Did I make a med error?

  1. just graduated nursing school in December and work at an assisted living. My boss is trying to say I made a med error. What happened was I was day shift nurse on Tuesday. I had a signed new order from the doctor for a patient to increase there lasix from 40mg daily to 40mg 2x a day. I followed all my steps. Faxed this to the pharmacy so they can put it in our EMARS, let family know if the med change, documented it, sent a message out to other nurses, and told other nurse in report. Well the patient was only receiving her 40mg a day. I didn't work day shift again that week so I really didn't know what happened after that. Can all this blame be put on me ? I guess I should have followed up again with pharmacy about this but I sent it to them and followed all my steps. Does some of the blame also go to the nurses who saw it on the message board and who I told in report? I feel like a terrible nurse
  2. Visit Emilythenewgrad profile page

    About Emilythenewgrad

    Joined: Feb '18; Posts: 16; Likes: 17
    Specialty: 1 year(s) of experience

    38 Comments

  3. by   Nurseinprocess
    Does not look like a med error to me, but I have never worked in an assisted living facility so I don't know how doctor's orders end up being acknowledged. If there is actually a computer system for giving meds, is there not also a computer system for the physician to input new orders? It looks to me that the nurse that you gave report to had some responsibility to ensure the new order was made active.
  4. by   Crush
    From what you wrote, it would seem you took the right steps. It does not sound like an error from what is written here.
  5. by   Emilythenewgrad
    No, we don't have anywhere for the physician to put in the orders. We have to fax them to the pharmacy and the pharmacy puts them in and we have to confirm they r correct. My concern Is that I didn't give the med at 5pm yet because I didn't see that the pharmacy had put it in the computer yet. I feel like the nurse for the next day shift should have followed up on this and looked for it.
  6. by   Emilythenewgrad
    Quote from Crush
    From what you wrote, it would seem you took the right steps. It does not sound like an error from what is written here.
    . That's what I was thinking too but my boss, DON is sending it into state as a med error. I just wanted more opinions before I tell my side.
  7. by   blondy2061h
    What is your boss saying you did wrong?
  8. by   Orion81RN
    Quote from Emilythenewgrad
    No, we don't have anywhere for the physician to put in the orders. We have to fax them to the pharmacy and the pharmacy puts them in and we have to confirm they r correct. My concern Is that I didn't give the med at 5pm yet because I didn't see that the pharmacy had put it in the computer yet. I feel like the nurse for the next day shift should have followed up on this and looked for it.
    Hmmm. If the new order was for the 2nd dose to be given at 5pm, I would have given it even if pharmacy was not caught up on entering it. You received the order, so its ok to give. I'm thinking that was the problem.

    I then would have documented that I gave the 5pm dose per md order.
  9. by   Orion81RN
    This makes me greatful we always put in our own orders. I wouldn't trust anyone but prescriber and myself to enter an order (in SNF anyway.)
  10. by   Emilythenewgrad
    Quote from Orion81RN
    Hmmm. If the new order was for the 2nd dose to be given at 5pm, I would have given it even if pharmacy was not caught up on entering it. You received the order, so its ok to give. I'm thinking that was the problem.

    I then would have documented that I gave the 5pm dose per md order.
    Ok, this makes sense. But would I be to blame for the resident not getting that dose all week?
  11. by   Crush
    Quote from Orion81RN
    Hmmm. If the new order was for the 2nd dose to be given at 5pm, I would have given it even if pharmacy was not caught up on entering it. You received the order, so its ok to give. I'm thinking that was the problem.

    I then would have documented that I gave the 5pm dose per md order.
    Ok so a specific time was not in the origional post. That may be what the issue is then. Although I am not familiar with Assisted Living policies. Agree with Orion81RN, I would have also given, documented, etc.
  12. by   MunoRN
    If what you describe is how the process is supposed to work then it would appear the ball was dropped by the pharmacy, but it also sounds like it's a bad process which is to blame if that's how it's actually supposed to work. Just to be clear, you use an eMAR, but to make changes to eMAR you write it down and fax that written change to an outside pharmacy which is then supposed to update the eMAR? That sounds extremely problematic. The changes should be made to the eMAR directly, so that even if the outside pharmacy drops the ball, the order change has at least been properly documented within the system that is being used.
  13. by   Emilythenewgrad
    Quote from MunoRN
    If what you describe is how the process is supposed to work then it would appear the ball was dropped by the pharmacy, but it also sounds like it's a bad process which is to blame if that's how it's actually supposed to work. Just to be clear, you use an eMAR, but to make changes to eMAR you write it down and fax that written change to an outside pharmacy which is then supposed to update the eMAR? That sounds extremely problematic. The changes should be made to the eMAR directly, so that even if the outside pharmacy drops the ball, the order change has at least been properly documented within the system that is being used.
    How should I continue from here? I know it wasn't a major error but how do I continue from here?
  14. by   MunoRN
    Quote from Emilythenewgrad
    How should I continue from here? I know it wasn't a major error but how do I continue from here?
    Ideally you would follow the process that already exists for error reduction and improvement, and identify the problem (neither the physician nor the nurse are keeping the eMAR up to date) and propose a solution (physicians and nurses change the orders in the eMAR directly).

    If there is no established process where you work for identifying and solving these problems then you would need to start with advocating for such a system.

close