is the med error my fault?

  1. I am wondering if I am at fault for a med error. I have been working as an LPN for almost 2 years. The pharmacy keeps putting this one med (Seroquel) in the morning pack because it is scheduled for once daily and the physician said to give it at night due to drowsiness. Therefore, the nurses have to save the Seroquel from 8am to give at 8pm. Unfortunately at my facility the pharmacy messes up all the time and the nurses have to make the supply work because the pharmacy does not repack meds. I did not switch over the MAR because when I do, I double check meds to make sure it is transcribed correctly. When the new MARS were transcribed by the head nurse on the first of the month a med that is given at 8PM was put on the MAR for 8AM. The morning nurse initialed that the med was given in the morning. I did not give the med because the MAR said it was already given for the day, the time had changed and I did not see the med leftover from the morning pack (although the morning nurse swears it was in the patient box). I am wondering if I should have given the medication at night even though the MAR said 8am and it was initialed as already being given once that day. I am wondering if the med error is my fault for not giving it at 8pm as previously ordered or if it is the transcriber (head nurse) fault for transcribing the wrong thing and initialing that she gave the med when she didn't. Thank you in advance for your replies.
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    About WatermelonW

    Joined: Sep '16; Posts: 1

    5 Comments

  3. by   Sour Lemon
    I wouldn't give a "daily" medication that had been documented as already given. As for who's at fault, I'd say everyone who should have clarified the order and time of day with the pharmacy/MD and didn't.
    Passing meds shouldn't require solving complex puzzles or trying to read each others minds.
  4. by   BSNbeauty
    The doc needs to change the time from 0800 to 2000. That way No errors can be made.
  5. by   quiltynurse56
    Go back to the order to find the doctor's order. If he ordered for evening, then the MAR needs correcting and the pack needs to be relabeled. Where I work, we are able to put the correct sticker on it or write on the pack the correct time.

    I agree, if the morning nurse had signed that it was administered, as it is a once a day med, you don't administer it later. I don't know necessarily that either one of you should get a med error. It sounds to me like the error came with creating the new MAR and the labeling of the med.

    All the more reason why I prefer electronic MARs.
  6. by   NuGuyNurse2b
    I didn't know there were facilities still transcribing. I did that over 10 years ago as a secretary. And we didn't even have all this fancy Windows-based computer stuff. our order entry system was DOS-based! we had patient stencils.
  7. by   doodlebuttRN
    Quote from NuGuyNurse2b
    I didn't know there were facilities still transcribing. I did that over 10 years ago as a secretary. And we didn't even have all this fancy Windows-based computer stuff. our order entry system was DOS-based! we had patient stencils.

    Lots of facilities still transcribe orders, and this is one of the issues that comes with it. I agree that if anyone is 'at fault' it is probably the pharmacy/MD/ person who was supposed to reconcile the MARs. However, had I been in your shoes, and the MAR (ordered for AM) didn't match the original order, and the med was given 12 hours ago, I would contact the MD and let them know. Id also call pharmacy. Agreed, just change it to 2000.
    This is more of a systems error. When U read your post, I thought, well geez, even if I had seen the med leftovers box, that wouldn't cause me to give the med. It could be in there for some other reason. I didn't learn mind-reading in nursing school either.

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