Is that my med error?

  1. 0
    Hello everyone!

    I'm a new LVN and just started to work on the floor by myself in a SNF. It was my second day yesterday and It was not very easy. I have a question to those of you who have been a nurse for years with tremendous experiences...
    To make the story short, I received a new order from the doctor. Here's the order: Give 3 more doses of IV cefepimine then start cipro po bid x 8 days after the last dose...So i noted the order, put it in the MAR writing + 3 more doses on the IV flow sheet, and then i put cipro bid x 8 days to be started on the date when the last dose of IV will be given...so here's the thing..the AM nurse didn't see the additional 3 more doses that was ordered so she didn't give the 2nd dose IV, but instead gave the cipro po... we went to the assistant DON, called the MD & so on....they asked us to make a med error report about that. the DON asked me to sign the med error report too, so I signed. but then i realized last night that i didn't commit any med error since i gave the 1st of the 3 doses, and she was the one who didn't give the 2nd dose and instead gave the cipro po...I want your insights please....i am not comfortable & i think of talking to our DON to clarify that. Thank you in advance.
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  3. 14 Comments so far...

  4. 19
    You noted the order, you transcribed it correctly on the MARs, you started the first of the additional 3 IV doses, and the other nurse missed the next dose. No, it is not your error.
    BackpackingRN, merlee, canoehead, and 16 others like this.
  5. 0
    No, that is not your error.
  6. 13
    If you were involved in finding the error you would need to sign the report as either the witness to the event or as the one filling out the report.
    How could you be responsible though? Relax and think it through. You transcribed everything correctly. Maybe it would be helpful to think of ways to alert other nurses when there's a new or tricky order. Do you have a shift to shift report where info like this can be passed on to the next shift? Or could you have put a sticky note on that med page with an alert to the nurse passing meds? Med error reports should not be used for punishment but to find out what happened and how to prevent it from happening again.
    tyvin, Mudder, BackpackingRN, and 10 others like this.
  7. 0
    Thank you for the reply
  8. 2
    First I'd like to say I believe you did great. I also believe this type of situation is not something a brand new LPN should handle by herself.
    Second, I hope the ADON and, or DON didn't stop with the med error form.
    It really doesn't matter to me who made the mistake. What matters is why did it happen. Did shift report break down? Is there a better way to flag MARs?
    My suggestion is don't worry about having signed the error report, instead find ways to avoid repeats and present your suggestions to the DON. Your DON's response will give you great insight on who you're working for as well.
    martinalpn and SilentfadesRPA like this.
  9. 4
    The new IV order should have been written as a SEPARATE order (not just +3) with clear start and stop dates. Maybe the order could read: Continue IV...times 3 doses.
    The PO ATB should have been written with a CLEAR start date (and shift/time if need be). If it was a paper MAR it should even have the date marked and previous dates crossed through.
    Anyway, you are not the one that GAVE the med incorrectly, so, yes it is technically not your error. However, writing the new order VERY clearly could prevent this.
    I do not know the line you signed, but it is not your error.
    Also, when in doubt about a new order, ask another nurse, even at change of shift.
    Don't worry, you will learn these things with time.
    martinalpn, Lissa, RN, Chin up, and 1 other like this.
  10. 4
    In my opinion it wasn't your error. It was the other nurse's error and a system error. It's crucial to flag things that are to start after something else finishes. A note right on the MAR can work, in red or highlighted somehow. Otherwise, depending on how things are written, someone might not understand the whole story. I still don't see this as your fault. You can tweak your method some, but the other nurse should have read the whole MAR before she gave anything.

    Med error reports aren't intended to punish those who make errors. They're intended to draw attention to things that can be fixed in the future.
    martinalpn, SilentfadesRPA, Esme12, and 1 other like this.
  11. 4
    i always made it a point to report new orders, at change of shift.
    in one place, we had a 'report book' in addition to verbal report.
    this was convenient for those who came in late, leaving early, or busy otherwise...
    really, like a backup book.

    you did a commendable job as a newbie.
    as stated, you will discover innovative ways to ensure communication is enhanced to extent possible.

    good luck, honey.

    leslie
    Debilpn23, Chin up, MBARNBSN, and 1 other like this.
  12. 5
    THANK YOU, THANK YOU to all the replies.. I didn't sleep the whole night & reading all your comments made me feel better. From this, I will make sure to really write the orders very clearly & flag it if necessary to prevent the same mistake next time. I was crying on my way home at 2 am about that, but I felt better now. Thanks a thousand again!
    nickos, JenniferSews, Debilpn23, and 2 others like this.


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