Transcription error

Nurses Medications

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I wanted to ask - if medication was transcribed wrong in the system, and medication was given as it was transcribed, and found out later that it was transcribed wrong from the original order in the chart, who would be responsible for the med error, the nurse who administer the medication as it was written or the nurse who transcribed it wrong?

the transcriptionist, and, perhaps the giver, if it would have been obvious to the "reasonably prudent nurse" that the timing was wrong.

Meds on paper MARS usually have to be signed off by 2 nurses. (and actually reviewed on the orginal order) Most electronic medical records have to have pharmacy approval before you can get it out of the machine, or over-rides that require 2 nurses.

With all that being said, a nurse should take a look at the original orders to review the plan for the day. Someone also does chart reviews, sometimes every 24 hours. So with all this reviewing going on, it seems unlikely that a transcription error can occur, but it does. So always take a look at the original orders,as you could be held liable as you should be reviewing the orders otherwise.

Specializes in Clinical Research, Outpt Women's Health.

Do nurses really have time to look at all the original orders in the chart every time they give a med? Yes, I am being sarcastic.

Specializes in Emergency, ICU.
Do nurses really have time to look at all the original orders in the chart every time they give a med? Yes I am being sarcastic.[/quote']

LOL! I wish!

This is where the beauty of EHRs really kicks in. No handwriting errors, just clear orders. They can still be wrong (especially when placed by the brand new intern who still has no idea what to do), but at least then, it is true nursing critical thinking that catches it.

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But one thing here also, what if the chart was reviewed too and even then the error was not caught at that time, then whos responsible for that?

Specializes in Emergency, Telemetry, Transplant.
But one thing here also, what if the chart was reviewed too and even then the error was not caught at that time, then whos responsible for that?

I would imagine whomever transcribed the order has to sign the order sheet. In addition, the RN who verifies the order must sign it as well. While I image both those individuals are responsible, the primary responsibility, in my mind, lies with the RN who did not make sure the order on the MAR was a correct "interpretation" of the order on the chart.

Specializes in Family Medicine.

I blame (in order of who I blame the most):

1. The facility (for not getting with the times and mandating doctors write orders in an EMR)

2. The doctor (for having illegible handwriting, if applicable)

3. The nurse who transcribed the order (for either not clarifying bad handwriting or for incorrectly transcribing a legible order)

Do nurses really have time to look at all the original orders in the chart every time they give a med? Yes, I am being sarcastic.

No, however, it is always not a bad thing to look at the orders at the start of one's shift.

But, How can you when you have 30 patients in long term, or almost 20-24 patients in short term?

It would seem as tho the initial transcribing nurse and the verifiing cosigner would be ay fault after all this is THEIR hancock of approval. When I get a new order I should be able to intrust that not one but TWO competant nurses have transcribed reviewed and verified appropriately....don't u agree?

Specializes in ICU.

Sadly, I used to see this all the time. The error falls on the RN who gave the med incorrectly. I only know this because I work nights and when we had paper MARs, it was our job to sign off the MARs for the next day, which meant, having to go into the chart and check all the med orders against the printed MAR. Our manager always came down hard on the RN who gave the med incorrectly, saying it was our job to check the orders for any med before giving, we could not blame the RN who transcribed the order or signed off the order on the MAR. However, if another RN caught a transcription error and it was signed off, the transcribing/signing RN would be at fault. Pharmacy used to make a lot of mistakes that were printed and we would have to correct.

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