California Scope for RNs regarding Zofran and Morphine

akflightmedic

akflightmedic

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I cannot recall, but are any of you CA RNs?

I know there is many opinions on combining these two drugs, and I do not care to debate the pros and cons of such. I am seeking factual information which supports or refutes that this is "illegal in CA as it is considered compounding which is not in RN Scope for CA".

I have been googling my butt off but cannot find the information one way or another. Are any of you CA RNs aware of this? Or if any other license levels know about this? Can a Paramedic mix them pre-hospital?

By mix, I mean draw up morphine and zofran in same syringe for single administration as opposed to two separate pushes.

Thanks
 
akflightmedic said:
By mix, I mean draw up morphine and zofran in same syringe for single administration as opposed to two separate pushes.
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forgive my ignorance, but why would you want to? I understand why you would give them individually, but what benefit do you get to combine them into a single dose?
 
Time saving....draw them up into single syringe, task grouping, time efficiency.

They are compatible and usually go hand in hand. A lot of times we give the zofran without any complaint of nausea, just as a prophylactic so you do not have to come back and deal with N/V.

I have been told by some CA RNs that this mixing in single syringe is considered "compounding" which is outside their scope of practice. And this action is quite normal in ERs, so I was trying to see if this really was disallowed or not.

I personally do not mix them, mostly because I do not think to do it when I am in the med room pulling drugs.
 
Demerol and vistaril are "compounded" as a matter of course. Do people still give Pen-G IM? Used to mix that with lidocaine all the time. Probably more examples if I thought about it for RN's. Nurses "compound" oral meds all the time.
 
Do not need examples or affirmation of what we do as a matter of routine...just need CA specific replies regarding exactly what I asked please and thank you. :)
 
akflightmedic said:
Do not need examples or affirmation of what we do as a matter of routine...just need CA specific replies regarding exactly what I asked please and thank you. :)
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Oh...sorry...those were California specific, Emergency Department common practice examples. You're welcome.
 
And the request of FACTUAL INFORMATION, meaning link me to a source either for or against. Not just random statement of internet dude. :)
 
Weird...getting a toxic, tool-ish vibe...Anyway, I think you're confusing "scope of practice" with "standardized procedures". They're related but not the same thing. The term "compounding" can mean different things too, which can add to confusion. Knowing what to ask is half the battle :D.

This is a document that might help:

https://www.rn.ca.gov/practice/npa.shtml

This is a document that will show that "standardized procedures" is a sub-context of "scope of practice"

Nursing Practice Act

www.rn.ca.gov www.rn.ca.gov

Might take some effort, but well worth it!

All available on the internet. Give those a try! :)
 
I do not know what to ask and explained it as best I could with what little I know. I assumed any CA RN would instantly know because of how this was presented to me in another forum as if it were some HUGE issue and a major No No in CA Land. I did google a lot before asking, just kept coming up dead.
 
While I am neither a nurse, nor from California, as per Section1. Section 2725.1 subsection B of the California Business and Professions Code (which can be viewed here https://www.rn.ca.gov/pdfs/regulations/npr-b-70.pdf):

No clinic shall employ a registered nurse to perform dispensing duties exclusively. No registered nurse shall dispense drugs in a pharmacy; keep a pharmacy, open shop, or drugstore for the retailing of drugs and poisons. No registered nurse shall compound drugs. Dispensing of drugs by a registered nurse, except a certified nursemidwife who functions pursuant to a standardized procedure or protocol described in Section 2746.51, or a nurse practitioner who functions pursuant to a standardized procedure described in Section 2836.1, or protocol, shall not include substances included in the California Uniform Controlled Substance Act (Division 10 (commencing with Section 11000 of the Health and Safety Code). Nothing in this section shall exempt a clinic from provisions of Article 13 (commencing with Section 4180) of Chapter 9.
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Agreed, I saw that....but there is no definition of compounding provided by the CA BON. So I went to the FDA site...and according to their definition, combining zofran and morphine is not "compounding". Do you interpret otherwise?

www.fda.gov

Human Drug Compounding

Compounded drugs can serve an important medical need for certain patients, they also present a risk to patients.
www.fda.gov www.fda.gov

Compounding is generally a practice in which a licensed pharmacist, a licensed physician, or, in the case of an outsourcing facility, a person under the supervision of a licensed pharmacist, combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient. Although compounded drugs can serve an important medical need for certain patients, they also present a riskExternal Link Disclaimer to patients.

FDA’s compounding program aims to protect patients from unsafe, ineffective and poor quality compounded drugs, while preserving access to lawfully-marketed compounded drugs for patients who have a medical need for them.

www.fda.gov

Compounding and the FDA: Q & A

Creating a medication tailored to the needs of an individual patient. FDA answers the “what” and “why” of compounding.
www.fda.gov www.fda.gov


What is compounding?​

Drug compounding is often regarded as the process of combining, mixing, or altering ingredients to create a medication tailored to the needs of an individual patient. Compounding includes the combining of two or more drugs. Compounded drugs are not FDA-approved.

Why do some patients need compounded drugs?​

A drug may be compounded for a patient who cannot be treated with an FDA-approved medication, such as a patient who has an allergy to a certain dye and needs a medication to be made without it, or an elderly patient or a child who cannot swallow a tablet or capsule and needs a medicine in a liquid dosage form. Practitioners in hospitals, clinics, and other health care facilities sometimes provide compounded drugs to patients when an FDA-approved drug is not medically appropriate to treat them.
 
I didn’t know nurses in general are still administering MS routinely. Locally at least I feel most RN’s are of the Fentanyl/ Zofran group.

@Akulahawk is probably another solid source for the CA RN folks on here. Aside from @E tank.
 
Is the only "compound" in question morphine and zofran? Or is mixing them just an example of something that RN's aren't allowed to do because it is "compounding"?

I've never before heard mixing a drip or drawing two drugs into the same syringe described as "compounding" and therefore outside the scope of practice for RN's. That is taught in nursing programs and is standard practice for nurses most places.

Then again, I know there are a craptun of wacky nursing policies floating around out there, and you are talking about California, so while on it's face it sounds like some internet experts spouting off about something they think they know but are actually clueless about, I can't say I'd be totally shocked to find out it's true.
 
akflightmedic said:
Agreed, I saw that....but there is no definition of compounding provided by the CA BON. So I went to the FDA site...and according to their definition, combining zofran and morphine is not "compounding". Do you interpret otherwise?
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I am definitely not qualified to make an educated interpretation of this question. However, as an uneducated person, I believe the confusion/disconnect is in the definition of the term compounding, and if/when the compounding occurs.

If the definition of compounding is any time two drugs are mixed together, well, that's a clear answer; except when you give two drugs back to back, they are compounding in the person's body. Instead of mixing them in the syring. they are being mixed in the body. is that compounding? using made up dosages, if you draw up 1 ML of morphine, and give it IV push, and then give 1 ML of zofran, without running the IV wide open to clean out the line completely, and make sure all of the morphine is gone before the zofran is given, and the drugs mix in the line, have you compounded, and are in violation?

Even the FDA definition says "regarded as the process of combining, mixing, or altering ingredients to create a medication tailored to the needs of an individual patient" which doesn't seem to be what you are doing; you aren't creating a new medication, you are just administering two medications at the same time. calling that compounding might be a stretch.

Based in my uneducated opinion, the meds are going to get mixed sooner or later (in the patient's body), and as long as you aren't pre-mixing the two drugs in a bowl/beaker/whatever, and then drawing up the dose based on their combined properties, I don't see how it is meeting the definition of compounding. I think the question really depends on what does the CA BON considers compounding, as well as what your employer consider compounding. might be a good idea to send an email for an authoritative answer.
 
I emailed the CA Board of Nursing/Scope of Practice Division. :)
They replied this morning that they will call me on Friday and set a time. I have zero dog in this fight, other than satisfying my curiosity while I plunge down the rabbit hole.
 
akflightmedic said:
I emailed the CA Board of Nursing/Scope of Practice Division. :)
They replied this morning that they will call me on Friday and set a time. I have zero dog in this fight, other than satisfying my curiosity while I plunge down the rabbit hole.
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It'll be interesting to see what they have to say about this.
 
I suspect this is a hospital (or several) in California that are making their own interpretation to cover themselves and their employees are confusing policy with rules and regs. Similar to most hospitals having an aggressive interpretation of HIPAA laws.
 
GMCmedic said:
I suspect this is a hospital (or several) in California that are making their own interpretation to cover themselves and their employees are confusing policy with rules and regs. Similar to most hospitals having an aggressive interpretation of HIPAA laws.
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Yea, you have a point there. I'm also thinking the same way.
 
GMCmedic said:
Similar to some hospital staff having an aggressively incorrect interpretation of HIPAA laws when it comes to providing patient information to EMS.
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fixed that for you
 
akflightmedic said:
I emailed the CA Board of Nursing/Scope of Practice Division. :)
They replied this morning that they will call me on Friday and set a time. I have zero dog in this fight, other than satisfying my curiosity while I plunge down the rabbit hole.
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Any updates? Please also post about your experience with sending in your inquiry, their response, customer service experience, etc.
 
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