Charting Med Errors

[southern_rn_brat]

Recently I had a pt in LTC that received Haldol from the pharmacy instead of Hectoral. She received 2 doses before the error was discovered. She has ESRD and about 36 hours after the last Haldol she was lethargic, etc. When the nurse asked me to assess her (Im the supervisor), I didnt know about the med error. After I got some stat labs the nurse told me about the med error. AHA! I thought, thats whats wrong with her. Labs returned normal and I asked the doc if we shouldnt just watch her, which we did and the next day she was fine.

Ok, here's my question. There was nothing in the chart about her recieving the Haldol. I wouldnt have known had the nurse not been there the day it happened and was able to tell me. The doc knew but didnt remember (she has 100 pts in our facility) until I asked her about it.

When I talked to the DON about it she informed me that we are not to chart med errors in the chart. Being me and always playing the devil's advocate I ask "what if there is adverse reactions like in this case?" she says it is our policy that we dont chart med errors that it is taken care of via incident report. I am thinking "but incident reports are not part of the chart". She says every where she has worked has never charted med errors in the chart. I disagree. I have always charted med errors...of course without placing blame...but have always charted them. In fact, I was taught that you chart it and monitor them for however long the policy or the doc says.

No, lol, before you ask, I havent looked at our policy yet. I was just reading my recent Nursing2006 and saw in the legal section, I think, a question about med errors and it made me remember I was going to check this out and ask yall.

I am NOT saying my boss or admin is trying to cover up anything! I just think that our policy is totally wrong. My boss is great about listening to another's opinions, especially if you have research to back it up. I would like to talk to her about this again because I dont agree.

How do yall do it?

[CoffeeRTC, BSN, RN]

Hmmm, I might have made a note to something of the effect. " Called to asses so ans so because of ...... noted.....noted res received Haldol at ......then I would chart MD called, family notified. then any follow up assessments. Of course a med error/ incident would be done, but in my facility we are placing these in the chart and when we do one its is to take place of the nurses note. I still do both and chart, chart ,chart.

[sanctuary, BSN, MSN, RN]

It is noted both on a Medication Variance form, and on the Medication Administration Record, as the two doses of the med she was Rx'ed was not given, but you need to record what she actually got. The MAR should get to the chart at the end of the month. A note to cover the nurse's assessment for effects would go in the progress note. No "error" need actually be written. Just a note like Michelle126 said. Wonderful that she recovered so well, but what if she hadn't? It would look like no one was tracking her reaction.

[nurse_clown]

i work in long term care. we have a policy regarding those types of drugs and narcotics. we start a seven day assessment. it has to start as soon as the med has been administered by the nursing staff. we have to chart each shift the effects and side effects of the med and sign our names. at the end of seven days, we summarize and determine if the med is effective or not, then report to the doc.

it's too bad it wasn't caught when the med first appeared. our pharmacy has a record book that we document the name of the med received and how much we recieved. when it's administered we have to remember the "five rights" etc. etc.

usually for med errors, we just fill out an incident report.

[kids]

I am in WA.

In every LTC/SNF I have ever worked in med errors were put on a 72 hour alert (VS & assessment Q shift).

With med errors we didn't call it an error, we just documented the facts...on this date at this time the patient received this med. The assessment was focused on the presence (or absence) of any side efects or adverse reaction to the medication.

Because the exact same 72 hour alert system was used anytime a patient started a new med or had a dose change on an existing med the only way to know an error had occured was to cross reference the med documented in the notes to the physicians orders.

[southern_rn_brat]

I am in WA.

In every LTC/SNF I have ever worked in med errors were put on a 72 hour alert (VS & assessment Q shift).

With med errors we didn't call it an error, we just documented the facts...on this date at this time the patient received this med. The assessment was focused on the presence (or absence) of any side efects or adverse reaction to the medication.

Because the exact same 72 hour alert system was used anytime a patient started a new med or had a dose change on an existing med the only way to know an error had occured was to cross reference the med documented in the notes to the physicians orders.

That's the way I have always done it too. Thanks for all your replies guys!