Advice on Challenging a Write-Up?

nurseprnRN, BSN, RN · Mar 19, 2015

I was among a large group of rns/lpns and medtechs who gave medication (drops) that were a different strength than written on the MAR (paper). The family brought in the medication (supplied by another pharmacy not our inhouse pharma) and floor nurses expected all meds should have been checked against the orders by the nurse manager. In addition, the family was very detailed about providing care information and we had two more unopened boxes. I administered drops for about 6 weeks and was confident I had the right medication for the above reasons and also because I did not see the strength value was different from MAR value. Per a later written comment by MD, it was better not to interrupt treatment while clarifying written order. Patient rec'd correct drops but MAR was never corrected and we were all issued a written warning (which stays on our record for 12 months) for failing to maintain 5 Rights. I would like to challenge this action as inappropriate and have all write-ups expunged based on "the right med was given" and all 5 Rights were maintained. Am I on strong ground?

No, you aren't, because you relied on somebody else to do your due diligence for you at some remove from the bedside ("floor nurses expected all meds should have been checked against the orders by the nurse manager"). The person administering the drug has the ultimate responsibility to do the 5 Rights, and one of those is checking against the written record. It's not clear why you "didn't see the strength was different from the MAR value," but I can see as this could be a problem. Somebody should have made sure the MAR was corrected, and (as is so common when responsibility rests with "somebody," nobody did.

Secondly, I would like to insist the company implement it's (sic) own procedure and conduct a "Learning from Defects" (which is a tool developed by Univ of Chicago) to address the process issues that exist at this facility.

Good idea.

Some of the process issues include: a) the box and bottles of eye drops are physically difficult to read due to poor placement of ingredients, strength, and form. b) the pharma labels on eye drops frequently do not match the bottle but the medication is correct. c) pharma labels often pull off and destroy manufacturer labels due to poor placement when you check label-to-bottle. These reasons make checking eye drop orders confusing and timeconsuming.

Time-consuming isn't an excuse. However, these other issues are very important. Has anybody spoken to the pharmacy about thse procedural problems? And what's up with "do not match the bottle but the med is correct"? How do you know how that could possibly be true? This is no way to run an airline.

And everywhere I've ever worked, the PHARMACY is responsible for checking all meds brought into the facility before they are ever issued to the patient care area, whether the meds come from a wholesaler, another pharmacy, or are carried in by a family member. The pharmacy should be checking labels, strengths, and so forth...and no more of this disassociation between bottle and contents.

d) Resident Units contain 12-14 patients, out in common areas, all of whom are dementia-dx and fall risks, and there are 3-4 patients who are mobile by w/c or who ambulate AND are either extremely high fall risks and/or agitated, yelling, or at times combative with other residents or staff most shifts. This environment makes it very difficult to concentrate during every med pass. Would it be reasonable to state that there are huge process issues that need to be fixed before HR/management issues written warnings?

Yes, but you (all) still have to eat the warning. Perhaps the fact that so many of your staff were unable to follow established, common nursing procedure is a warning to the facility that something needs serious overhaul...but that doesn't excuse the nursing error in med administration.

Most of my effort in the past 2 years here has been focused on keeping patients from falling or hitting each other. I do not believe it is humanly possible to invest myself in fall prevention and concurrently make all of the phone calls needed to clarify potential med errors.

Well, "somebody" has to do this, and that somebody is, in fact, the nurse who administers the medication. There are few responsibilities more critical than giving meds properly, and the checks and balances are in the process of the 5 Rights for a reason. I wouldn't advise going before a court or a BoN (or an employer) using "I was too busy doing something else" to excuse a med error, even if, as you aver, no actual error occurred.

Good luck. Perhaps this is the wake-up call that everyone needs.

Meriwhen, ASN, BSN, MSN, RN · Mar 19, 2015

My question is that if you (you and the other nurses written up) saw that the MAR was incorrect, why didn't any of you say or do something about it to get it fixed?

nurseprnRN, BSN, RN · Mar 19, 2015

My question is that if you (you and the other nurses written up) saw that the MAR was incorrect, why didn't any of you say or do something about it to get it fixed?

Before she edited out a lot of the original post (which I have quoted earlier), she said she was too busy doing fall prevention to do it.

Most of my effort in the past 2 years here has been focused on keeping patients from falling or hitting each other. I do not believe it is humanly possible to invest myself in fall prevention and concurrently make all of the phone calls needed to clarify potential med errors.

faithkindness · Mar 20, 2015

Thank you for your time and your thoughtful comments. I am struggling with the hard line reasoning of 1) med errors warranting punishment; 2) pulling a med error out of the context of all the factors at play when that error occurred. Recognizing the context of an error is not excusing it. It is an effort to learn from the mistake. People seem to use hammers in nursing when they talk about med errors. Hammers hurt people. Fixing a broken process helps people do better.

It is not possible, for most humans, to accurately check details in a chaotic environment. There's a lot of research to support this, but I don't see it being applied in nursing.

I agree we have to get Pharmacy labels to match eye drop ingredients exactly. I wish it were possible to have pharmacy verify meds brought in from home, and will ask the administrator. Maybe she'll surprise me.

faithkindness · Mar 20, 2015

Yes, that is true. There was so much going on. I was also concentrating on getting all meds and treatments passed and communicating patient specific issues to direct care staff. Starting this week, I am writing every little detailed discrepancy down on paper (we are not electronic yet) and delivering to manager q shift. I have to figure out a way to keep a copy without patient identifiers. I wonder if it's legal to keep copies in a locker at facility?

nurseprnRN, BSN, RN · Mar 20, 2015

Yes, that is true. There was so much going on. I was also concentrating on getting all meds and treatments passed and communicating patient specific issues to direct care staff. Starting this week, I am writing every little detailed discrepancy down on paper (we are not electronic yet) and delivering to manager q shift. I have to figure out a way to keep a copy without patient identifiers. I wonder if it's legal to keep copies in a locker at facility?

Not if there's an iota of identifiable information on it. To make sure it doesn't get "lost," cc it to the manager, DON, the company risk management office, and (if applicable) the head of pharmacy, drop them off on your way out the door at the end of the shift, and make sure everybody knows that everybody got it.

You can label it "internal work product" if it makes everybody feel any better, but if you ever get asked about it under oath you can-- must --reveal it.

And fergawdsakes don't take anything like that home.

And start looking for another job, because yours is toast.

Meriwhen, ASN, BSN, MSN, RN · Mar 20, 2015

Not if there's an iota of identifiable information on it. To make sure it doesn't get "lost," cc it to the manager, DON, the company risk management office, and (if applicable) the head of pharmacy, drop them off on your way out the door at the end of the shift, and make sure everybody knows that everybody got it.

A handy tip to help prevent paperwork from getting "lost": if you have to give a copy to a secretary or an assistant because the DON/Manager/whoever isn't there, be sure to get the assistant's full name...and make sure the assistant SEES you writing down their name. And causally mention that you'll check in with the DON/whoever later to make sure that they did receive the paperwork.

That way, if the DON says they never got it, you can say, "I dropped it off Tuesday at 12:20 with Mary Smith".

BrandonLPN, LPN · Mar 20, 2015

Ultimately, having a ton of fall risk and demented residents is no excuse for administering a medication that doesn't match what is ordered. Even in LTC or assisted living or wherever you work.

It seems your facility needs to set some systems in place to deal with all these MAR discrepancies.

Some sort of 24 hour chart/order review is absolutely vital. Every place I have worked, the night shift LPN or RN is responsible to review every order written in the previous 24 hours, making sure the order makes sense, is noted correctly in the MAR and that the corresponding medication has arrived and is labeled correctly. Provided the night shift LPN checks every single order every night (which should be an ingrained part of his routine), transcription and labeling errors will be caught in a timely and efficient manner.

Coming up with a system that eliminates as much as possible these sorts of errors is a much better option than you presenting daily lists of discrepancies to your shift manager. It is more efficient, safer and better for you than what you're planning. Those lists will not make you very popular with your manager or your coworkers.

faithkindness · Mar 25, 2015

Thank you. Hope you are wrong about the toast prediction.

jadelpn, LPN, EMT-B · Mar 26, 2015

A process for home meds needs to be clarified. If the family brings in a home med, then the MAR needs to reflect same, and the MD needs to look at the home meds and choose to order them or not. Usually, pharmacy also checks the meds, as then a label is created for the facility and added to the patient's med box within the med dispenser.

When a paper MAR is created, it then is usually reviewed and signed off by a second nurse. This is another safety precaution that should be put into play. If the second nurse sees errors, then they need to be fixed at that time, so that these things don't happen.

The eyedrop that is reflected on the MAR--is there "any such thing" as the strength that was written--in other words, if you are talking about 5% as opposed to .5%, what is reflected on the MAR doesn't even exist--so that plays into knowing what meds you are giving. Look em up--or ask pharmacy--a really good habit to get into, especially with any newer nurses who you don't want to teach poor practice. And if the MD was of a "more is better" with the eyedrop and intentionally ordered a larger dose, clarify.

There should be a nurse doing the MAR. If you have a unit secretary transcribing, then I am not sure if that is a process that should continue. This is a transcription error, and error on the part of the 2 nurses who signed that the MAR was correct. Also, you should have a "patient may take home meds" order. That may or may not protect you, but at least it verifies that the patient can be given the med from their home supply. Apparently this went through one month on one MAR, transcribed over to MAR #2, and then went on for another 2 weeks.

No one was (I assume) suspended or any other grave consequence, and hopefully, if there was a verbal/written warning on anyone's employee file, I would hope it was signed for acknowledgement of receipt only. And at this point, if you are motivated to change the process, you could bring up a new policy to make sure that this doesn't occur again. And the way to do that is to first look at the current policy, make any changes that are warranted, and partner with pharmacy to deal with patient's home/own meds. Make sure that one nurse is the MAR nurse, and charge is perhaps the second signer on the MAR. Check the order against the home meds. Make sure that pharmacy has a copy of the order--another layer of protection--as they compare the order to what they have.

I am sorry that this happened to you. Make sure that you compare your orders to the MAR, and then bring the MAR with you when you give meds. That way you can compare what is on the MAR to what you have, and be sure that they match. Yes, it does take more time, however, perhaps one med nurse per _____ patients may not be a bad thing.

Best Wishes

faithkindness · Mar 26, 2015

Very helpful! And I am motivated to help change the process. Thank you so very much for your supportive comments and recommendations. Kind Regards.