On my 2nd week of orientation, I saw this happen under 3 different nurses.
The patient's medication packet was empty and the trainer pulled the drug from another patient's medication packet to satisfy the MAR; because as we all say, if it's not documented, it was not done.
The 4th incident was a patient's NPH, no NPH bottle, and the 4th nurse said to me, "I know this is wrong but this is how you do it, take this NPH (another patient's NPH) and draw what you need." I refused and asked for the emergency kit, and it was also empty.
What would you do? Where to report other than LTC Ombudsman? This is criminal and they have to be punished.
Specializes in nurse consultant; adult/peds medicaid.
Borrowing is NEVER the answer because it sets up a cycle of borrowing. It is however part of the nursing culture. How often does admin borrow from Peter to pay Paul, then Paul works short because Peter is collapsed at home. Same thing except now instead of staff, we are talking about meds. Meds get out of ordering sequence when Peter and Paul borrow. Peter is out of meds and Paul's will not arrive until tomorrow.
It is every nurses responsibility to document and notify when a med is not on hand. If the med is not there, it cannot be given. Period.
Borrowing is illegal, it is up to every nurse to protect their license. Big pharma does not care about your nursing license. They only care about their business model, which makes them lots & lots of money!
If the meds are not on hand d/t borrowing then the system is broken. My guess is the borrowing all started when a med was not delivered even with many pharmacy notification attempts. After many years of medication tracking, I found this to be the root cause in most cases.
Nurses MUST advocate, not passively bow to big pharma & admin. It is NOT your fault that a med is not there for your med pass. REFUSE TO ACCEPT BLAME or enable the problem. Part of advocating is a detailed paper trail of admin & pharmacy notification when a med in not on hand.
It is not the staff nurse who is in charge of fixing the system, it is administration. This is a system error and should be documented as such on your medication error incident report.
If a med is not on hand d/t pharm error, reflect that on your report. Person committing the error... name your pharmacy. You are the one who is reporting the error. When you call the doc, cover your butt and get an order to hold, stat, or replace the omission. Now you have not made a med error... and you show clear documentation to the powers that be, they will know all about a missing med.
Report to the state. It will get them moving. I know you are no longer there, but dont continue this at another place. Remember you call the MD and get an order to hold. That way you can circle the med on the MAR.
Havin' A Party!, ASN, RN
2,722 Posts
Great post, Gypsy! Thanks for sharing your situation.