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?
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.
bite your tongue and let it go.....because you had not properly completed your documentation before giving the med.....thought the DEA would take a very dim view of the the other persons lack of documentation as well.
I have no idea how many hospitals, clinics, nursing homes, use computerized charting and medicine dispensing systems? Maybe not as many as you assume? Our out patient surgical clinic doesn't have computerized anything, I will admit I have made med errors, just can't say I have made them via computerized charting.
I forgot to sign the prn sheet after giving Roxinol, I did sign the narcotic sheet along with a nother nurse because it is a liquid and the dosage on the bottle can sometimes look a little off. I work in a nursing home and I am assigned to 23 patients. I get interrupted by staff, family and residents. I did pass the info on in report. My question is, is it a med error? (if its not signed it wasn't given) Can you still document the prn med if it is within 24 hours
I don't think many ltc facilities use computerization at all and it is a shame because there is so much opportunity for human error. Also, I would much prefer doing patient care than digging through reams of papers to find the appropriate box to initial. At a former facility, we used ChartMeds; super easy to use, I caught on in 15 minutes and it handles all documentation automatically and makes sure all regs are complied with and nothing is forgotten.
I have worked at the "esteemed Mayo Clinic". If a narcotic is not documented as given, it is grounds for immediate dismissal. Nurses stay late to review the Pixis narc report, make sure all narcs are documented as given.
Can't see the value in this as narcs are still very easy to divert, if the nurse so desires.
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!
We have the system where we scan patients and meds, but we have a computer mounted on the wall in each patient room...so no iso concerns.
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.
morte, LPN, LVN
7,015 Posts
bite your tongue and let it go.....because you had not properly completed your documentation before giving the med.....thought the DEA would take a very dim view of the the other persons lack of documentation as well.