Do you give meds without seeing the MDs order if he MAR has been checked?

[canadianRNeducator]

I am a new nursing instructor. I was never taught to always check every order for every med I give. I just told all my students that if they have a MAR with a med that is a reasonable dose, the patient doesn't have an allergy to it, all the seven rights are addressed, there seems to be an appropriate reason to give that med to the pt, all the assessment parameters are met and...... the MAR is signed be the previous RN to say they have checked it against the doctors order------------then it is ok to give that medication. I told them that if they have any concern about a med on the MAR to inspect further and start by looking at the doctors order. That said, if everything seems in order and the night nurse has signed off on the MAR then it is ok to give it.

Then, in the instructors meeting I was told in no uncertain terms it is basic nursing expectation to check the MD order for every medication, by the same nurse that gives the med. That does not ring true to me. In a world with 30 hours a day in it perhaps, but I have never seen anyone practice that way. why would we have the practice of checking MARs and signing that we checked them then if it is an expectation of the next nurse to go back to the doctors order anyways???

so, two questions.

Is it legally or standard of practice wise an expectation that the same nurse who gives a med must check each med on a MAR against the MD order before giving it themself?

Is it your practice to always check every med you give with the doctors order or do you administer meds based on a complete and RN checked MAR without looking at the MD order unless you have concerns?

Thanks for the feedback.

[bookwormom]

I have students give the meds after checking the MAR, unless it is an unusual order or a narcotic.

[grandmawrinkle]

I don't think anybody does this or it is even reasonable.

Our eMARs are signed off by the pharmacist, then the administering RN. After that, the next shift signs it off as well, so it essentially a double-check. After that, nobody looks at the original order.

So for patients on 30 different meds that have been there for 3 weeks you are supposed to go back and look up every original order? That's nuts. Nobody would ever get any work done.

[drmorton2b]

When in doubt check the original order.

[BarryGrad RN]

I agree with grandmawrinkle.

It is unrealistic that you will go back and check the chart for every order of every medication. That is the reason hospitals have protocols for verifying the medication/

What I think is most important to teach your student is why the patient is in the hospital NOW and why they are giving the medication.

From my experience, I have noticed that patients that have stayed 20+ days in the hospital the story of what has happened to them gets lost and is usually incorrect. I think its actually more important to read some of the consults from the beginning of the admission to see what has happened to your patient.

For example, I just had patient transferred to me from ICU, who had been in the hospital for 20+ days. I really didn't get a background story on what has happened to her and why her surgery was on hold. I then looked back at her originally admit notes from the ED, and noticed that this patient had no past medical hx or surgery's. She had came in with the chief complain of syncope and sob, ended up being in afib, placed on heparin drip, went into HITT and had pneumonia, went into septic shock, came back, extubated, and transferred to my unit. The previous nurse didn't know why she wasn't on any Lovenox, or heparin drip since she was running constantly in afib. All it took was reading a couple consults and progress notes, and I knew the whole story of the patient and I understood why she wasn't reicieving any Lovenox, and needed clearance from neuro and cardio for a lap choly.

[wee_oneRN]

I work in NICU so we are very careful with our meds, but we don't check the MD order each time we give a med.

Our charts are thinned frequently, so we don't always have the original order on hand to check the meds with. Our procedure: new orders are checked against the neofax/drug book and faxed to pharmacy. Then, written on the MAR and Kardex/SBAR.

Night RN checks the MARs against the kardex and initials. Then at each change of shift BOTH RN's must check the kardex against the MAR and initial. We must also review all MD orders over the last 12 hours and be sure they have been followed through with and documented (new med, x-ray, dietary).

While giving a med only the MAR is used but any questionable order would be followed back to the original order. Two RN's must sign for each med (with the exception of a few like multi-vitamins).

I don't think it is feasible to check every single drug against the MD order every single time. It would take hours to just find the original orders in some charts. It would be nice if more information was required on the MARs though (normal dose range, pt indication). It would be easier to spot errors.

[OttawaRPN]

Is it legally or standard of practice wise an expectation that the same nurse who gives a med must check each med on a MAR against the MD order before giving it themself?

Is it your practice to always check every med you give with the doctors order or do you administer meds based on a complete and RN checked MAR without looking at the MD order unless you have concerns?

Thanks for the feedback.

Certainly not a legal standard in Ontario. As others have stated, there is no time for that kind of nonsense. Although it would be a good idea for students to verify MARS with dr. orders to help expand their learning, same as looking up meds they are unfamiliar with. We can all remember - "never give a med you don't know." Students at my facility need a cosign for insulins and narcs, otherwise they're on their own.

New orders are transcribed by our ward clerk then the nurse verifies and signs - that is the two sigs. Any errors will come back to the nurse as she is accountable. Anything questionable OF COURSE has be followed up, as well as incomplete orders. MARS that are rewritten are double checked by nurses on two different shifts.

Sure mistakes have been known to happen, are we not human?

[BluegrassRN]

So what do the other instructors recommend you do when you no longer have paper charting?

Our docs enter orders directly into the EMAR system. The pharmacist verifies it, and it pops up in the EMAR. There is no order to verify...the EMAR is, in fact, the order.

Your fellow instructors are so far from reality, I'm curious as to what else they require of their student nurses? Sharpening needles after hours? Do they only allow unmarried women of good moral character into the program? Do their students also sweep the unit twice a day and take turns carrying in coal once a day to feed the furnace?

[KaroSnowQueen, RN]

...Then, in the instructors meeting I was told in no uncertain terms it is basic nursing expectation to check the MD order for every medication, by the same nurse that gives the med....... why would we have the practice of checking MARs and signing that we checked them then if it is an expectation of the next nurse to go back to the doctors order anyways?? ...Thanks for the feedback.

Excuse my terminology here, but ARE THEY HIGH???!!!!????? *wine:smokin:

WHO in the world would have actual time for that?

If you are checking for original orders for five (or eight!) patients, some of whom may have come from other facilities and/or been there for days and days and on other units previously, some of whom have physicians with excellent handwriting (HA! I can wish, can't I) and many more whose physicians scribble out things like a chicken with its head on fire, even an experienced nurse would end up wasting precious HOURS of time looking this stuff up.

It is NOT and CANNOT be, even in their white ivory tower world, "basic nursing expectation to check the MD order for every medication, by the same nurse that gives the med......." No one does it, no one can do it, and they are just not using their heads for anything besides a hat rack in this case.

Your colleagues need to get a grip and enter the 21st century. :welcome:

[Asystole RN]

At my facility it is standard practice to check each NEW medication order to the Nurse against the written order. Since our MARs are actually hand written we make photocopies of every new order and keep in the MAR for 1 week.

Seems crazy but last Thursday night a Nurse new to a particular patient checked the written order compared to the MAR and found a huge med error. Not only did the noting RN mistranscribe the med but so did the pharmacist and the med was given for 4 days.

Order 125mcg, given 12.5mcg

oops

Remember...pharm techs are dispensing the meds, not pharmacists.

Teaching students to check the order is a good practice IMHO. Will they always do it on the floor, no? They must first learn the rules before they will understand what rules can be bent and what rules can be totally broken.

[BluegrassRN]

But surely not EVERY order? You would never ever get anything else done!

[DustaRN]

I always check the mar with the med rec form that is signed by the physician before as part of my morning chart checks before giving meds. if the med rec form is not signed then yes, I look at the individual orders for each med. not checking can cause accidents, the pharmacy does make mistakes and ultimately it is your job to know what the patient is getting.