Did I make a med error?

Nurseinprocess · Mar 16, 2018

Does not look like a med error to me, but I have never worked in an assisted living facility so I don't know how doctor's orders end up being acknowledged. If there is actually a computer system for giving meds, is there not also a computer system for the physician to input new orders? It looks to me that the nurse that you gave report to had some responsibility to ensure the new order was made active.

Crush · Mar 16, 2018

From what you wrote, it would seem you took the right steps. It does not sound like an error from what is written here.

Emilythenewgrad · Mar 16, 2018

No, we don't have anywhere for the physician to put in the orders. We have to fax them to the pharmacy and the pharmacy puts them in and we have to confirm they r correct. My concern Is that I didn't give the med at 5pm yet because I didn't see that the pharmacy had put it in the computer yet. I feel like the nurse for the next day shift should have followed up on this and looked for it.

Emilythenewgrad · Mar 16, 2018

From what you wrote, it would seem you took the right steps. It does not sound like an error from what is written here.

. That's what I was thinking too but my boss, DON is sending it into state as a med error. I just wanted more opinions before I tell my side.

blondy2061h, MSN, RN · Mar 16, 2018

What is your boss saying you did wrong?

Orion81RN · Mar 16, 2018

No, we don't have anywhere for the physician to put in the orders. We have to fax them to the pharmacy and the pharmacy puts them in and we have to confirm they r correct. My concern Is that I didn't give the med at 5pm yet because I didn't see that the pharmacy had put it in the computer yet. I feel like the nurse for the next day shift should have followed up on this and looked for it.

Hmmm. If the new order was for the 2nd dose to be given at 5pm, I would have given it even if pharmacy was not caught up on entering it. You received the order, so its ok to give. I'm thinking that was the problem.

I then would have documented that I gave the 5pm dose per md order.

Orion81RN · Mar 16, 2018

This makes me greatful we always put in our own orders. I wouldn't trust anyone but prescriber and myself to enter an order (in SNF anyway.)

Emilythenewgrad · Mar 16, 2018

Hmmm. If the new order was for the 2nd dose to be given at 5pm, I would have given it even if pharmacy was not caught up on entering it. You received the order, so its ok to give. I'm thinking that was the problem.
I then would have documented that I gave the 5pm dose per md order.

Ok, this makes sense. But would I be to blame for the resident not getting that dose all week?

Crush · Mar 16, 2018

Hmmm. If the new order was for the 2nd dose to be given at 5pm, I would have given it even if pharmacy was not caught up on entering it. You received the order, so its ok to give. I'm thinking that was the problem.
I then would have documented that I gave the 5pm dose per md order.

Ok so a specific time was not in the origional post. That may be what the issue is then. Although I am not familiar with Assisted Living policies. Agree with Orion81RN, I would have also given, documented, etc.

MunoRN, RN · Mar 16, 2018

If what you describe is how the process is supposed to work then it would appear the ball was dropped by the pharmacy, but it also sounds like it's a bad process which is to blame if that's how it's actually supposed to work. Just to be clear, you use an eMAR, but to make changes to eMAR you write it down and fax that written change to an outside pharmacy which is then supposed to update the eMAR? That sounds extremely problematic. The changes should be made to the eMAR directly, so that even if the outside pharmacy drops the ball, the order change has at least been properly documented within the system that is being used.

Emilythenewgrad · Mar 16, 2018

If what you describe is how the process is supposed to work then it would appear the ball was dropped by the pharmacy, but it also sounds like it's a bad process which is to blame if that's how it's actually supposed to work. Just to be clear, you use an eMAR, but to make changes to eMAR you write it down and fax that written change to an outside pharmacy which is then supposed to update the eMAR? That sounds extremely problematic. The changes should be made to the eMAR directly, so that even if the outside pharmacy drops the ball, the order change has at least been properly documented within the system that is being used.

How should I continue from here? I know it wasn't a major error but how do I continue from here?