1. Forgotten to sign off (chart as given in computer charting system) a medication given?
2. Followed another nurse that had forgotten to sign off (chart as given in computer charting system) a medication?
3. Followed a nurse to failed to sign off (chart as given in computer charting system) any medications for that day?
4. Forgotten to sign off (chart as given in computer charting system) a narcotic PRN medication?
I have and am wondering if this is as common as I think it is. Would be great if it would automatically record it when pulled from dispenser...any other ideas?
Specializes in LTC, assisted living, med-surg, psych.
Yep, guilty on all counts. And what systems? I've never worked anywhere there was a Pyxis or other supposedly foolproof medication system.........we still do things the old-fashioned way. Thank goodness! I'd hate to plug my personal information into a machine every time I give a med, then have to scan my patients as though they were items from the supermarket.
Re giving meds, I'll be the first to admit I'm not perfect.........I don't make very many mistakes because I'm thorough and careful, but I figure that anyone who claims they've never made any sort of med error is either fresh out of school or lying.
Yep, guilty on all counts. And what systems? I've never worked anywhere there was a Pyxis or other supposedly foolproof medication system.........we still do things the old-fashioned way. Thank goodness! I'd hate to plug my personal information into a machine every time I give a med, then have to scan my patients as though they were items from the supermarket.
Re giving meds, I'll be the first to admit I'm not perfect.........I don't make very many mistakes because I'm thorough and careful, but I figure that anyone who claims they've never made any sort of med error is either fresh out of school or lying.
I don't like the scanner method. It is a pain. There is always someone on isolation, so the cart can't go in their rooms. Then we have to make a print out of the pt's arm band code to scan that instead. And we STILL have to chart by hand the time we gave the prn and for what reason, even though that is ALREADY documented in the pyxis system.
ITA about whoever says they never made a mistake are either a new nurse, or they are lying!
they told her they could charge her with diversion.....which is kinda funny if you knew her.......whether they actually could make it stick, who knows,and who wants to find out.......additionally, as some one else mentioned, i think in this thread, a diverter is going to have THE best charting, lol....of course until their disease process gets far advanced i suppose......
i really wish you had security come up and dump that damn sharps container.....it would have been so much simpler....ah 20/20 hindsight
Management refused to get sharps container or look in it or anything;I wish I would have known who to turn to above them to look out for my rights. Extremely odd and suspicious that they didn't want to find out the truth....IMHO
I consider myself to be pretty thorough and don't make many errors to my knowledge...however, with the computer charting system at the hospital I worked at always being down and the computers most of the time not being readily available when you need them at the time you give your medication I am certain there have been more than a few times I didn't chart off prns. Inadvertently of cours. Then again if we realized we forget we would go back and sign it off...
I consider myself to be pretty thorough and don't make many errors to my knowledge...however, with the computer charting system at the hospital I worked at always being down and the computers most of the time not being readily available when you need them at the time you give your medication I am certain there have been more than a few times I didn't chart off prns. Inadvertently of cours. Then again if we realized we forget we would go back and sign it off...
That has been a problem with us, too. The pyxis system would get wonky and not let anyone in, sometimes for hours at a time. I miss the old fashion way of handwritten MAR's with meds already in the med carts.
We had an incident 2 weeks ago where our computers went down, and didn't come up for HOURS. We're giving meds (mostly by memory) since we're not supposed to print out med lists d/t HIPAA. I called pharmacy, told them, hey, we're down, I've given demerol 50 3x to Ms. X in Room Y, but I can't chart it, no computer, but I'm letting you know (and this is a PRN pain med every time she can get it patient, frequent flyer). The outage is hospital wide.
Just to cover my backside, I call the head of pharmacy and tell him.
So, I come in, and have an email -- I didn't chart the PRN demerol. I called pharmacy AGAIN. We were down, remember? Remember me, I'm the one who called you and told you I gave the med. "Well, you didn't chart it in the computer."
If you can tell me how you chart on a dead computer, you need to be in IT, not nursing....
1. Forgotten to sign off (chart as given in computer charting system) a medication given?
2. Followed another nurse that had forgotten to sign off (chart as given in computer charting system) a medication?
3. Followed a nurse to failed to sign off (chart as given in computer charting system) any medications for that day?
4. Forgotten to sign off (chart as given in computer charting system) a narcotic PRN medication?
I have and am wondering if this is as common as I think it is. Would be great if it would automatically record it when pulled from dispenser...any other ideas?
1)We do paper charting, but yes, I have forgotten sometimes.
2) The nurses I usually follow don't EVER chart their PRN's and half the time don't document respiratory treatments OR routine meds either!
3) See #2
4) See #1
I have been complimented by nursing administration that I am one of the few nurses in our facility that actually DOES chart my meds and treatments and so on....
yesterday a Resident asked for prn pain medication. it was scheduled q8hours prn. I looked in the MAR and saw that the last time it was given was 7pm the previous night (it was now 10am) I gave her the pill, then went to sign the Narc book. It was signed out at 6:30am by a Resident Assistant (a whole other story). She did not sign the MAR nor tell me about giving it when I came in.
I informed my DON (who happens to be the RA's daugher) and she repremanded me for not asking her if she gave any narcotics or checking the narc book first (I looked in the MAR which is the legal document)
Was I wrong or right? Any help would be needed. I'm thinking about quitting, but I really love my residents and the job.
So sorry this happened to you. Sounds like she is trying to put the blame on you when in fact the person who medicated her prior to you did not document properly. It happens all the time. Just be sure to cya in the future. Check the narc book before giving any narcotic meds to ensure that a dose has not been given that you were not told about.
And we STILL have to chart by hand the time we gave the prn and for what reason, even though that is ALREADY documented in the pyxis system. 
It happens all the time. Just be sure to cya in the future. Check the narc book before giving any narcotic meds to ensure that a dose has not been given that you were not told about.
caringchic
69 Posts
YEP to all four, especially on those days from hell. Wouldnt it be nice if all systems could talk to one another especially nurses!