Near Miss, or a hit?

oramar · Nov 19, 2000

This happened about two years ago after the hospital where I worked eliminated the pharmacist on the night shift. It is the night supervisor's job to fill the order from the pharmary. I took a verbal order for 30 mg. of a certain med. from a MD. I have a bad habit of writing my 3s to look like 8s because the loops are sort of tight. A secretary took the order off as 80mg., another RN thought it looked like 80 mg. and signed the order off. The supervisor brought down the whole bottle of the medication because nurses are not supposed to dispense medications and the instition gets around the "no nurse dispense rule" by saying that bringing the whole bottle down does not constitute dispensing meds. The only thing that saved us was the bottle contained 10 mg. tablets and the LPN who was supposed to actually give the med had never given 8 tablets before and thought it was a bit odd. She asked me about it, I just happened to be the nurse that wrote the 3 that looked like a 8 so the error was caught at the last second. Would the blame have mostly been mine cause I wrote the confusing dose, it sure would have and I acknowlege that. Is the system that allows so many people to handle an order before it gets to the person who actually gives the medication with out a pharmacist present set up to fail, I think so.

Brian, ASN, RN · Nov 20, 2000

Please note that this months survey question is related to this topic. I will close this thread, so there is not duplicate discussions.

The New Thread called:

Have you ever been responsible for a medication error that caused harm to a patient?

Can be found at: https://allnurses.com/bb/Forum1/HTML/001286.html

Please direct all responses in that discussion. Thanks

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Brian Short

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