med error?

Nurses General Nursing

Published

Specializes in med/surg.

Just exactly is a "med error." I know if you give a wrong med to a patient that is certainly a med error. But if you make a mistake at the pxysis and hit the wrong button, but catch yourself and correct it and then give the right patient the right med? Isn't that what the 5 rights are about? Like having another nurse check your calculations or insulin dose. What if you offer the wrong med to a patient, but the patient tells you it is the wrong med and you go back to check and give the right med, is that a med error.

Any info would be appreciated. I have looked on the BRN nurse practice act, but couldn't find anything specific. Am I looking and not finding the info I want?

Thanks

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Specializes in Education, FP, LNC, Forensics, ED, OB.

Hello, boxter,

I moved this thread for you.

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Specializes in OB, NP, Nurse Educator.

On the floor where I work if the wrong medication does not actually go into the patients body then it is not considered a medication error. We do consider it an incident and it is tracked by QA. If a nurse has multiple incidents then questions are asked such as: do they know the 5 rights? do they know how to use the equipment? are they just careless? Then this is followed up on with intruction, mentoring, or disciplinary action depending on the case.

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Good question. In my SCHOOL program, up until and including the last day, students would bring to the clinical instructor the MAR and each medication they were about to give a patient. Student had to show every vial used to draw (ie: insulin) and if there was a mistake there, then it was considered to be a med error--since you were, in fact, about to GIVE that set of meds to the patient. There was no room for the patient recognizing a problem and then it getting corrected.

However, I don't know if this is the case in the "real world"....would seem to me that you might make a med error, but not one that isn't corrected before administration, which would then make it an "untrackable" med error. But I don't know for sure, I'm just thinking out loud with you!

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Specializes in cardiac, med-surg, some critical care.

A "med error" occurs when a patient is given the wrong med.....be it a wrong dose, at the wrong rate, or wrong medication altogether. The 5 rights are perfect checking tools....use them!

Catching yourself before you give a wrong dose/ med.....will shake you up, but for the good!

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I always used to prepare the meds before bringing them to the patient. I observed my preceptor doing it differently, and I liked how she did it. Now I keep them in their unit dose packaging and open them in front of the patient. That way I remember what I'm giving, I can tell them what I'm giving, and they can let me know if they think something's not right before I've wasted a pill or potentially given a wrong medication. Already I've found this of benefit.

Who says old cats can't learn new tricks?

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Specializes in Telemetry & Obs.
I always used to prepare the meds before bringing them to the patient. I observed my preceptor doing it differently, and I liked how she did it. Now I keep them in their unit dose packaging and open them in front of the patient. That way I remember what I'm giving, I can tell them what I'm giving, and they can let me know if they think something's not right before I've wasted a pill or potentially given a wrong medication. Already I've found this of benefit.

Who says old cats can't learn new tricks?

That's how I do it, too. All those different shapes, sizes, and colors run together in my brain so I NEED the unit dose packaging to know for sure what each med actually IS before giving it to the patient. I'm so anal about making a med error that I keep them in order according to the MAR and give them in that order.

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Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

What you are describing is a "near miss" med error.

Our facility likes to documents near miss events, to watch for trends and errors before they occur, but we rarely, if ever report them.

http://krouwerconsulting.com/Essays/NearMiss.htm

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The 3 checks also work for me.

First, I take the MAR to the pyxis, and check each med and dose against the PYXIS report as I pull them. Discrepancies are investigated, and unfamiliar meds are looked up.

Then, I check each individual med against the MAR as I prepare it.

Then, I check the MAR against the pt.s nametag at the bedside as I tell the pt. what the meds are for. (When the pt. is not sentient, I ask myself: What for, appropriate given condition, and allergies AGAIN.

Hope this helps.

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I do lots of checks but I also verbally tell my patient "You had this ibuprofen at 1pm and its a six hour dose. Its now 7pm and its been six hours so you may have it again." Maybe its dorky but it works for me.

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Specializes in Emergency.

In nursing school, I got a write up for giving a 1700 po reglan at 1800. I know in school we are allowed a 30 minute window before and after, so the proper timing would have been 1630-1730. Because it was given an hour past the ordered time, it was considered a med error. My only clinical notification. What a bummer. Now that I am a "real nurse" my meds are late for at least one pt every day now...either an iv med couldn't be given d/t lack of iv access and need to restart, or a med is missing from the pt casetter, or PT is ambulating pt, or the pt is nauseous, or pt is off floor for testing...I could go on and on. I agree with the six rights rule...if it doesn't all check out, then there is an error.

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Specializes in med/surg.

Thanks to all of you. Your replies all made good sense. It was my understanding that if the wrong med went into the body, it was a med error. It is good to know the information about the incidents.

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