Oh, the irony . . .

  1. Just finished a employer-required on-line tutorial on med errors (I work in MS-ICU at a large mid-west hosp), and had to laugh about it. Our pharm is always behind in scheduled deliveries; last Tues it was 4 hours behind. We scan our meds, and there is no option available for "pharm late again." I guess my employer does not consider a pt getting his meds late due to the pharm a med error . . .
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  2. 16 Comments

  3. by   oramar
    Oh you just hit a sore spot with me. A while back I was taken to task for documenting in my notes that an important medication was very late due to slow pharmacy. It was very, very late and multiple attempts to get it including a personal trip to pharmacy brought no results. I understand that pharmacies can go into overload and melt down, have seen it many times. However, if I don't document the reason the drug is late and the multiple attempts I made to get it the blame for it's lateness falls on me. However, managment was up in arms because they felt that putting the whole process in my notes cast the institution in a bad light.(yes I informed everyone I was supposed to inform including manager, doctor and supervisor) I was nearly fired over it. What they were actually telling me is that I was supposed to just accept the blame so that the institution would not look bad. That is what they think nurses are there for and as far as they are concerned my license is just a layer of protection between them and lawsuits. That is what I call playing the patsy and NO I won't do it.
  4. by   Levin
    Does your software have progress notes?
    If so then you could document the reason the drugs were scanned late in them.

    Regards,
    Levin
    Last edit by Levin on Nov 24, '07 : Reason: spelling
  5. by   EmmaG
    I agree with granny.. I've charted that a med wasn't available and what I'd done to try to get it up. Never been reprimanded for doing that--- yet.

    The computer MAR at the last hospital I traveled would pop up a little box if a med was out of the accepted time frame (early or late). There were choices for 'med not available' or 'patient not available', among others. Which was good, because it was the doc entering the orders who chose the administration times, not pharmacy. So more often than not, we'd have meds on the screen flashing as late that were due hours before they were even mixed and brought to the floor. Some were even ordered to start at a time before the doc had even put in the orders. If they were ordered stat, I'd not only click 'med not available', but add a comment as well.
  6. by   Diahni
    Quote from mishysmom
    Just finished a employer-required on-line tutorial on med errors (I work in MS-ICU at a large mid-west hosp), and had to laugh about it. Our pharm is always behind in scheduled deliveries; last Tues it was 4 hours behind. We scan our meds, and there is no option available for "pharm late again." I guess my employer does not consider a pt getting his meds late due to the pharm a med error . . .
    'm

    Mishysmom: Did you hear about Dennis Quaid's newborns receiving one thousand times the dose of heparin? I like the scanner idea, but I see it has its own problems. As long as everybody is too busy, I'm afraid med errors will continue. What do you do if a med is four hours behind? Just give it?
    Diahni
  7. by   SuesquatchRN
    Quote from Emmanuel Goldstein
    I agree with granny.. I've charted that a med wasn't available and what I'd done to try to get it up. Never been reprimanded for doing that--- yet.
    I was written up for it.
  8. by   LibertyBellPN
    Unbelievable!
    Our pharmacy drives me nuts! I work LTC/skilled unit. We had a pt readmitted from the hospital on IV ABTx, and the med never arrived on my shift OR the next! I made all the phone calls, (which didnt get me the med) and in retrospect the poor pt should have just stayed in the hospital--since he couldn't get the appropriate tx from us in a timely manner. UGG!!!
    Anyway, I didn't realize I could do this, but I wrote them up--as an incident report! And that was one long piece of paperwork that didn't bother me in the least! Of course, I am sure nothing ever happened; we still contract with them, and they are still slow, make mistakes etc.
    I know they are overworked. Maybe it's the facility's fault? It's just frustrating for me as the nurse.
  9. by   CoffeeRTC
    If I did a med error form for every missing or late med, I wouldn't have time to get up from the desk and pass my 3 hrs worth of meds:spin: SRSLY, it has gotten that bad. A good bit of it is the nurses not reordering the med or realizing it will be running out soon or faxing it on time for it to come on time, but then we have the pharmacy. ...........
  10. by   Medic04
    UGH This seems like a On going issue everywhere. My RNs are always telling how our Meds are late, MARS not printed, and even the wrong list of Meds on some pts even after SEVERAL calls.

    To hold the RN at fault of the pharamcy is just outragous, there is no excuse on that one. Maybe if it did look BAD they would get their butt in gear instead of coming after the RN.

    Oh I forgot no one is to blame except the RN and Tech., Admin, MDs and families do not make mistakes............
  11. by   CVICURN2003
    A few weeks ago our pharmacy sent an antibiotic with the correct emar "sticker" on...so it scanned correctly as the right med, right dose etc. except..the actual bag (it was levaquin) was a different (incorrect dose). This has happened quite a few times unfortunately.
  12. by   Shantas
    I aways get a lecture from the pharmacist when I am 30 min late for administering IV Vanco, but they never give themselves a lecture when they are late delivering the vanco.....
    In our hospital we keep the patients med in a locked cabinet inside the patients room. So oneday I was about to give my patient his meds but the tray had the name of the patient who was in that room prior to my patient, I also found some of my patients meds but they are all mixed up. So in order to avoid any med error I faxed a request form to the pharmacy explaining the situation (they get mad if you call them, they say they are too busy!), 2 hours gone by I still did not receive the meds. So I called them. I talked to a pharmacy tech...I told her what happened, She started to ask me 100 of questions...her first question was ...did you check the med room, then did you check the patients room, then why dont you just sort the patients med out from the tray...In the mean time I just had it...I told her "what was your problem with dispensing the meds again?" she got mad and she told me to calm down...then I told my charge nurse to deal with her as I was about to yell....uffff
  13. by   EmmaG
    Quote from CVICURN2003
    A few weeks ago our pharmacy sent an antibiotic with the correct emar "sticker" on...so it scanned correctly as the right med, right dose etc. except..the actual bag (it was levaquin) was a different (incorrect dose). This has happened quite a few times unfortunately.
    I worked with eMar too... Had a premixed heparin labeled as flagyl (same shape bag, same color lettering). The label covered the front of the bag, but when looked at from the back, clearly said "nirapeH".

    What happened is the pharmacy techs line up the bags on the counter, slap the labels on, and the pharmacist goes through and initials each one. Someone was tired, overworked, stressed or all of the above, and wasn't paying attention. We had a number of incidents where the labeling was wrong, but this was the worst (as of the time I quit, anyway).
  14. by   mishysmom
    Quote from Diahni
    'm

    Mishysmom: Did you hear about Dennis Quaid's newborns receiving one thousand times the dose of heparin? I like the scanner idea, but I see it has its own problems. As long as everybody is too busy, I'm afraid med errors will continue. What do you do if a med is four hours behind? Just give it?
    Diahni
    Hi Diahn The med was an IV IGG; yes, I gave it, actually it was 5 hrs late. I documented in the notes that it was given immediately after it arrived from the pharm; also documented what I went thru trying to get it. I have not heard of anyone on our unit, or in the hosp for that matter (my daughter is an RN who works in admin in our oncology unit) ever being disciplined for giving a med late due to a late delivery. At our last meeting our unit director mentioned our med scan percentages, and just let it go. We are in the middle of transitioning to all computer charting, and everything is out of whack. By the way, does anyone love computer charting as much as I do????

    I heard about the Quaid babies; here in Indy last year several babies died from the same OD. I beieve in the Indy case it started with a pharm error?? Does anyone remember?

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