Medication Errors/ Medication Management Advisory Committee

TiffyRN, BSN, PhD · Dec 16, 2003

Having reviewed what the nurses following me had to say, I have to agree and revised my own post. How about we leave it at. . .

Pyxis machines can be great, but be very cautious.

cannoli · Dec 16, 2003

Personally, I don't think this is the place for this type of information.

SmilingBluEyes · Dec 16, 2003

I agree w/cannoli here.

Home Health Columnist / Guide · Dec 16, 2003

Check out the institute for safe medicine practices.website and sign up for their free newsletter. They have the info you need: http://www.ismp.org

Newsletter:

http://www.ismp.org/NursingArticles/index.htm

Medication Safety Alerts:

http://www.ismp.org/MSAarticles/msa.html

Great safety articles here:

http://www.ismp.org/MSAarticles/recentarticles.html

NEWSTART · Dec 16, 2003

I don't want to make anyone uncomfortable.. Thanks KarenRN. I just don't know where to start on this and how can one nurse make a list of WHY medication errors happen anyway.

I'll leave you all alone Thanks anyway

Karen:confused:

RainbowLPN · Dec 18, 2003

I agree I do not think this is the right place to discuss something this important. I can give you a couple general idea that might help you though. I know for one that in nursing homes some nurses must pass medicatuions to as many as 37 patients. That does not leave much time for double checking. Also I have seen mistakes made by ward clerks. These people who have no medical license taking off doctors orders. Somtimes I don't think they know how serious their job really is. :eek:

Kyriaka · Dec 27, 2003

When I was a burn patient a nurse accidently gave me Tylenol instead of Tylox.

But it really was not the nurses fault. He couldnt read the Dr.'s handwriting.

Huq · Dec 28, 2003

Originally posted by Kyriaka
When I was a burn patient a nurse accidently gave me Tylenol instead of Tylox.

But it really was not the nurses fault. He couldnt read the Dr.'s handwriting.

Not the fault of the nurse?

Giving medication when unable to read an order is the same as giving medication without an order.

oramar · Dec 31, 2003

if you ask me doctors handwriting is high on the list if not number one

CoffeeRTC, BSN, RN · Jan 1, 2004

Speaking of nursing homes...timing is always an issue... If one nurse has to pass to 20+ pts, what happens if they are distracted during med pass? some meds are often given late

ktwlpn, LPN · Jan 1, 2004

Originally posted by cannoli
Personally, I don't think this is the place for this type of information.

I disagree-I think it can be very beneficial to us all to discuss it here.We surely won't give too many details...There is a great deal of info available on the 'net also...I'll go...................The first major med error I was responsible for was in acute care-the unit clerk took a one time "now" order off twice-one time now and agin in 4 hours...The RN covering for me and responsible for checking the orders after the unit clerk took them off missed it the transcription error...I did not check the chart myselff before giving the med-I did not routinely do so then because as an LPN in that facility I was not permitted to take off my own orders and I just depended on the system to work....In this case-it did not......That was a valuable lesson-you can't get complacent about this type of thing and if you are giving the med you need to accept the responsibility...The next major error was not mine but I was working on the unit with the nurse that responsible-in LTC we may have 40 patients to pass meds to within a limited time frame....Add the particular challenges of passing meds in a dementia unit and you are really pushing to get through....This nurse gave a fella someone else's meds..it was a pre-pouring thing and on this unit not uncommon...I know I had med cups in my hands numerous times and the ambulatory residents would get away from me....I am not one to waste multiple meds...but that is dangerous....We had one gal in particular that you had to actually pin to the wall with your body while you got her meds ready-they just don't understand directions...Thankfully our DON has seen the light and each large unit now has 2 med carts so at most we are giving meds to about 20 residents at a time.....Now if everyone would leave the nurse alone during the med pass we would be golden....But that will never happen...