[ICU_floater]

We have a med. administration system where we scan all meds due, then scan the pt. arm band... all goes well and then you administer, click chart and your done.


I was giving .3 of clonidine which comes in .1mg individual doses from the pyxis. I grabbed 3 and scanned the first one 3 times. Yep! The other two were restocked with a med that was not clonidine. I only caught it because of the different shape as I was opening the packets in the room.

Taking the short cut and not scanning each one was a bad judgment call (I know!!!) But I wrote up an incident report for this to be shared once I told my peers and they admitted doing the same on occasion.

Crazy as it sounds, the scanning system can give you a false sense of security and I don't obsessively triple check everything against my non existent paper mar before handing the meds over (once cleared the the MAK system you administer).

Yep it was bad practice, I hope to alert anyone else who's cut this corner that pharmacy techs do make errors so please scan each med

Anyone who has used the MAK system knows how it can take so much time to get that dang bar code to scan and we try to find ways to speed it up. I'd obviously chosen the wrong way to save time

thanks

[Suesquatch]

That's a great tip, and a good catch.

[luvpeplrn]

Good catch on your part! Now you've learned from that mistake, which is GOOD!!

[caliotter3]

Thanks for the tip. Though I've never worked with scanning meds, now I know something to watch out for.

[isenephthys]

Originally Posted by caliotter3

Thanks for the tip. Though I've never worked with scanning meds, now I know something to watch out for.

ditto. thank you for sharing your experience.

[fleur-de-lis]

I hate the med scanners. Supposed to be safer but takes the critical thinking out of it. My unit had a pt who had a q day sleeping pill ordered (I forget which one), and the pharmacy had put it in for 0900. The med was given in the morning for 3 days before someone caught it!!! You should read the progress notes, "pt is very lethargic..." Uh, yeah, you just sedated him!!! Then night shift had to deal with him sundowning all night! Maybe it still would have happened with paper MARS, but the scan-and-go-mentality creates a false sense of security, IMO.

[NurseguyFL]

I had a similar experience with Meditech. You are correct. Scanning systems rely on the pharmacy to properly prepare and stock the right medications in the right dosages, and also on accurate setup of the medications, dosages, and times on the MAR but this is not the case 100% of the time so we still have to pay attention to every package of medication that we are giving to the patient.

[Diary/Dairy]

Thanks for the tip - I do not like scanning too much for much the same reason (about not thinking about what you are doing!!)

[elizabells]

We do the same thing with breast milk in my NICU- some of the moms who don't have a great supply have a thousand little bags in the fridge - we're only required to scan one per feeding. I had a VERY near miss the other day with another patient's bags intermixed with my kiddo's.

[Emmanuel Goldstein]

Originally Posted by NurseguyFL

I had a similar experience with Meditech. You are correct. Scanning systems rely on the pharmacy to properly prepare and stock the right medications in the right dosages, and also on accurate setup of the medications, dosages, and times on the MAR but this is not the case 100% of the time so we still have to pay attention to every package of medication that we are giving to the patient.

Absolutely. That is the main draw-back to scanning, IMO. Nurses get too complacent and don't pay attention.

Our pharmacy re-packaged a number of meds in order to barcode them; on more than one occasion, I found the pill contained was NOT as labeled--- and only because I knew what the (real) med was supposed to look like.

Probably the scariest event was a bag of heparin (25000 u/250cc) mislabeled as an antibiotic and given over an hour to one of our chemo patients who just happened to have a platelet count of less than 20. That won her a night in ICU.

Scanning is simply a safety tool. But it certainly does not replace the "5 rights".