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?
According to nursing standards, YES, you are supposed to check the chart for medication orders each shift to make sure that the MAR is correct.
Does this happen every time, everywhere? Absolutely not.
Is it the correct procedure? Absolutely. When you write on the chart that you have done a chart check (whether an entire check or for meds only), you are stating that you have checked the MAR against the entire chart.
I've never heard of this, what "nursing standards" are you referring to? The only universal standard I am aware of is that the RN double check orders once entered against the original order (defined as a "standard" by my state's NPA). Many facilities go beyond that with a double check of the previous shifts new orders with the oncoming RN, or a 24 hour chart check, but I've never heard of re-checking each med order going back through every order for that admission.
I am amazed...20 years ago, we would have 10-12 patients a piece on a med-surg unit without a CNA. It was expected that we check the MAR with the Kardex-after checking the Kardex with the chart. Moving on, 10 years ago on step down unit with 5 patients we did the same thing. Same thing now in a teaching hospital with electronic charts and MARS. Without checking, you are basically relying on the people that worked before you to not make a mistake...are you willing to bet your license that they didn't???
In my hospital when a new order is written or a new patient is admitted, the unit clerk scans orders to the pharmacy, puts orders in the computer for labs, diet, activity.etc. and then the chart is given to the charge nurse. The charge nurse then looks at these orders, checks them against what the pharmacy has profiled on the emar and what the unit clerk has entered in the computer and if everything checks out will note them electronically and on the paper chart. The floor nurse will then see a new order pop up on the emar and should also get a copy of the written order in the box(each pt has a slot in the med room to place copies of new ordres). The floor nurse can see if this order has been noted or not. If it is a med that needs to be given urgently the floor nurse(RN) can go ahead and note it(after checking the original order) and give the med. The night shift nurses do 24hr chart checks. They only go back 24 hours, it would not be feasible to go back through the entire chart,they are checking the paper chart with the electronic chart. Now, even with all of these safeguards mistakes can and do happen. As nurses, we need to use our common sense and our critical thinking skills as they pertain to our patients. When teaching students, I believe you have to teach them the old tried and true way and when they are orienting on their first nursing job they will be taught by their preceptor the policies of the hospital and the fastest and most effecient way of doing medication administration. Hopefully, they get a preceptor who cares enough to actually show them how to do it right with the patient's well being in mind.
We also have the 3rd Shift Nurse doing 24 hour chart checks, she is the one who looks at all new orders, compares them to the Dr's orders and checks that they are entered correctly onto the MAR. During shift report we are told of any new orders taken since chart check, we confirm they are on the MAR, and if unexpected we check against the Dr's order (this rarely happens). If I run into a drug I have never seen (or the dosage seems strange) before, I check against Dr's order and look the med up in the latest Drug Book. I have between 20 and 30 patients (depending on the unit I'm working on) to check each med against Dr's orders would take longer than my 8 hour shift.
The entire idea of manually checking orders, counting on the doctors to update and sign MAR's when any patient may be seeing 3 or more doctors is an accident waiting to happen and conveniently puts the entire burden on the already overburdended RN. This may be okay for a 30 year old that had a TAH but it just doesn't work for high accuity patients with 3-5 pages of meds.
The real answer is the emerging closed loop medication systems. Doctor orders med via CPOE which has intelligent decision support, feeds directly to pharmacy and the pyxis, mar is electronic E-MAR and patient identifier is scanned before administering med. Protects everyone and helps you to focus on patient care.
Speaking as a new nurse just out of school, every time we gave a med we had to check the original doctors order against the MAR. Thats how I was taught and I thought that was just practice everywhere. I was just hired as a nurse and was wondering how I would find time to do this for each med for each patient.
Speaking as a new nurse just out of school, every time we gave a med we had to check the original doctors order against the MAR. Thats how I was taught and I thought that was just practice everywhere. I was just hired as a nurse and was wondering how I would find time to do this for each med for each patient.
In an ideal world that would be the thing to do. However time does not permit this. Being a new nurse is terrifying. The trick to nursing is being self confident enough to be comfortable with your decisions, but not overly confident which can lead to mistakes.
... 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?
Thanks for the nursing history lesson, BG. Very funny!
I worked as the only RN for 27 beds, and part of my night job was to go through every chart, compare it to the orders, correct anything not right, and sign off on it.....for patients with no additional orders, that was the only check against the orders for the day. Of course, new orders were dealt with on her shift- but I went over those again the next night. I never checked orders with every med pass...that would take forever.
Common sense is going out the window with the paranoia that seems so pervasive. IDK.... just seems like too much duplicate work.
I worked as the only RN for 27 beds, and part of my night job was to go through every chart, compare it to the orders, correct anything not right, and sign off on it.....for patients with no additional orders, that was the only check against the orders for the day. Of course, new orders were dealt with on her shift- but I went over those again the next night. I never checked orders with every med pass...that would take forever.
Common sense is going out the window with the paranoia that seems so pervasive. IDK.... just seems like too much duplicate work.
ditto to the above, it would be wonderful to practice the ideal nursing we learned in school, but this is the gritty real world. Also much of Nursing School was a teaching experience. Checking a new order against the MAR is something you should know about. I check if the order seems wonky to me.
MunoRN, RN
8,058 Posts
I've never heard of this, what "nursing standards" are you referring to? The only universal standard I am aware of is that the RN double check orders once entered against the original order (defined as a "standard" by my state's NPA). Many facilities go beyond that with a double check of the previous shifts new orders with the oncoming RN, or a 24 hour chart check, but I've never heard of re-checking each med order going back through every order for that admission.