Explain test question, please

NICU_Nurse, BSN, RN · Sep 30, 2003

Oops, I missed a couple of things!

Also:

Pharmacy is extremely busy. You may have 1-10+ patients, but they have hundreds. You cannot rely on pharmacy!!! It is your responsibility to fax down orders and ensure that they receive them so that your patient can get the med in the first place; if the fax machine isn't working or they're busy and don't see the fax, or whatever, you need to call them and let them know that you're sending something/sent something and that you're waiting, or ask them how long it will be, or, if the fax is broken (or whatever system you use), you need to tube down a hard copy or bring it to them first-person or WHATEVER you need to do to get that order to them. If your patient doesn't get their med, it's *your* responsibility, not pharmacy's. If, for some reason, pharmacy is not sending you what you need and you've gone out of your way to make sure that they're aware of the need, then that is the time to be whipping out an incident report and filing against them. Trust me, start filling those out and stuff gets done lickety-split. Well, since it's your responsibility to ensure that the meds are ON the MAR in the first place, then it makes sense that it is *also* your responsibility to make sure that d/c'd or expired meds or dose/frequency/form changes are noted appropriately as well. I know that some of you guys are students- prepare yourselves. Pharmacy is wonderful sometimes. Sometimes they are not, and that is putting it lightly! If pharmacy doesn't get your fax saying that, say, the Dopamine drip was d/c'd, well, they will continue to make that drip and charge the patient for it and send it to the unit, and they'll just collect in a big 'ole pile until you come along and take care of it.

Also, as for what Colleen mentioned, as far as I'm aware, the original script should be in the chart under Doctor's Orders. If the chart has been thinned (ie, in LTC where a resident may live in-unit for long periods of time, or a chronic patient like our babies in the NICU, an order update or clarification should be written before they take out all of those old orders and send them down to medical records). Somewhere in that chart, there will be SOMETHING with the original orders on them; whether they're neat and easy to find depends on the MD and facility.

sonnynurse · Sep 30, 2003

The Law is the law and yes we are legally responsible for every medication given...but and here is the big BUT...whether I am working in an acute care setting with 6 patients or a long term setting with 20 patients...there is absolutely no way that I have time to sit down with my patient's chart and verify that the medication that is written on the MAR is correct. Having said that...being a nurse I have knowledge about medications and their actions and there purpose etc. So reasonably I should know many a thing over the medications being given to my patient..if I am at all unsure..I look it up either in the patients chart and/or the drug handbook and make sure that I am absoultely sure about the drug. ANother note I want to make is that we as nurses "should have" confidence in our fellow nurses and if the medication is signed off to be correct , (as in our facility the nurse initials the MAR after the secretary transcribes it... so we know officially checked the original order) then we "should have" reasonable assurance that it is. However, having said that, I must say that I have seen many medication errors due to transcribing errors by the secretary that was signed off by a nurse to be correct...and ultimately that nurse was held accountable for it, not the nurses giving it. But at another facility, I have also seen each and every nurse accountable for that error because they did not check it each and every time they came on shift. How can we..we wouldn't have time for our patients...Such a frustrating problem.

NICU_Nurse, BSN, RN · Sep 30, 2003

And finally, I'll give you an example, first-person...

When I first started in the NICU, we had a space on the flow sheet where all meds were written with the appropriate times. We were to circle the times and then initial next to them when the meds were given. We had MAR's, but they were for pharmacy use only- we did not sign off on the MAR's. The only thing we used them for was updating- if something was new or old, we made a note and sent it to pharmacy so they could update their records. *Our* record was the flow sheet.

One of my babies was getting Gentamicin q36. Apparantly, five days earlier, someone had mixed up the dates. When they filled out the meds and times on the new flow sheet that morning, they put the next day's date on there (ie, the 27th when it was really the 26th). This threw the dosing schedule completely off. No one caught it. Five or so days later, I had the baby. I checked back and noted when the med was last given, and saw that it wasn't due on my shift. So, no med given that night. A chart audit caught this mistake and guess who got written up? Me. Because I was the last person there, I was written up for not checking the accuracy of the dates (ie, starting with the original date the med was ordered and then counting forward). That baby missed a dose of med because of me. Not just because of me but it was my responsibility to catch that, and I didn't. Thank goodness it was only an antibiotic!

However, think of this: Sick babies have crappy drug metabolism. Their kidneys are fricked up, their output is horrible, the drugs stay in them much longer than they're "supposed" to work. If someone had put, say, the previous day's date on there, and I would have said, "Oh, look, it's due today!" when it was really not due for another 24 hours, I might have given that antibiotic. Sounds little, but for our babies, one extra full-strength dose of an antibiotic could mean a greater than toxic level in their bloodstream, all because of one little error.

The point of all this drawn out posting is that you have to be super-vigilant. Your patients are depending on it.

cannoli · Sep 30, 2003

That sounds like a systems problem to me and if you got written up the nurse that put the wrong date on it should have been written up also! Did you write her up if no else did? Wouldn't the computer generated MAR, if used, have the correct date on it?, which would have been verified by your checking.

NICU_Nurse, BSN, RN · Sep 30, 2003

Well, call me paranoid, but *I'm* not going to sit in court and say, "But your honor, I didn't have TIME to do that!" This is how I see it: I'm in court. Lawyer says, "Did you check the order?" and I say, "No, I was too busy and/or didn't have enough time and/or had too many patients."

Now *he* can reply with:

Is it part of your job description to verify all meds are correct before giving them?

Did you file an assignment-against-objection form because you had too many patients?

Did you accept that assignment and thus make yourself accountable for all your actions during that shift with all of those patients in the eyes of the law?

If you filled out an assignment-against-objection form and then took the assignment for that shift, does that form free you legally of all repurcussions that occur because of your negligence when administering medications?

And the answers are yes, maybe, yes, HELL NO.

Even when you complain formally (the form) you are still legally responsible for giving those meds in an accurate way. All the form will do in a court of law is prove that you KNEW that the assignment was overload, that you KNEW that you had too many patients, and that that STILL wasn't enough for you to go out of your way to verify those meds. I mean, you were aware that you were short on time, you took shortcuts, and your patient died as a result. Knowing those things should have made you MORE concerned about accuracy, not less, know what I mean?

NICU_Nurse, BSN, RN · Sep 30, 2003

I don't know if the other nurse('s) got written up; it was confidential. I know that *I* got written up.

I know that it was my fault. I trusted the other nurses. I made a mistake. Does that mean I wasn't majorly p.o'd at the other nurses? Of course not! I was livid! I was devastated. I was a brand new RN- that happened when I was only nursing for about two months!! But, a fact is a fact- it was my fault that I didn't do WHATEVER I HAD TO DO to make sure that that med was given on time on the correct day to that baby.

Which, of course, is why I'm extra careful now. You only need to be written up once, if you ask me, to prove how easy it is to make mistakes like that. Learn by example!! :)

EastCoast · Sep 30, 2003

I would love to hear someone with legal expertise figure this out. I would venture a guess that the blame would fall across the board if they did a thorough investigation. (i understand this is a 'test' question).

There was a case in Colorado where a newborn died b/c they got the wrong dose of pcn via the wrong route. The order was written by an NP. When a root cause analysis was done it was found that 57 people (yes 57) were involved in this error from the writing to the administration.

For anyone who checks every single med on the MAR against the original order (on a regular med/surg unit with a full patient load )I applaud your throughness but I honestly think it is unrealistic and I do not see how you can do this in an acute care setting with the volume of patients and meds one gives. It's nice to have the platform that one does that but do you really do this everyday on every patient for everymed?? this would amount to many many meds (figure 7-8 meds/6 patients).

At our facility when the medsheets were rewritten (Q 7 days) it was then the time the original order was checked against the MAR.

I think it is very very good that NICU has extra effort to assure med safety. However, the patient/nurse ratio is less than that on a regular med/surg unit. so it seems reasonable.

gina-kay · Sep 30, 2003

The Bar code med admin method takes the heat off in that way.

Orders are written in the computer, signed off by the RN and Pharm in the computer. Then given at bedside by swiping the patients ID wristband and the med package to verify accuracy. If you follow the system it is practically impossible to have a med error or for pharmacy to even send a med that is outdated. We have had this for over a year and I am not sure of the exact statistic, but I know med errors are about down to none.

cannoli · Sep 30, 2003

In units where the nurses have one or two patients they can do shift chart audits and checks. On the med-surg floor where the nurse has 7, 8, or more patients the policy may be different. It is not necessarily the policy to check meds against the order each shift, if it is policy one had better be doing it.

At one hospital, for instance, the 24 hours chart audits are done on the 11-7 shift. The preprinted MARs come from the pharmacy on 11-7 and are checked for accuracy by the 11-7 nurse. Days and evenings do not do a MAR check. New orders that come in on days/eves are hand written on the MAR.

Obviously, if one has a question about the order or the med, one goes to the source.

Any med error is serious but much more so in an infant, I can see where that type of policy would exist in an NICU but it doesn't necessarily exist elsewhere.

Brownms46 · Sep 30, 2003

I worked on a contract at a small hospital, and they would have two nurses check the new orders together, at the end/beginning of every shift. Siging off with two initials at the of each page of orders. This was helpful in making sure nothing was left off the kardex or the MARS. We would constantly find orders not appropriately signed off, errors in the way the order was transcribed, and orders that weren't transcribed.

But no matter what, the nurse who gives the med is the one responsible for the error. One of the first things I do when I arrive on a unit, is check orders, and I can't even begin to say how many times this has saved me. Or when I question an order, d/t pts dx or it's the first time the med is given, or it's an antibotic or short term med I always check and see what the order says.

You can't always check everything, but sometimes I get a major funny feeling, that tells me to check something out, and I have rarely been wrong about doing so! JMO

NICU_Nurse, BSN, RN · Sep 30, 2003

I want to clarify that my only experience has been in NICU's. :) That's *our* policy; I can't speak for other units.

EastCoast, when you said the med sheets were rewritten q7, what does that mean? What was the med sheet- is that like a MAR, or what you use instead of an MAR?

tonchitoRN · Sep 30, 2003

gina-kay - don't forget the basic principal of computers: gigo. garbage in garbage out. if it is put into the computer wrong there is still a chance for an error.