Misconduct

  1. Has anyone ever heard of a nurse being terminated for gross misconduct after accidentally omitting an entry when transcribing MARs from one month to the next?
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  2. 42 Comments

  3. by   klone
    Is this a trick question?
  4. by   Abbycat
    No, it's not.
  5. by   morte
    Quote from Abbycat
    Has anyone ever heard of a nurse being terminated for gross misconduct after accidentally omitting an entry when transcribing MARs from one month to the next?
    my heavens, who is still using paper?
  6. by   Abbycat
    The MARS come from the pharmacy but were incredibly inaccurate every month. New orders were never on the MARS- it took a couple months or more. I accidentally omitted a seizure medication and consequently the medication was not given. The pt had a seizure after not receiving the medication for approximately 10 days. He was treated in the ER, given a loading dose of Depakene, treated and released. I had never received any kind of disciplinary action prior to this. It was simply human error. I've been a nurse for 35 years and never had any issue like this in 35 years.
  7. by   kcochrane
    Quote from morte
    my heavens, who is still using paper?
    Unfortunately many places still do.
  8. by   dakotadenise
    Quote from morte
    my heavens, who is still using paper?
    Both places I prn/parttime at (nursing home, assisted living) use paper MARs and we nurses are responsible for comparing them every month for accuracy.
  9. by   Davey Do
    Quote from Abbycat
    Has anyone ever heard of a nurse being terminated for gross misconduct after accidentally omitting an entry when transcribing MARs from one month to the next?
    Quote from Abbycat
    I accidentally omitted a seizure medication and consequently the medication was not given. The pt had a seizure after not receiving the medication
    Now that I think about it, perhaps I should have include this information in Audrey Smagic's "Tell on yourself if you dare..." thread:

    When I first started at Wrongway Regional Medical Center 15 years ago, a similar circumstance occurred. I was admitting a patient and inadvertently transcribed a home meds wrong. I believe the patient received a lower dose of dilantin in the hospital than they were taking at home.

    The patient ended up having a seizure and the error was found in the investigation. I don't recall the details exactly, but for some reason I was not held in total responsibility for the error and merely received counseling from my supervisor.

    I am sorry this happened to you, Abbycat. We all make mistakes.
  10. by   klone
    In a "just culture" facility, no, this would not result in a termination. Instead, it would be seen as a system issue, starting with the requirement to transcribe new MARs by hand, which is fraught with the potential for error (which is why most facilities have gone to BCMA).
  11. by   Here.I.Stand
    Quote from klone
    In a "just culture" facility, no, this would not result in a termination. Instead, it would be seen as a system issue, starting with the requirement to transcribe new MARs by hand, which is fraught with the potential for error (which is why most facilities have gone to BCMA).
    This!! And clearly there are systems issues here. Since the MARs are sent from the pharmacy, how in hades is the nurse 100% responsible for a med error reaching a pt? Where is the PharmD's responsibility?
  12. by   meanmaryjean
    Quote from Here.I.Stand
    This!! And clearly there are systems issues here. Since the MARs are sent from the pharmacy, how in hades is the nurse 100% responsible for a med error reaching a pt? Where is the PharmD's responsibility?
    While no longer in clinical practice, it frosts my buns how NOTHING is EVER pharmacy's fault. Ugh!

    OP: Seems like a policy change wherein a second set of eyes gets put on those MARs is in order.
  13. by   SpankedInPittsburgh
    Yeah we all do make mistakes & this one ld certainly be forgiven after 35 years of service. Good Luck!!!
  14. by   Davey Do
    Quote from meanmaryjean
    While no longer in clinical practice, it frosts my buns how NOTHING is EVER pharmacy's fault. Ugh!
    This singes my shorts also, meanmaryjean.

    Just last weekend, I put in home meds Rx by the MD for Namenda 5mg HS. Pharmacy wanted verification for the med, as Namenda is usually given BID. So, until the MD clarified the med, pharmacy refused to dispense it. So instead of getting a single dose of Namenda at HS, the patient got none.

    Where is the sense in that? There are other examples. I think WRMC's pharmacists are phacist. Or Fascist.

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