help needed!!accidentally accessed/changed physician's medication reconciliation list

Nurses General Nursing

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I'm a new nurse and I just realized that when I was documenting medication history, I accidentally accessed the physician's medication reconciliation list and added two medications. The nurse who oriented me at that time helped me to reset the list and it should be back to the original.

I know it's an honest mistake, but I realized that this can be seen as practice out of my scope. my question is should I let the computer people at my work double check the patient's chart to make sure all the changes I made was reset? also will I be disciplined or lose my license due to this?

thank you.

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Specializes in PICU.

You should be fine. The error was corrected. Did you double check with your preceptor and the patient that the list is correct now? If so, relax.

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Specializes in Pedi.

You didn't write an order or a prescription, did you? If not then you're not practicing outside of your scope. It is well within the scope of a nurse to take and document a medication history.

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Specializes in Trauma, Teaching.

We are expected to fill out the med reconciliation areas, some docs get annoyed if we haven't gotten all the history.

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Specializes in ICU.

We fill out the med-rec ourselves. The doctors expect it to be complete and on the computer so they can see it.

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I don't think you practiced out of your scope unless you are prescribing them and not just adding them to the chart. It may not be what your clinic wants you to do, but that's not the same thing as going out if your scope.

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Specializes in Med-Surg, Emergency, CEN.

You were putting in a history. You did not order any new medications. You got help (a witness) and corrected the mistake.

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I did accidentally ordered new medication. I put two medication in the wrong place (not in the history section)!

I remember that the preceptor helped me reset those changes, but now I am not 100% sure anymore. I can ask the computer person to take a look at the patient's chart to make sure that those changes are indeed reset, but I'm worried whether I will be reported or my license will be in danger... thank you.

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how could you have access to that screen without a MD password?

I did accidentally ordered new medication. I put two medication in the wrong place (not in the history section)!

I remember that the preceptor helped me reset those changes, but now I am not 100% sure anymore. I can ask the computer person to take a look at the patient's chart to make sure that those changes are indeed reset, but I'm worried whether I will be reported or my license will be in danger... thank you.

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Specializes in DOU, Medical-Surgical.

What type of electronic charting is your facility using? I may have an idea how that had happened, as some systems can be confusing. I'm sure when you ordered the medications it asked for an order from the physician. Make sure to know that's a red flag if it happens again, as documenting meds by history shouldn't ask for an order. I wouldn't worry about any disciplinary action as it was corrected.

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I did accidentally ordered new medication. I put two medication in the wrong place (not in the history section)!

I remember that the preceptor helped me reset those changes, but now I am not 100% sure anymore. I can ask the computer person to take a look at the patient's chart to make sure that those changes are indeed reset, but I'm worried whether I will be reported or my license will be in danger... thank you.

A) I am certain the the new medication was not *ordered* until it was signed off by the doc.

B) Don't buy into the license paranoia... your license is at no risk at all. If you had tried to cover up the error, *then* your license might be at risk.

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Specializes in ICU.

I'm sure you're fine, especially since you corrected the error.

I'm wondering what computer system everyone else uses and how their meds get put in, though! I put in med orders all the time, pharmacy confirms them and puts the orders in the pyxis, I confirm pharmacy's listing, and then I give them. I don't put them in until I've gotten a telephone order from a doctor, but in theory, I could just say I had a telephone order when I didn't and a patient would end up getting a medication, you know? The physicians have 24-48 hours to go in and verify that it actually was an order that they wanted, so something "ordered" by the nurse could in theory be given for up to 2 days before anyone caught it. It would be very easy for me to put in a medication and have it given.

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