Disciplined for med error, but I did nothing wrong

[Nurse Beth, MSN]

Dear Nurse Beth,

Hello, I have written to you in the past and have been enlightened and have also been able to enlighten my managers.

Scenario

I'm working in a nursing home. There is a resident on Zoloft 10mg daily. On September's recap, which is all still done manually, a nurse wrote duplicate on the MAR when there was not a duplicate. The med was not given or signed out for all of September because it said duplicate on the order. Resident had no adverse reactions, his behavior was normal for him. I work on a Dementia unit.

So at the end of September, the nurse doing recaps could not find the recap for September, it had been put in August (which is the one that said duplicate) She eventually found it and questioned the duplicate as she did not see a duplicate order.

There is no consistency on this med cart the nurse who would normally be on there has been out since January. There have been at least 12 different nurses probably more on that cart in the month of September and none of us picked up on the order not being a duplicate. The administrator (who is not a nurse) wants to give everyone who was on that cart for the month, on every shift of September a med error for not giving a med that was yellowed out and said duplicate.

I do not have a problem admitting an error if I make one, but I do not believe that this is an error on med nurse. I believe it is an error on the nurse doing recaps. Please help all of my co workers are waiting for a response.

---

Dear Not my Error,

Recaps are done monthly in LTC to review the new MARS against the physician's orders to ensure accuracy before the start of the next month.

In your case, a medication error of omission was made every day for one month but was caused by one nurse.

I would ask the administrator who is charging you with a med error exactly what it was you were supposed to do differently, because you'd like to understand your mistake and change your nursing practice accordingly. In other words, if you see an order marked out as "Duplicate" on the MAR, is it your responsibility to double-check the double-checker (nurse who completed the monthly recap)?

Following that logic, are you also supposed to double-check every order on the MAR?

Pull your facility's policy/procedure on medication administration to be sure of your facts.

If you and I are correct, the administrator will not have a policy-based answer showing that you missed a step. The step that does seem to be missing is a root cause analysis. Root cause analysis is an important step towards preventing future errors.

Best wishes,

Nurse Beth

Author, "Your Last Nursing Class: How to Land Your First Nursing Job"...and your next!

[chare]

1 hour ago, Nurse Beth said:

[...]

...In other words, if you see an order marked out as "Duplicate" on the MAR, is it your responsibility to double check the double-checker (nurse who completed the monthly recap)?

[...]

The entry had been highlighted as duplicate. If this were in fact a duplicate entry on the MAR there should have been an active order listed as well. As there apparently wasn't this should have prompted further investigation.

I do agree that this is clearly a system error and find it rather extreme that the administrator wants to write up every nurse that had been on the med cart

[JKL33]

4 minutes ago, chare said:

If this were in fact a duplicate entry on the MAR there should have been an active order listed as well.

Yes. A (relatively) easy process change for the future. When there is a yellowed-out duplicate take a second to make sure that medication is listed elsewhere on the MAR. That is way less a problem than a med that hasn't been transcribed at all, for instance.

I could go either way on this one, and my decision would depend on extraneous factors (personalities, culture, time constraints, staffing, etc). Depending on these I might decide to take my lumps this time around, or conversely, decide that it might also be appropriate to beg the question whether you are supposed to always double check the double-checkers. Because there is definitely no time for that, and they are have made someone responsible for the recap for a reason.