# End of the (Med) Error: or, How NOT To Bomb Your Survey - page 2

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... Read More

1. 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.
2. Quote from not.done.yet
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.
Can 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.

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.
3. Y'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!
4. Quote from Ashley, PICU RN
At any rate, I think we've proven that it's a poorly written order.
Yeah, 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.
5. How 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?
6. 1.5 tabs, not 1.5mg.
7. How 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.
8. ATC doesn't mean you can't hold a dose if patient is somnolent or something. It's important to use judgment.
9. where are you getting your #s, sounds like your still making med errors,

"Warfarin 2 mg tab, 1.5 tabs PO Q PM on Mon-Wed-Fri, alternate with 4 mg on all other days." to me that is 1.5 tabs once a day in pm, equal to 3 mg (2mg tabs X 1.5), so it 9 mg total for all three days not "10 mg on the other three" infering 10 mg a day and "alternate with 4 mg on all other days" is equal to 4 mgs a day totaling 16 mg for 4 days, not "when he's supposedly getting 7.5 mg of warfarin 4 days a week", maybe you posted the order wrong but I am pretty sure my "math" is right , since i am using your order, "Warfarin 2 mg tab, 1.5 tabs PO Q PM on Mon-Wed-Fri, alternate with 4 mg on all other days." to do the calculations
10. Quote from AndiSN
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.
Don't have time?, shortcuts?, condescending at times? ideal world? for us to be able to do things by the book but it just doesn't work like that.? REALLY, well i guess you don't value your liscense, cause at this rate your going to lose yours, med errors are the # 1 killer of patients when it comes to iatrogenic causes. Good luck if you continue with your attitude towards safe practices. If you don't have time and have to take shortcuts then either get administration to help or find a more professional facility
11. Med techs are pushing LPN's out of jobs.
12. I find the unit dose mentioned in orders problematic. On the MARs from NHs, the drug and unit dose is shown on the first line, while the administration dose, route, and timing is shown on the second line. Why is that done in NH/LTC/ALF?

When I transcribe for my admissions, I do it the more direct and less ambiguous way: drug, dose, route, timing. One time during chart checks, I saw that the admitting nurse put the unit dose as the administration dose, underdosing the patient. This is a system error, IMO.