Didn't follow through and caused med error

jadelpn, LPN, EMT-B · May 18, 2015

The lesson in this is that if someone is ordering and then administering a medication, THEY need obtain said medication, and chart accordingly. Do not ever pull a med for anyone that you are not going to administer yourself. Period. And said doctor can also write said order himself. There is no need for a verbal with the MD right there.

And how I would present myself in the meeting in 5 days is that you have been counseled on 2 occasions, with a plan in place. You have worked on and are working on goal achievement in both cases. That you were presented with an MD who gave you a verbal, and then chose to administer the medication themselves, after directing you to pull the medication. (and over ride which is ANOTHER no-no with narcs in a lot of facilities).

Then you were asked to document on all of this, which you did not complete. (Which I would also question why the person who witnessed your over ride did not question this whole process--and directed you to document/what the policy is accordingly. That nurse I would think would have known better, and I believe you mentioned this was your charge nurse, who again, should have taken this on--it is really convoluted at best). And I also am curious as to why when the nurse who was covering your break did not see in said med dispenser machine that the med had just been given.....or at least pulled...as well as why a "stat" med was not given after what at least 1/2 hour? There needs to be some responsibility for due diligence if someone is giving a stat narcotic not very stat....if that makes sense, as you are lunching. It just doesn't make sense. And it should have been questioned.

If the expectation is that a nurse take over your patients for your lunch, and you want them to administer your meds, you need to catch them up on that aspect effectively. And I would also not really get into the practice of that. You have one half hour. THEN you can continue on your med pass. And I would also be interested in if the patient was assessed for pain prior to another dose of meds that were given "I just got this" or a pain scale that is in the realm of not needing say 2 mg of dilaudid, would have made a nurse take pause I would think--but the likelihood of that could be negotiable.

It is not your fault nor your issue that an MD who is on the unit can not access meds. In the future, any "weird" requests I would take directly to charge and seek assistance in carrying out/documenting accordingly. And I would ask in this meeting what SHOULD you have done in this instance for future reference. Because quite frankly, I am highly unclear on how you are taking the fall for a multi-nurse and MD request gone awry. Further, and this is another take-away, do not ever witness a med you are not going to watch be given, and don't ever witness a waste you don't see wasted. And any MD is out of their tree if they believe a nurse is going to allow some sort of "I threw away a vial" with narcs. Seriously?! Awesome! Not. And the same MD would have threw a NUTTY if you drew up the med in the med room and wasted accordingly with the charge RN, no?!

Just a weird combination of foolishness. And I am not sure I would want to continue to work there.....

If you are having difficulty adjusting to your role, then you need to get direction on how to make that better. Delegating is something that can be learned. I am sure as an LVN you were delegated to. Most LPN's figure that this is going to happen, so get some direction there. If LVN's or CNA's are not taking your direction, that is another thing entirely, that needs to be addressed by charge or your manager.

Let us know how it goes.

rainbowpumpkin · May 18, 2015

I don't think you're going to be fired. If they were going to fire you, they would do it today or tomorrow, not in 5 days. You're probably just going to have a meeting to discuss the issue and how to prevent it in the future, or you may be disciplined - but I don't think this is a death sentence for you. It happens. Think of ways to avoid this in the future, as have been discussed on this thread, and bring those up to your supervisor.

FloatRN19 · May 18, 2015

I skimmed for the most part but one thing I didnt see(skimmed) was next time you're forced to take lunch, make sure to tell them the last time each patient got something prn. If it would be easier keep a small square of paper in your pocket, room med and time on it. Just ads another level of security.

CCRN2BE · May 18, 2015

Why would you not chart that another nurse reported to you that a med was given? Do you just leave that charting action blank? Or do you disregard that you were told the med was already given and give it again?

I will not accept responsibility for charting the administration of a medication given by anyone other than myself. Yes, I would leave it blank and I would find the person who actually gave the medication and make sure they understand it is THEIR responsibility to chart a med that they have given, not report it to me so that I'll chart it for them.

MunoRN, RN · May 18, 2015

I will not accept responsibility for charting the administration of a medication given by anyone other than myself. Yes, I would leave it blank and I would find the person who actually gave the medication and make sure they understand it is THEIR responsibility to chart a med that they have given, not report it to me so that I'll chart it for them.

You're not charting that you gave the medication, you're charting that it was reported to you the medication was given, that's all you're taking "responsibility" for. Knowing that a nurse reported to you it was given and intentionally not making a record of that seems reckless and creates an unnecessary potential for harm to the patient.

Let's say for instance that just prior to shift change, the MD orders an additional dose of coreg be given to a patient now, which they give. Since it's also shift change for the pharmacist it may well be another two hours before there is an available charting action for it. Are you saying you would demand that the nurse stay an extra two hours just waiting to chart to that?

CCRN2BE · May 18, 2015

The lesson in this is that if someone is ordering and then administering a medication, THEY need obtain said medication, and chart accordingly. Do not ever pull a med for anyone that you are not going to administer yourself. Period. And said doctor can also write said order himself. There is no need for a verbal with the MD right there.

Exactly. I think most of us will find ourselves put in uncomfortable positions by physicians or colleagues wanting us to cut corners such as documenting on their behalf, as they may be busy or are in a rush. Some find it difficult to say no when asked to do something like this, but remember that "I did it because I was asked to, even though I knew it was wrong " is a lousy defense in a courtroom.

We need to grow backbones and stand up for ourselves and our practice when pushed into these corners. Many of these "silly or time-consuming" rules are in place for a reason and when they are not followed is when SENTINEL EVENTS happen.

CCRN2BE · May 18, 2015

You're not charting that you gave the medication, you're charting that it was reported to you the medication was given, that's all you're taking "responsibility" for. Knowing that a nurse reported to you it was given and intentionally not making a record of that seems reckless and creates an unnecessary potential for harm to the patient.
Let's say for instance that just prior to shift change, the MD orders an additional dose of coreg be given to a patient now, which they give. Since it's also shift change for the pharmacist it may well be another two hours before there is an available charting action for it. Are you saying you would demand that the nurse stay an extra two hours just waiting to chart to that?

No, however I would not chart on behalf of that nurse even in this situation. That's not the answer. If a now or stat Coreg dose is added and given to the patient, there is no excuse for it to take 2 hrs for it to show on MAR to be able to be charted, shift change or not. Shift change does not = everything happening grinds to a halt; everything doesn't always fit neatly into preset shift hours.

If that's what is happening (2 hr wait), then there may be some severe deficits in policy and procedure that need reviewed.

MunoRN, RN · May 18, 2015

No, however I would not chart on behalf of that nurse even in this situation. That's not the answer. If a now or stat Coreg dose is added and given to the patient, there is no excuse for it to take 2 hrs for it to show on MAR to be able to be charted, shift change or not. Shift change does not = everything happening grinds to a halt; everything doesn't always fit neatly into preset shift hours.
If that's what is happening (2 hr wait), then there may be some severe deficits in policy and procedure that need reviewed.

Shift change and report does actually mean that report should not be interrupted by non-urgent issues, uninterrupted hand-off communication is an essential part of patient safety, even for pharmacists. Adverse events including patient deaths have occurred due to unnecessary interruptions of pharmacists.

The potential for harm to the patient here is that by knowingly leaving it uncharted you are leaving open the potential for the patient to receive a double dose, a risk you are allowing without any offsetting risk related to ensuring that the chart accurately reflects what was given.

imintrouble, BSN, RN · May 18, 2015

I usually check the last administration time that pops up on pyxis, when removing PRN meds.

Some of my colleagues are notorious for not signing off PRNs in a timely manner. It's just an extra level of safety I do.

Pyxis tells me the last time a drug was removed. I can even investigate further and find out who removed it.

Don't all Pyxis machines provide that option?

Karou · May 18, 2015

No, however I would not chart on behalf of that nurse even in this situation. That's not the answer. If a now or stat Coreg dose is added and given to the patient, there is no excuse for it to take 2 hrs for it to show on MAR to be able to be charted, shift change or not. Shift change does not = everything happening grinds to a halt; everything doesn't always fit neatly into preset shift hours.
If that's what is happening (2 hr wait), then there may be some severe deficits in policy and procedure that need reviewed.

Would you feel comfortable charting it as given by someone else (we have an option for "given by other"), and adding a comment/note like this, "given at blab blah time as per off going RN, insert name" ? Or what about even leaving the MAR charting blank but putting in a nurses note saying that at shift change during report the off going RN stated they gave whatever medication as ordered.

My concern would be that if the patient had some kind of negative outcome and when reviewing the charting, you get asked why you didn't give the uncharted medication. It would be your word against the off going nurse if she claimed that she didn't give it and that you were supposed to.

Anytime I have something funky like that come up, I will put in a nurses note right after report stating what I was told in report by the previous RN.

kbird03 · May 20, 2015

I feel so bad this happened to you as it could happen to many. As you are a new RN, I know that it can be difficult just knowing what we are allowed to do and not do can be overwhelming. There are certain working environments when we are new that we don't know what the norm is and what isn't. This could be an excellent learning opportunity and policy changing event. First off the doctor who doesn't have access to the pyxis and MAR, shouldn't be giving medications, but as we all know many environments allow for that and that should be addressed. Fast and hard rules should be in place. I know 14 years ago when I was a new nurse on a med/surg. floor we only had paper charting, doctors would have us override in the pyxis many times so that they could get lidocaine, etc. what ever they wanted and we just did it and it was never even charted on. I did because I was told by the doctor to do it and it was meds. that nurses weren't allowed to even give on the floor. Nothing ever came of this, but had there been an event it would have been my name pulling out these meds. and no where documented given not given. It sounds like your process and system need to be addressed and fixed. There should be teaching for all that was involved in this incident, as you are not the only one at fault. In this case fast and hard rules should be implemented. Hard and fast rules are like when we hang blood in no way do we do it without another RN just not going to happen as we all know the weight of this rule that we could actually kill the patient if we don't follow this hard and fast protocol. The problem is trying to implement protocol and hard and fast rules if it isn't life or death, this is where we so busy we don't have time to always follow what we know we should. Hard and fast rule would be like if you pull out of pyxis you have to give it no matter what no exceptions. Yeah, try telling that to a doctor who is rushing to relieve pain, not always realistic, or we have meds. pulled not unwrapped but someone else gives them and charts them no big deal and why should I have to put them all back, so she can pull them again what a wast of time. In a perfect world there would be no verbal orders and we would all scan all meds given prior to giving. Unfortunately, real world hospital situations call for us to break rules and processes and that is what leads to problems. Another fast and hard rule anything STAT has to be given by the nurse taking care of that patient and not a covering RN no exceptions. This is also a hard rule to enforce because STAT these days is an order so often really what does it mean. Our hospital STAT is 15 minutes no more, ASAP 30 minutes no more, Routine within 2 hours. No one really follows that because how often is anyone really timing anything, or looking at their watch. If the rule was ordered STAT that nurse in charge of that patient should be the only one to carry it out, that is hard because we all need a break at some point where does it end? I would even go as far as any order STAT must be addressed as to why not given and only by the nurse who was in charge of that patient at the time it was ordered STAT. In other words, I'm assigned to this patient during 7-3p.m. STAT ordered at 3p.m. I have to address it by carrying the order out and completing charting, or some other plan etc. The only exception would be that STAT order could only be carried out by charge nurse once it was "confirmed" with the patient's assigned nurse - end of story no exceptions. The problem with a rule like this who has time to chase the nurse who didn't chart. I saw Zofran ordered stat for a patient (it was ignored never charted on and the system still had it in red this was four days later). No one cares it was only

Zofran and it four days later. Just like when we hang blood there are some hard and fast rules that we just never break two RN verify this is just the way it is because if not done the patient will die! There is just a weight that hangs for certain nursing interventions that make us accountable. Just like medications I would never give a medication that someone else opened up or drew up and handed it to me. You know those fast and hard rules that you just don't break because it is part of the hospital environment and we all know better because it has been drilled in our heads. In this case sounds like I said your process and system is broken, and now you need to see that there are steps in place so that it doesn't happen again. Getting doctors to follow hard and safe is sometimes impossible, but us as nurses need to stick together and make sure they do or at least set up processes that help us cover our butts and ultimately keeps our patients safe. Also getting hard and fast rules to be followed is hard when it is only "Zofran" who cares if it wasn't charted on he not nauseous now, I'm not going chart on it that it was given by someone else even if the patient told me he got it. Sometime we are just too busy to call down to the ER nurse and find out did he get this did you forget to chart it etc. In this situation had you not been allowed to get medications, for the doctor it would have stopped there. Had STAT meant something to the covering nurse she would have questioned why it hadn't been given. If she wasn't allowed to carry out the STAT then she would had not done it. I know I am rambling but there are ways of fixing this, so that it doesn't happen. You being "new" may have been some of the reason, but hard and fast rules are made and need to be drilled in. Just like if there is in place narcotics ordered for the patient is only to be given by the nurse caring for the patient no exceptions that could have helped prevent this from happening too. That would be hard to follow because we have to go to lunch at some point and we can only give pain meds. when they are due and having 6 patients well you get the picture. This needs a hard and fast rule too. I had a sickle cell patient who was a frequent flyer and she had pain medications ordered q2h, other nurses would help out else the one who was assigned would have just drowned, so it is hard to implement fast and hard rules because there are so many situations that require a break down in safety. I hope your manager sees that because this is certainly a learning and changing policy moment, not just you were at fault.