Top 10 reasons we get fired!-Medication Errors - pg.3 | allnurses

Top 10 reasons we get fired!-Medication Errors - page 3

Number 5 in my series of Articles about the top ten things to get fired, discusses medication errors. Making mistakes in health care tends to be frowned upon more than any other career, the... Read More

  1. Visit  jtmarcy12 profile page
    0
    How is it possible that a different person got the wrong blood tranfusion when 2 nurses MUST verify the tranfusion? I'm sorry I am at a lost to even try and guess how that can happen when each nurse must check the arm band against the blood they are holding in their hand, then have the patient ( if alert) to state their name, then each nurse verify the information on the blood against the doctor's order, they sign off again stating the name of the patient and the blood to be transfused, then you take vital signs, I monitor for the next 15 minutes for any S&S of any untoward effects, if the facility is not doing even some of this something is wrong.
  2. Visit  Ruby Vee profile page
    2
    Quote from jtmarcy12
    How is it possible that a different person got the wrong blood tranfusion when 2 nurses MUST verify the tranfusion? I'm sorry I am at a lost to even try and guess how that can happen when each nurse must check the arm band against the blood they are holding in their hand, then have the patient ( if alert) to state their name, then each nurse verify the information on the blood against the doctor's order, they sign off again stating the name of the patient and the blood to be transfused, then you take vital signs, I monitor for the next 15 minutes for any S&S of any untoward effects, if the facility is not doing even some of this something is wrong.
    It was a CVICU, where many blood products are given every shift. Folks (some folks, anyway) seem to get a little lackadaisical toward correct procedures when you have 6 units of RBCs and 6 units of FFP to be given in an hour. This particular nurse, who I'll call Moe, asked me to check products with him.

    "OK," I said, and started for the room.

    "Oh, no," he replied, and held out the patient's addressograph plate. "We can check it out here."

    Even though I was brand new to the facility, I refused to check blood in the hallway with an addressograph plate. Moe got angry, and collared another new nurse, who readily agreed to check blood in the hallway. And then Moe put the addressograph plate away, walked into the wrong patient's room and hung the blood. I can only assume that the second incident happened much the same way.
    LadyFree28 and jtmarcy12 like this.
  3. Visit  runningcrazy profile page
    3
    Realism: Every nurse has made a medication error. It is up to that individual to admit error. I think ego and lack of respect for others is blatant in our "profession."

    Realism: Nurses lie in their documentation. If our documentation was accurate to the times medications were actually given, management would have to make changes either through decreased workload, quiet time for medication pass, or increased time for medication pass.

    Realism: We try to please others departments such as pt/ot, medicine, to look better. We do ourselves a disservice. The time we spend with the patient is valuable to the patient. If pt wants to work with the patient, and you are passing meds, they have to wait. Everyone pushes the nurse out of the room, well our work is equally important as well.
    hope3456, jtmarcy12, and madwife2002 like this.
  4. Visit  ShaundaFMelton profile page
    0
    Interesting Hmmmm. Don't know if I want to repeat that one
  5. Visit  sistrmoon profile page
    0
    It's oversimplification to say "Just follow the 5 rights and there will be no errors." Sometimes there are systems failures. For example, a heparin drip with no rebolus that was initially rebolus and the boluses were never taken out of the system. So you scan the bolus, and the system doesn't alert you, so you scan the patient and give the bolus. But it's a med error because a bolus shouldn't have been given, and the boluses didn't drop out of the system when the main order was changed. Ideally, the main order should be linked to the boluses and they should drop out when the order is changed, or a warning should pop up when the bolus is scanned. Ideally.
  6. Visit  madwife2002 profile page
    0
    If you follow these simple guidelines you can potentially eliminate errors!
    I did not say follow the 5 rights and there will be no errors-see above.
    If you read the original order in the patients chart would it not say Heparin infusion no bolus? Would you not go back and check the order with something like heparin?
    Heparin is something which isn't given long term, so the RN should be checking that order and having conversations with the Dr


    Quote from sistrmoon
    It's oversimplification to say "Just follow the 5 rights and there will be no errors." Sometimes there are systems failures. For example, a heparin drip with no rebolus that was initially rebolus and the boluses were never taken out of the system. So you scan the bolus, and the system doesn't alert you, so you scan the patient and give the bolus. But it's a med error because a bolus shouldn't have been given, and the boluses didn't drop out of the system when the main order was changed. Ideally, the main order should be linked to the boluses and they should drop out when the order is changed, or a warning should pop up when the bolus is scanned. Ideally.
  7. Visit  sistrmoon profile page
    1
    Quote from madwife2002
    I did not say follow the 5 rights and there will be no errors-see above. If you read the original order in the patients chart would it not say Heparin infusion no bolus? Would you not go back and check the order with something like heparin? Heparin is something which isn't given long term, so the RN should be checking that order and having conversations with the Dr
    There's a lot more to the story but at my facility currently the orders are in the computer(MAK and CPOE) but the flow sheet is on paper. There were actually conflicting orders in the system and the paper flow sheet said rebolus. It looked like the pharmacy had changed the order directly with the dr but not notified anyone and not taken the bolus orders out. The order and bolus were verified with a 2nd nurse per protocol. This is obviously a system that needs to be changed for safety with a high alert drug like heparin. The error was discovered 24 hours after the bolus was given, it was an appropriate bolus if the orders had called for rebolus, pt was fine. Just giving an example of doing everything "right" and still an error happening.
    madwife2002 likes this.

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