Explain test question, please

EastCoast · Sep 30, 2003

Hi, I agree with you and think that it is a peculiar misleading question. Reasonably you can not 'double check' every med against the original order. It is a given that if an RN takes off an order and transcribes it that he/she is in fact assuring it is taken off accurately. Secondly I would add that the original order had to go through pharmacy who obviously continued to dispense the med after the 3 rd day. Unless there was particular notation on the med sheet that said 'stop this drug on such and such date' my opinion is that the person at fault is the original transcriber.

tonchitoRN · Sep 30, 2003

sorry i must give my opinion. yes, it is possible to check each med. with the original order. it is a must. as far as the kardex many institutions did away with those because of mistakes. the kardex is an outdated concept in my opinion. if you administer a med that is wrong you are at fault. now you would be surprised how many times this happens: lots. i was always taught in school never to trust your fellow nurses because if they make a mistake and you do the same then everyone is at fault.

the legality of the problem is "you give it, you are responsible for it."

any other ideas?

TLS · Sep 30, 2003

Oppinions are oppinions are oppinions. It doesn't matter what we "think" is right, it matters what the law says we are responsible for. The law clearly states that your license makes you responsible for EVERY med that you are to give (the 5 rights) reguardless of who we think or reguardless if we have time to check our med orders against the chart. i know there isn't always time for that (an objective observation from a new grad) but as far as black and white on the boards or preparation for: the answer is you the nurse giving the med.....I agree with EastCoast. It "should" be the transcriber, that's what I "think". I would like to know how do other nurses handle that situation in real life. Do you totally trust your co-worker or do you double check all your meds every morning?

cannoli · Sep 30, 2003

Unless you work in an Utopia, there is no way to check each med with the original order, there is not time, unless you plan to spend many more hours than you are already spending past the end of your shift. Management may also have something to say about that also if checking meds is not in their current policy, as happened when the kardex was done away with at one hospital, nurses were not to check meds but to go with the MAR. I know that that is not going to protect the license but it might protect the job, if one cares about that.

Todd SPN, this does not answer your question, I realize that.

In the real world, I think it would be pretty much impossible to check every med against the original order, when you have many patients and many meds.

colleen10 · Sep 30, 2003

As a first year student and one covering the Med Admin. Process I agree with TLS - the nurse is legally responsible for the administration of the drug despite who was at fault for writing it incorrectly or checking it. The Nurse is the check & balance to the Dr. not the Transcriber, Kardex or MAR.

However, not having all that much hosp. experience and currently doing clinical in a facility that uses KARDEX I still do not know how the nurse actually giving the drug at that moment would be able to check the original script. Do they keep the original hand written/signed script on the floor or in the pharmacy, etc? The KARDEX we used is still a "transcribed" order from the doc. It's not the original order written out.

I agree that this is one of those "tricky" questions where despite the fact that in "real life" a nurse would not have the time nor resources to check all scripts themself, in the "theory" world of NCLEX the nurse is still responsible.

redshiloh · Sep 30, 2003

Don't know if anyone else does this but we use the kardex as a place to record treatments, patient diagnosis, ect.

colleen10 · Sep 30, 2003

PS, remember, anytime a nurse is about to administer a prescribed intervention the very first step is check/verify the order, then gather equipment, explain procedure, wash ya' hands, etc.

jansgalRN · Sep 30, 2003

If I learned one thing in nursing school, it was that the nurse is ultimately responsible. In this case, the one who gave the med because of the risk of harm to the patient. The kardex is basically a written report that is updated q shift according to the orders. The kardex is NOT a legal document and therefore would not hold up in court. We are individually responsible for all meds, treatments and any actions taken while a patient is under our care. All original doctors orders should remain on the unit, in the patient chart. Checking orders from the original is the only way to ensure that the other methods are accurate (whether it be a kardex, MAR, or a computer printout or profile of some kind). I know that it is not always practical, but if your unit believes in continuity of care, then you may see many of the same patients so you don't always have to go back and check from the beginning. If you work in an area where the patient turnover rate is high, then you don't have to look through as many orders.

sjoe · Sep 30, 2003

"It doesn't matter what we "think" is right, it matters what the law says we are responsible for. The law clearly states that your license makes you responsible for EVERY med that you are to give (the 5 rights) reguardless of who we think or reguardless if we have time to check our med orders against the chart. "

Exactly right. This is the bottom line whether or not we might think it is unfair, impractical, etc. There is NO excuse in the eyes of the law. Something to think about when assigned to work "short" or given "mandatory overtime" or floated to an unfamiliar unit or when accepting more patients than we can reasonably take care of. Is the job worth the chance we are personally and professionally taking?

NicuNsg · Sep 30, 2003

Isn't it, the nurse is ultimately "Responsible" for the error and the transcriber is "Accountable". It is a crazy chain of events that takes place after a doc signs off, by it is the responsiblity of nurse to oversee the order.

NICU_Nurse, BSN, RN · Sep 30, 2003

In our NICU, we use a Kardex to *aid* the nurses- as someone mentioned, it is NOT a legal document, nor is it part of the chart; it gets discarded when the patient is d/c'd. Furthermore, it is written in pencil and is freguently outdated, as it is the ultimate LAST thing you do before leaving the unit (in other words, if you're busy, it goes by the wayside). Because of this, it can literally be days or WEEKS since an accurate note was made on one of those. It exists solely as a helpful reminder to staff; a single card listing quick notes of interest or something to help you give a quick, organized report covering all major issues.

Furthermore, in our unit, it is REQUIRED that we check each and every order for medications prior to giving them to the babies. We do this every single shift, every single day, period. One of the first things we do when arriving on shift is do a chart check, and that means starting with the most recent orders and flipping back to the very first day of admission to verify ALL tx's/orders/meds before we even begin working. Yes, this can be daunting, especially if the baby has been there for ten months (or even one month on a sick baby leaves you with 40+ pages of orders to check sometimes!!). This is why we frequently ask the MD's/resi's to do an "order clarification", in which they sum up all current orders- this is considered to supercede the old, possibly outdated orders so we have less to flip through. Also, the unit clerks often do chart auditing and thinning, in which they take out all the old orders and file them with medical records, but this doesn't always get done when it should.

And to top that off, yes, we have computer-printed MAR's. On our unit, each nurse prints one out for the next shift. Sounds fool proof, right? Think again. You not only have to print the MAR out for the oncoming nurse, but you are *supposed* to check it for accuracy. If something is expiring, you need to renew it. If something is no longer being given, you need to fax a copy to pharmacy with a note asking them to make the appropriate changes. This, also, does not always get done when it should- AND it's a courtesy from the other nurse before you, not a hard-and-fast rule. If I come on shift and just give meds according to the MAR without checking them there is a very strong possibility that I will be making all sorts of errors depending on how astute and conscientious the nurse before me was. Or how busy he/she was.

So, the Kardex is not considered "reliable". The MAR is not considered "reliable" (it's only as reliable as your previous nurse). The only reliable (and LEGAL, as sjoe and others have said) source is the original MD order.

Todd, to answer your questions,

No, the MAR is not to be taken as gospel. :)

and

Yes, if you give a med in error because you went from either the Kardex or the MAR or both (without verifying the original order), you will be faulted.

Remember what they taught in nursing school: Check, check, check those orders, and think of what a prudent nurse would say in a court of law. Would a prudent nurse say, "But she printed it out, she should have checked it!"? No. This is precisely why, time constraints or no, there is a multi-level verification system for medication administration (MD, you, pharmacy, then you again with your five rights).

Now, I don't know what other units do, but in the ICU that I work on currently, as well as my former facility, we were required to check the original orders. I don't know if it varies from unit to unit (ie, med/surg vs. ortho vs. LTC vs. ICU), but in a court of law it wouldn't matter.