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

  1. 19

    An experienced nurse's view of some of the issues that contribute to errors in medication administration, which is one of the most vital tasks we perform in this profession. WARNING: all of the incidents portrayed herein really happened, and real nurses and med techs were involved. They are not for the faint of heart nor the easily freaked-out.

    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 of---stupid, careless errors committed by staff who are too busy, too overwhelmed, or yes, too lazy to use the safe medication systems in place.

    Many years and many surveys/inspections after my very first as a manager---the one that got me fired for the first and only time in my career---I've come to be rather protective of my med room. When we bring on new med techs, the first thing I hand them is my dog-eared nursing drug reference and teach them to look up each and every medication they don't know, BEFORE they give it. But somehow, when State is around, we discover things like this little gem, written in the MAR by hand (and without a start date or initials to boot):

    "Lamidal 50 mg tab
    1 PO QD for urinary tract infection".

    First question: What the deuce is Lamidal? I'll be the first to admit that with hundreds of new drugs coming out every year, I'm always having to look things up (that's why my yearly drug book usually falls apart before the next edition arrives). But when I went to look up this particular med, I couldn't find it......anywhere.

    Second question: The resident's UTI had cleared up two months ago,and a follow-up UA had been negative. So why was she still taking a medicine for UTI? I realize that some patients must take prophylactic antibiotics for chronic UTIs, but this lady wasn't one of them.

    So I went to look at the original order, which was written in the typical doctor's handwriting. But it was clear as day that the order read Lamictal, 50 mg PO QD, which obviously is NOT for a bladder infection......and the mistake had continued from month to month. Needless to say, it made us look pretty foolish in front of the surveyors.

    Here are a few other issues that raise their ugly little heads during med transcription and administration that not only make even a good facility look really stupid, but endanger the patients our systems are designed to protect.

    Failing to actually read the order.

    You'd think it would be simple to transcribe an order like "Warfarin 2 mg tab, 1.5 tabs PO Q PM on Mon-Wed-Fri, alternate with 4 mg on all other days." But if you're not paying attention, you might see only the "2 mg tab" on M-W-F, and thus underdose your patient. It's a lot of fun to explain this to the anticoagulation clinic when they're on the phone demanding to know how the patient's INR could be 1.1 when he's supposedly getting 7.5 mg of warfarin 4 days a week with 10 mg on the other three....

    Giving an unfamiliar drug without knowing what it is, what it does, and what to watch for.

    How anyone can do this with a clear conscience is beyond me, if for no other reason than CYA. After all, it's your rear that's going to be barbecued when a patient is harmed and you have to testify in a court of law that you didn't know what side effects to monitor for because you never bothered to look up the med. And with the Internet available practically everywhere, this information is literally only a mouse-click away. There are NO excuses!

    Allowing distractions when pouring medications.

    At one facility where I worked some years ago, I had some trust issues with the staff, so I came in unexpectedly at dinnertime on a weekend 3-11 shift to see what was happening. Right out of the starting gate, I saw that two of the CNAs were in the med room, which was against the rules, and they were gossiping with the med tech while she was popping pills. Not once did I see the tech even glance at the MAR or the pill cards while she was doing it. And when I compared the med cards against the MAR, I found that she'd pulled the 2100s instead of the 1700s.

    Neglecting to document medications in all the right places.

    During our recent survey, we narrowly escaped a 'harm' tag for sloppy narcotics documentation on one particular resident who uses a lot of PRN pain meds. (Which should've triggered a pain assessment on my part, IF someone had notified me and/or IF I'd been auditing the MARs as often as I should.) The med would be signed out in the narcotics book and on the front of the MAR, but not on the back; or, it would be signed out in the narcotics book and documented on back of the MAR but not on the front; or, it would be signed out in the narcotics book and not accounted for on either the back OR the front of the MAR. Nine med techs almost had to go to OccMed and pee in a cup, while three managers holed up in the administrator's office for two solid days putting all the puzzle pieces together to prove that there was no narcotics diversion going on.

    Administering meds on auto-pilot.

    About a year ago, I was consulting in one of our sister facilities about their survey results, which made ours look like a walk in the park. At lunchtime, the corporate nurse and I watched in amazement as their med tech passed meds in the dining room, which included the administration of several insulin injections.....without benefit of the diabetic MARS in front of her as she dialed up each insulin pen. These happened to be perched on the table in the room we were occupying as we reviewed charts.

    When we asked the tech why she didn't take the book with her on insulin rounds, she responded casually, "I didn't want to bother you all. Besides, I know everybody's sliding scales anyway."

    'nuff said. These are all great ways to bomb a survey or inspection and put one's license at risk. Don't let them happen to you!
    Last edit by Joe V on Oct 15, '12
    HappyWife77, not.done.yet, sapphire18, and 16 others like this.

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  2. Visit  VivaLasViejas profile page

    About VivaLasViejas , ASN, RN

    VivaLasViejas has '17' year(s) of experience and specializes in 'LTC, assisted living, geriatrics, psych'. From 'The Great Northwest'; 56 Years Old; Joined Sep '02; Posts: 25,476; Likes: 37,796.

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    24 Comments so far...

  3. Visit  wooh profile page
    8
    Quote from VivaLasViejas
    Neglecting to document medications in all the right places. During our recent survey, we narrowly escaped a 'harm' tag for sloppy narcotics documentation on one particular resident who uses a lot of PRN pain meds. (Which should've triggered a pain assessment on my part, IF someone had notified me and/or IF I'd been auditing the MARs as often as I should.) The med would be signed out in the narcotics book and on the front of the MAR, but not on the back; or, it would be signed out in the narcotics book and documented on back of the MAR but not on the front; or, it would be signed out in the narcotics book and not accounted for on either the back OR the front of the MAR. Nine med techs almost had to go to OccMed and pee in a cup, while three managers holed up in the administrator's office for two solid days putting all the puzzle pieces together to prove that there was no narcotics diversion going on.
    Why is it required to document in THREE places? I can understand narc book and on the MAR, but why would it need to be documented TWICE on the MAR, that just seems to be asking for trouble.
    ktliz, hiddencatRN, not.done.yet, and 5 others like this.
  4. Visit  txredheadnurse profile page
    4
    Wooh it would need to be documented three places if the controlled drug is a PRN. In narc book, on front of MAR and then with an explanation on the back of MAR. Even with Emars still requires documentation three times if controlled drug is a PRN. Routine/scheduled controlled drugs don't require the separate documentation as to why/follow up if effective.
    VivaLasViejas, Esme12, SHGR, and 1 other like this.
  5. Visit  JZ_RN profile page
    2
    It would make it easier on your staff if you changed a PRN med that is constantly used to an ATC, then less pain assessments, less charting, less work for all, and patient gets atc pain control.
    RkfdNurse1 and VivaLasViejas like this.
  6. Visit  WanderingSagehen profile page
    3
    ATC is great until your pt is so stoned out of their mind just for our convenience of not having to assess....... happened just recently at my job... great for drug companies.
  7. Visit  Ginger's Mom profile page
    3
    In my state, we do not use med techs. What is a med tech scope of practice, are they educated like nurses? Do they transcribe orders? Are they responsible for interactions?
    anotherone, sapphire18, and TJ'sMOM like this.
  8. Visit  Not_A_Hat_Person profile page
    0
    When I worked in assisted living, narcotic PRN pain meds had to be documented in 5 different places.
  9. Visit  NotFlo profile page
    3
    Certainly nurses can and do make all of the above errors BUT...maybe places should use actual nurses for med administration instead of med techs? I know, I know med techs are cheaper.

    Plus the more places something is supposed to be documented the more chances there are for discrepancies. My facility requires narcs to be documented in four different places. It's really annoying.
    anotherone, TJ'sMOM, and VickyRN like this.
  10. Visit  Ashley, PICU RN profile page
    12
    Quote from VivaLasViejas
    Failing to actually read the order. You'd think it would be simple to transcribe an order like "Warfarin 2 mg tab, 1.5 tabs PO Q PM on Mon-Wed-Fri, alternate with 4 mg on all other days." But if you're not paying attention, you might see only the "2 mg tab" on M-W-F, and thus underdose your patient. It's a lot of fun to explain this to the anticoagulation clinic when they're on the phone demanding to know how the patient's INR could be 1.1 when he's supposedly getting 7.5 mg of warfarin 4 days a week with 10 mg on the other three....
    I could read this order five times and still get it wrong...

    2mg tablets of Warfarin. Give 1.5 tabs on M,W,F. That's 3 mg of Warfarin, is it not? Alternate with 4mg of Warfarin (that would be two 2mg tabs or one and a half 4mg tabs- 6mg total) on all other days. I can't for the life of me figure out how the patient is supposed to be getting 7.5mg 4 days per week and 10mg on the other three.

    There really should be two separate orders here. One that says Warfarin 7.5mg M-W-F. Another that says Warfarin 10mg T,Th,S,Su (using approved day abbreviations). Does it really matter that they are 2mg tablets? That just confuses things.
  11. Visit  AndiSN profile page
    6
    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.
    roughmatch, anotherone, TJ'sMOM, and 3 others like this.
  12. Visit  txredheadnurse profile page
    2
    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.
    I 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.

    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?
    HappyWife77 and VivaLasViejas like this.
  13. Visit  amygarside profile page
    0
    I 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.
  14. Visit  apocatastasis profile page
    3
    To 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...


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