Did I make a med error?

Nurseinprocess · Mar 17, 2018

I don't understand why your boss told you that they were sending/or reporting this med error to the State. What is that supposed to mean? Is that something you have to be afraid of working in an assisted living? I could see a report going in your file, maybe, but unless you have a pile of them why would it be reported to anyone outside your facility? I don't understand how the patient missed the second dose the next few days. Did the new order never get seen by anyone but you?

TriciaJ, RN · Mar 17, 2018

When you next talk with your DON about this, try to resist being defensive. Tell her you take med errors seriously and being conscientious is important to you. Ask her what you specifically should have done differently that would have led to this medication being appropriately administered subsequent to your shift. If there is a step you missed, this will be a learning experience. She will likely acknowledge that it is really a systems error and maybe the system can be modified for additional safety.

Typically the BON does not care about mundane med errors. They have bigger fish to fry. There might be some legal requirement for ALFs to report all med errors but unlikely that you would have a compromised license because of it.

RNJenn47201 · Mar 17, 2018

When you next talk with your DON about this, try to resist being defensive. Tell her you take med errors seriously and being conscientious is important to you. Ask her what you specifically should have done differently that would have led to this medication being appropriately administered subsequent to your shift. If there is a step you missed, this will be a learning experience. She will likely acknowledge that it is really a systems error and maybe the system can be modified for additional safety.

In addition to this, since you are in ALF/SNF you may want to change the time of the second dose of Lasix to earlier than 5pm. If these elderly folks are up urinating all night, it's a pretty big fall risk. If you bring this up to your boss, they may appreciate you looking out for the resident's and may take what is mostly a documentation error a little lighter.

Mavrick, BSN, RN · Mar 17, 2018

When does a med order become "official"? When you hear it over the phone and write it down, when you fax it to the Dr. office, when you receive the signed fax, when you fax it to the pharmacy, when pharmacy signs off on it and enters it into the eMar??

If the process of your hearing the order to pharmacy entering it into the eMar takes several hours or even days, when does the order become active? You can't be expected to follow an order that isn't active. Administering a medication without an order is outside your scope of practice and a nursing board would be very interested in a facility that expects you to do that.

Jedrnurse, BSN, RN · Mar 17, 2018

Does your facility have multiple nursing coverage shifts? "Back in the day" we used to do 24 hr checks on the orders, i.e. night shift would double check and co-sign any orders that were written during the day. I realize that having the pharmacy enter orders into your MAR might negate some of the benefits of this, but still, having another set of eyes check up on orders might help...

Orion81RN · Mar 17, 2018

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

No way

Orion81RN · Mar 17, 2018

Ideally you would follow the process that already exists for error reduction and improvement, and identify the problem (neither the physician nor the nurse are keeping the eMAR up to date) and propose a solution (physicians and nurses change the orders in the eMAR directly).
If there is no established process where you work for identifying and solving these problems then you would need to start with advocating for such a system.

And do it in a non-defensive way. Don't burn bridges. Lord knows I have, and it sucks when it comes back to bite you, such as when needing references for your next job.

caliotter3 · Mar 17, 2018

Does your facility have multiple nursing coverage shifts? "Back in the day" we used to do 24 hr checks on the orders, i.e. night shift would double check and co-sign any orders that were written during the day. I realize that having the pharmacy enter orders into your MAR might negate some of the benefits of this, but still, having another set of eyes check up on orders might help...

Distinctly remember the house supervisor on night shift doing these checks in one of the facilities where I worked. She kept on top of this and mistakes were rare.

Julius Seizure · Mar 17, 2018

I don't understand why your boss told you that they were sending/or reporting this med error to the State. What is that supposed to mean?

I wondered this too. Reporting the error, the facility, or reporting YOU?

And report to who exactly...to "the state"? Do they mean the Board of Nursing? The Centers for Medicare & Medicaid Services (CMS)? The Department of Health? The governor him/herself?

Being reported to some vague entity called "the state" strikes me as a scare tactic when no more specific information is given.

Emilythenewgrad · Mar 17, 2018

I don't understand why your boss told you that they were sending/or reporting this med error to the State. What is that supposed to mean? Is that something you have to be afraid of working in an assisted living? I could see a report going in your file, maybe, but unless you have a pile of them why would it be reported to anyone outside your facility? I don't understand how the patient missed the second dose the next few days. Did the new order never get seen by anyone but you?

It should have been seen by the other nurses. I had it documented, told them in report, put a messsage out to everyone. So that part I have no idea.

Guest1030015 · Mar 17, 2018

All nurses make medication errors at some point; the ones who say they haven't are either being dishonest, aren't self-reflective, or simply have never recognized their errors. We are human beings, and we make mistakes. The other day I had a nurse tell me that in her 30 years of nursing, she has never made a med error. When I was rounding on her patient later, I noticed that she had hung a bag of Zosyn and left the secondary line clamped. My guess is that she wouldn't consider that to be a medication error.

If I were you, I would tell your DON that you feel that this incident highlights process issues that make medication administration unsafe for your residents. Explain that you are upset about what happened, and want to prevent it from happening again at a facility level... for patient safety. Offer to work with her directly or form a committee to address these issues. Have this conversation in person, and then follow up by e-mail or in writing.

In the meanwhile, I would find a new job. Whether you made a mistake or not, there are clearly large process issues involved in this situation, and it seems like your administrators would rather finger-point than work to improve the process so that it won't happen again to other patients. Taking your post at face value and assuming that there aren't other circumstances involved, reporting a nurse to the state for this seems fairly unconscionable. You aren't diverting, practicing impaired, nor did you do something grossly negligent.

angeloublue22, BSN, RN · Mar 18, 2018

First of all, if the process you explained was followed then I don't see how this is a med error on your part. I agree with Emilythenewgrad. The process has too many steps and there are too many places for the process to get messed up. Nurses should be able to change the MAR as the order changes, not just rely on someone else to do it, but you have no choice. Second, since when are simple med errors sent to state? I thought they were supposed to be considered teaching moments and used for quality improvement. The error should show your DON that the process needs to be improved.