Bio-statistics Survey

MMC.RN · Apr 20, 2016

Yes

There was an error on our Baxter rolls. A doctor discontinued a medication, the order was faxed but the rolls were already done and they weren't fixed by pharmacy so when they were sent up, the med was still on the roll.

Wrong med

I would say transcription

Unsure

AngelKissed857, BSN, RN · May 16, 2016

You might get a better response if you created a survey monkey and provided the link, just a thought.

nursej22, MSN, RN · May 16, 2016

Yes

yes

so many meds given late because they aren't available from pharmacy. No retraining as far as I know, just "we are busy, you know."

cecile9155, BSN, RN · May 16, 2016

Yes caught one.

Wrong dose.

Pharmacy didn't supply the correct dose. However several nurses administered the drug anyway before I caught the error. Not sure what happened after I reported the error.

Here.I.Stand, BSN, RN · May 18, 2016

I'm going to answer in narrative format, because your OP is very hard on my eyes. Use my answers how you see fit. Also FYI, there's probably a ton of actual literature about med errors if you do a search on CINAHL or Google Scholar.

First I have to say, "made" is a more appropriate verb in this context than "committed."

I and nearly every nurse alive have technically made countless "wrong time" errors because we have too many patients to safely medicate in a 2 hr window (although I have heard in LTC, to get around this the provider may order the med for "a.m." vs "0800." The most pts I have taken care of at a time is 10, and between scheduled meds, prns, phone calls, bed alarms, other requests for help etc. I almost never did the whole a.m. med pass in under 2 hrs.) But that aside......

I've made and found a small handful of wrong time errors by simply not seeing a med as my eyes scrolled down the computer screen. In my case, I saw them an hour or two later and gave the meds. More frequently, wrong time errors happen because the pharmacy doesn't deliver them on time. Occasionally when attending to an emergency (code, high ICPs etc.) with one pt I may delay seeing my other pt. Of course, if the other pt needs something very critical I will ask for help, but if it's just a scheduled dose of Zantac, it's going to be late.

I've found a couple wrong med/wrong dose errors. One, the offgoing RN hadn't known that Vicodin contained APAP so gave Tylenol for breakthrough pain, two hours after giving two Vicodin. The other, the pharmacy sent the wrong amount of Tegretol in a pre-filled syringe. ALWAYS check the contents of your syringes!! The label, if accurate, indicated that the pt should get 10 ml based on concentration and ordered dose. Syringe contained 20 ml.

The biggest one I've seen was caught by myself and the LPN I was working with. I was confused why my pt who'd been dx'ed with an acute condition hadn't been ordered any meds by the covering NP (weekend in SNF) I called, and the NP said she did order the meds...nope, not in the chart... so she gives me the order and I go about my day. A while later, the LPN covering the other half of our unit is sitting in our work room looking horrified...she'd just treated a pt with meds and then learned the family had opted not to go full-out comfort care for the pt, but not treating acute conditions aggressively. Said meds were the same ones the NP ordered for my pt. What happened? Paper charts, identical first names, nearly identical/unique last names. (What I mean is not names like Smith or Jones, but names likely from the same Eastern European country with 2 letters' difference.) The RN caring for my pt the day before, took a telephone order and entered it into the other pt's chart.

After that one, they changed our name-alert flagging system somewhat, but otherwise I hear nothing after the event report is filed. I've never seen anyone getting retrained. Honestly though, in the case of most med errors I've seen it's not an issue of training.