Whose medication error is it?

MJB2010 · Aug 23, 2011

The person who sent the wrong MAR made a clerical error, not a med error. I am not familiar with the process at the ER but seems like a long list of possibilities on who should be held accountable, but I have to say the doctor really should have caught it. Was the patient not able to communicate to say what they took? I think this would go to one of those investigations where they determine where the flaw is in the process and how to prevent it from happening again, way more than one person messed up here. Glad the patient is ok.

wooh, BSN, RN · Aug 23, 2011

Who should be repramanded for this mistake?

Nobody. It should be used as a learning experience.

o0nurse0o · Aug 23, 2011

The patient is an elder patient and has a polypharmacy of meds, so that in mind, it is doubtful that she would be able to correctly relay the meds she was on.

I can say that the nurse at the personal care home was repramanded with a 3 day suspension and when returning to work, returns on a 90 day probationary! I dont feel this was proper punishment!

Upon readmission, the dr actually kept the dosing that she received at the hospital rather than returning to her proper prehospital meds! I mean, the what if's surely are there!!! Yes! Is it right to have the mindset of the potential harm that "could of been" for punishment?

Why should a clerical error be given such harsh punishment when the hospital dosing the meds probably did not even chalk it up as a med error!

FRUSTRATED in the entire situation!!!!

gcupid · Aug 23, 2011

You all should know that whoever sent the wrong mar would be the one reprimanded...

tyvin, BSN, RN · Aug 23, 2011

Whoever sent the MAR should take the primary blame.

Sun_danc3rRN · Aug 23, 2011

Whoever sent the MAR should take the primary blame.

In my personal opinion it was the responsibility of those who prescribed the meds for the patient's stay in the hospital. Even if the clerical error was made, the ED docs get paid a lot of money to do their job, including the responsibility for receiving the MAR with the wrong name on it. But this sounds like it was a breakdown in the system. First the clerical error of the wrong MAR being sent, the ED staff not reading the name and other identifiers on the MAR that was sent, the wrong meds being prescribed for inpatient, etc. In my hospital it would be a nurse who does the med reconciliation after they go through the ED and are admitted to the floor, but even then, we call the doc if they didnt already check off on it, and verbally go thru each medication prescribed, and the corresponding DX for each and every med. It seems to be that this incident should be used as a learning opportunity for both the residence the patient was sent from, all the way to include the docs and nurses that were involved in the patient's care at the hospital. :nurse: Thankfully the original poster stated that nothing bad came from this, and if they can learn where the breakdown occurred the whole way around, then they stand a chance of fixing it so it doesn't happen again. :nurse:

jbluehorseh · Aug 23, 2011

The patient is an elder patient and has a polypharmacy of meds, so that in mind, it is doubtful that she would be able to correctly relay the meds she was on.
I can say that the nurse at the personal care home was repramanded with a 3 day suspension and when returning to work, returns on a 90 day probationary! I dont feel this was proper punishment!
Upon readmission, the dr actually kept the dosing that she received at the hospital rather than returning to her proper prehospital meds! I mean, the what if's surely are there!!! Yes! Is it right to have the mindset of the potential harm that "could of been" for punishment?
Why should a clerical error be given such harsh punishment when the hospital dosing the meds probably did not even chalk it up as a med error!
FRUSTRATED in the entire situation!!!!

what if the patinet died or was harmed???????

tyvin, BSN, RN · Aug 23, 2011

In my personal opinion it was the responsibility of those who prescribed the meds for the patient's stay in the hospital. Even if the clerical error was made, the ED docs get paid a lot of money to do their job, including the responsibility for receiving the MAR with the wrong name on it. But this sounds like it was a breakdown in the system. First the clerical error of the wrong MAR being sent, the ED staff not reading the name and other identifiers on the MAR that was sent, the wrong meds being prescribed for inpatient, etc. In my hospital it would be a nurse who does the med reconciliation after they go through the ED and are admitted to the floor, but even then, we call the doc if they didnt already check off on it, and verbally go thru each medication prescribed, and the corresponding DX for each and every med. It seems to be that this incident should be used as a learning opportunity for both the residence the patient was sent from, all the way to include the docs and nurses that were involved in the patient's care at the hospital. Thankfully the original poster stated that nothing bad came from this, and if they can learn where the breakdown occurred the whole way around, then they stand a chance of fixing it so it doesn't happen again.

The primary blame would go to whoever sent the MAR.

sistasoul · Aug 23, 2011

This sort of thing happens because nurses and Drs are run ragged. The healthcare profession is so busy I am surprised more things like this don't happen.

We are pushed beyond our limits trying to get everything done and not incur Overtime.

The breakdown in the system was not enough time. That is usually the source of errors. People are rushing and stressed to get done so management doesn't get on their backs. Being pulled in too many directions at the same time is another source of the breakdown in the system. I think this is all common sense but the higher ups who have never worked as a nurse or an MD will never get it.

littlewingrn · Aug 23, 2011

Had the same thing happen last year in reverse. Patient admitted to LTC from hospital with wrong MAR. Luckily, we caught it during the admission process. If we would have administered the meds (wrong Patient's MAR was a diabetic with insulin - correct patient was not) we would have been responsible - would have been our med error for not ensuring correct patient during reconciliation process. That being said, my thought process this early in the morning is not great so I may be wrong, but, the provided MAR to the hospital (although wrong) was not an "order". The admitting team wrote the med orders. Once it goes through that many hands, would the floor nurses be responsible for administering the wrong meds when they were ordered off of med reconciliation? At that point, would they realize they were the wrong meds? Would they be responsible for reconciling the MAR from the SNF when it was already done during the admission process? Wow, what a mess!

kcksk · Aug 23, 2011

I know in our hospital a lot of time people come in with their medications written down on a piece of paper. They get transcribed onto a med rec sheet and then the md determines if they will be continued or not. The poster stated that the meds were similar so if a pt has a hx of htn and there is a bp med ordered, hi chol and that med was ordered, etc throw in your standard colace, multivitamin, etc there probably wasn't anythng that stood out as a "why is she on this?" Another learning opportunity and a reminder for all of us to be careful.

That being said, I have helped out in the ED where the nurse has handed me a med form, asked me to to write out the med rec form and I have no idea of the pt name and who it was for.. I only transcribed.