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