End of the (Med) Error: or, How NOT To Bomb Your Survey - page 2
by VivaLasViejas Guide
As any nurse knows, a state survey or JCAHO inspection tends to bring out the worst in a facility. And as any nurse-manager knows, the survey team usually uncovers mistakes that we never even dreamed our departments were capable... Read More
- 2Oct 14, '12 by txredheadnurseQuote from AndiSNI can hear and understand your frustrations but there is nothing in this article that is deviating away from the basic rights of med administration. I don't believe the OP's intent was to make anyone feel inadequate but rather to remind all of us that whenever we decline or refuse to follow the basics mistakes can and do happen. Unfortunately those mistakes can have tragic outcomes for both the residents and for the nurse(s) who made the med errors. IMO no one should ever be too busy to check the med against the MAR, to use the MAR in the first place & not your memory & to fail to document the meds appropriately. It is really difficult to prove your innocence during a med diversion investigation if you wait until the end of your shift to sign the meds out. Why? because I can promise you that this "time saving" habit results in more meds not being signed out on the narc log, not being documented appropriately and even being omitted.All of that would be wonderful and all well and good if people actually had time to do all of those things. I know that the facility I work in we do end up taking shortcuts but it's not because we are all sitting around socializing. The vast majority of us are working our tails off constantly. I am still pretty new to all of this but even the nurses and the med aides that have been at this for years struggle to get everything done. It's easy to sit in the position of a supervisor and say all of the things that should be done but not so easy to actually do them. My supervisor worked the floor on what is normally my shift the other night and by the time I got there I could tell she was getting her rear handed to her. I am not someone who is easily offended and I can generally see all points of view but honestly your article came off as a little condescending at times. In an ideal world I would love for our shifts to go like this and for us to be able to do things by the book but it just doesn't work like that.
I audit med carts and MARs almost every working day and I find these kinds of issues constantly. Sometimes the errors could be avoided by having more appropriate nurse to patient ratios but I have seen these types of errors in facilities where the nurses only do accuchecks, insulins, G tubes and nebs so it is not always a matter of too many patients and not enough time. It usually is a matter of taking unsafe short cuts and work arounds and not using a few minutes at the beginning of your shift to check your cart, stock accordingly and make yourself a work sheet and prep for things like accuchecks. Honestly would you want someone pouring meds from memory for you or a family member? Would you want someone not to check to make sure those eye drops and insulins aren't expired so your family gets meds that are still effective and safe from contamination?
- 0Oct 15, '12 by amygarsideI understand that nurses have really a very hard job to do. They try to balance a lot of things but I think that not knowing the side effects of medicines can be a big mistake for anyone. It does not only harm the patient but it can also affect the reputation of the hospital and its staff.
- 3Oct 16, '12 by apocatastasisTo clarify one or two of the points from a different perspective, I'm a psych NP who is required to spell out tablet strength and instructions based on tablet strength. Even though I am at a 2-3 week crisis psychiatric jail/ER diversion facility with 24/7 NP coverage (with 1-2 psych NPs on site 16-18 hrs a day), and even though we use order sheets as in SNFs or inpatient settings... we are technically classified as an RTF, which is an outpatient setting in our state. So we have been required to spell out [drug] [strength] [form], instructions to take x [form] [schedule], etc. as on an outpatient prescription. I'm sure this differs state to state, but it seemed stilted to me as I've always worked ER or ICU.
When I write orders, to be excessively (obnoxiously?) clear, because I think that's what is necessary in these settings, I usually write an order along the lines of, e.g., "warfarin 2mg tabs, take 1.5 tabs (=3mg total dose) on a, b, c." Then a separate order of "warfarin 2mg tabs, take 2 tabs (=4mg total dose) on on day x, y, z." Particularly with potentially dangerous drugs like warfarin, we need to all be on the same page. Of course, we need to make sure of the proper dose of any drug... last thing we need is someone getting too much (or too little) olanzapine, or clonazepam, or doxycycline, or...
- 6Oct 16, '12 by Ashley, PICU RNQuote from not.done.yetCan you explain this? The order doesn't say to give 1.5 mg. It says to give 1.5 tabs. The tabs are 2 mg. 1 tab = 2 mg. 0.5 tab = 1mg. 1.5 tabs = 3mg.1.5 mg on three different days is not a 3 mg dose. It is 4.5 mg dose. Only pointing it out because two people in this thread made the same calculation error.
Yes, 1.5 mg on three different days would be a total of 4.5 mg in a three day period, but that's not what the order says.
Recopied from the OP, emphasis mine:Warfarin 2 mg tab, 1.5 tabs PO Q PM on Mon-Wed-Fri, alternate with 4 mg on all other days."
At any rate, I think we've proven that it's a poorly written order.
- 2Oct 16, '12 by VivaLasViejas GuideY'all have illustrated my point beautifully.
And these aren't even nurses or nursing students administering these medications. They are technicians with a few weeks' training, at best. The fact that unlicensed assistive personnel are giving critical medications everyday with as few errors as they do is a miracle in itself. But as we've seen here, even experienced RNs/LPNs can write orders incorrectly, or in such a way that the next nurse after them becomes confused and gives the wrong med on the wrong day/time. All the more reason to take medication administration very seriously!
- 3Oct 16, '12 by woohQuote from Ashley, PICU RNYeah, if these many nurses can't figure out an order, especially when we're leisurely looking at it rather than under the stress of taking care of too many patients in too little time, there's a problem with the order.At any rate, I think we've proven that it's a poorly written order.
- 1Oct 17, '12 by bradleauHow about those Extended Release pills that get crushed and given per tube or apple puree? You take MS Contin crushed/ given....and you may very well have a crisis on hand. Try explaining the need to assist the breathing of someone you gave the pill to?
- 0Oct 17, '12 by PistachioHow about the time I looked up a (male) patients medication only to find out it was a breast cancer medication. No history of breasts or cancer of any kind. Written by a resident three days earlier. Question it and a prompt order was written to d/c. No one had any idea how or why it was written for in the first place, but he got three days of it.