Would you write this up?

[TigerGalLE, BSN, RN]

Hey everyone. I didn't write something up Wednesday and now I regret it. A nurse left at 1500 wednesday and we all picked up an extra patient. So during my 1700 med pass I saw that this patient had Colace (liquid) 500mg po BID. First of all we usually give 100mg capsules either daily or BID. The only time we give liquid is if they can't swallow pills or have a feeding tube/PEG. BUT this is 5 times the normal dose!!! I saw that the nurse before me had signed off the 0900 dose. So it looked like it had been given once today already!!! So i look in the chart and I can't even find an order for colace.. The only order there is a laxative of choice order. When we have that order we usually ask the patient what they take at home and write a new order. So I call the pharmacist. The pharmacist is speechless.. doesn't know how this happened, can't believe someone would put that large of a dose on the MAR.. ect.. We D/C it right away... BUT the pharmacist also can't find any record that the colace was given this morning... it wasn't pulled from the pixis.... So we don't really even know if it was give. I asked the patient if he had received any laxatives or stool softners today and he said no..

So this tells me that

1. There was no 24hour MAR check on third shift. This is supposed to be done when the new MARs are printed at midnight....

2. The nurse before me.. who has been a nurse for 30 years??? either noticed it and didn't fix it.. signed off a medicine that she didn't really give? and didn't check the chart to confirm the order?

It was only colace.... but next time it may be something serious... I didn't write it up. Now I regret it. Can you still write something up a few days after the fact? I'm also thinking of calling my DON today just to let her know what happened. I think this is a serious safety issue. Not only nursing but pharmacy too.

[UM Review RN, ASN, RN]

Yes, I would tell your DON about it, exactly as you have here.

[Advocate1]

Is it possible to ask the other RN about the situation. Maybe she rec'd a verbal order and didn't put it in.

If you can't talk to her I'd talk to your MGR

[StrwbryblndRN]

It would be good to make sure this is brought up to someone. If something like this happens enough then maybe a system could be set up to help eliminate errors. If no one says anything then no one will know to implement anything.

Just my thought.

[Weeping Willow]

talk to her first. If you don't get a satisfactory answer, run it by your DON. Something is afoul. Glad you caught it. It could have been dangerous.

[mianders, RN]

You should discuss it with the nurse. It is always important to have all the facts before you write someone up. You would appreciate the same courtesy. The "normal" dose for colace is 50-360 mg/day in a single or devided dose. This should be decided by the patients response to the medication. It would not suprise me if a physicain ordered a 500mg dose.

[TheCommuter, BSN, RN]

I don't believe in skipping the chain of command. Therefore, speak to the other nurse first, and see what she has to say about this issue.

I usually become resentful and disgusted when a coworker reports me to management without running the situation by me first. Often, the mishap was not as sinister or calculated as everyone made it out to be. Honest mistakes happen. Still, a dose that is 5x the normal dosage should be reported, but see what the other nurse says first.

[truern]

Once upon a time my daughter took that much colace....until we figured out it wasn't doing any good and her doc dc'ed it.

I'd mention it to the other nurse first before saying anything to management. There could be a perfectly good explanation.

Also, all of our meds aren't in the pyxis...some are in patient's drawers and some in labeled drawers in the med room, therefore there wouldn't necessarily be a pyxis record of her getting the colace...IF you have the same sort of system in place.