Medication Errors....

[momandstudent]

I am the occ. health/education/infection control nurse at a SNF and I am trying to come up with some material to help alleviate medication errors among our nurses. Right now, when an error is found, a form is filled out and the nurse and DON discuss what happened and what steps will be taken to prevent further mistakes. Many, many times, the nurses say, "Will pay closer attention or will take more time during the pass." Our DON is new and would like me to come up with some sort of "homework" for the nurse(s). She did give me a packet to go through this weekend which is about 60 pages of combined reading and essay questions. I have not thoroughly read it (it is the weekend ) but I was wondering if anyone else had any good ideas. I am going to post this in some other areas on the board but thought I would start here as it gets more traffic!!!! Thanks for any input.

[BostonFNP, APRN]

It wasn't a question of LPN vs. RN. Part of the reason this forum exists is for us to be able to vent. I don't belittle or disparage any of the nurses who work for me. I am NOT an administrator...just the humble DNS who has as much or more stress than anyone else in the building. Apparently, if one is a manager, one is not allowed to vent. If I were a new grad, I could say whatever I wanted and no one would care. We should ALL be free to say what we feel on here.

The flame away comment was said because I knew people would take offense. Unless I point my finger at you, don't be taking offense when I vent on here.

yowza

You have earned some judgement-free venting. You are right, it is inexcusable for that to happen now matter what education the nurses had. And it is not my fellow Cape bias. :)

[CapeCodMermaid, RN]

I've never heard of becoming an LPN in 10 months! It took me 16 months full-time. I'm an RN now and don't think there is enough difference between the two to make one more proficient at med pass than the other. Med errors are often due to not paying attention to the 5 rights, something taught in ALL nursing programs. Besides playing the blame game is divisive and not constructive.

In Massachusetts, LPN school is 10 months....used to be 18...now it's 10.

I checked the MARs when I got to work today...all the mistakes were made by LPNs, but, again, that isn't really the point. The point is we are not making widgets. We are taking care of people...the sickest, frailest people there are. We need to try as best we can to be mistake free. We need, at the very least, to feel something when we make a mistake and not just say "I was busy." That's all I'm saying.

Honestly, if I offended all y'all, I apologize. I do not apologize, however, for having high standards.

[thenursemandy]

I too have high standards. You're right about us having a duty to those in our care. We absolutely do! I wish that med errors never occurred. All I can do is make sure that I don't make them, and if I spot one, let the other nurse know. Ive written incident reports on other nurses from time to time. I think if the other nurse knows that you aren't "picking on them", and that we all make mistakes, and to be more careful they likely will. Not everyone understands the gravity a med error could have. I wish everyone were more aware and proactive in prevention. The ones that think no big harm could occur are the ones that seem to make the most errors. They say ignorance is bliss. I say ignorance is deadly.

[thenursemandy]

This is a little off topic, but.....10 months is crazy! What kind of education can you achieve in that short amt of time? When I did my LPN, it was at a community college. I needed credits in Math, Psychology, English Composition, Anatomy and Physiology etc. Do lpns in your state go to vocational schools that skip over Gen Eds?

[mickeypat]

Ok, I don't know about your facility, but the one I am at has LPN's that pass meds. RNs are charge and LPNs pass meds. So, would totally make sense that the LPNs are the ones who make the med errors. Also, sometimes the errors are not caused by the LPNs, it may be because of the person putting in the orders had the wrong information. I had to redo a bunch of orders that had been put in from one set of orders sent earlier in the day and then a second or third set of revised orders came in later!!!!

[miasmom]

Med errors happen. I hate it when it happens. I feel guilty when it happens. If we all work together then it will get better. Stop blaming. Look at the big picture and see what can be done to improve the nurse the systems. Life is not perfect. People are not perfect. Systems are not perfect and we all know the is nit engough money truely staff a snf for as sick as this peoplecare. We all care about our patients and our coworkers. Learn and moove on.

[wyogypsy, RN]

What I hate is that when I find a med error (or usually errors) because some nurses don't use their MARs, I am the one spending my time filling out the med error form because I 'found' the error. Then the nurse that 'made' the error gets a talking to, if that. I would much rather be able to write down the date and time of the med error, even the nurse making the error, and give it to you. Then the nurse that 'made' the error could complete the med error form. Maybe if they have to spend time completing enough of these they will learn to use their MARs? Honestly I can't begin to write all of the med error sheets that I should write and just let the minor ones go. No, I don't feel good about that - but after turning in the same nurses over and over and over again for errors related to not using their MARs I have lost my faith in that system.

[MarggoRita]

At our facility the nurse that finds the error photocopies the mar and med card or makes a note of explanation of what was found, turns it into the don, and then the nurse who made the error is handed the photocopies and incident report to fill out, makes more sense for the investigative part since they can explain better the hectic interruptions or other reason the error was made.