­ety of lev­els.” War­den Harper de­clined to dis­cuss the jail’s com­mu­ni­ca­tion with staffing agen­cies or Mr. Leonatti.

Six staffing agen­cies pro­vide em­ploy­ees to the jail, with agency em­ploy­ees mak­ing up the ma­jor­ity of the jail’s reg­is­tered nurses and li­censed prac­ti­cal nurses.

Nine­teen full-time reg­is­tered nurses are county em­ploy­ees in ad­di­tion to one part-time nurse and eight nurses who work on a perdiem ba­sis. Staffing agen­cies pro­vide 18 reg­is­tered nurses.

Ad­di­tion­ally, six full-time and one part-time li­censed prac­ti­cal nurses are county em­ploy­ees, and 19 li­censed prac­ti­cal nurses are pro­vided by staffing agen­cies.

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