How common are “wrong time� med errors?

[cchao]

In your experience, how common and how severe are wrong time” med errors? How much of it is just being 31 minutes off and not a big deal, and how much is a real problem? Is it something that you worry about?

To give more background, I am not a nurse but am interested in healthcare technology (so I apologize in advance for dumb questions!). It seems that barcode medication administration (BCMA) helps a lot with the other rights. For med timing though, it can only prevent a too-early” error. But in practice, is it more common to have a too-early or too-late error?

I am also curious, what do you think are the main causes of these errors? Is it bottlenecks at the Pyxis that delay everybody's morning med pass? Being constantly interrupted by call lights? Or just being assigned to too many patients at once, that it's impossible to get everything done in time?

Do you use any tools or processes to manage the scheduling of meds?

[Rose_Queen, BSN, MSN, RN]

Many facilities have policies stating that meds have a window. For example, at my facility, a med scheduled for 0900 can be given anywhere between 0800 and 1000 and be considered on time.

I don't work in a patient unit where I routinely give meds, so I have no input on the why meds are given off schedule, although I think the random times meds are assigned to be given by pharmacy may play a role. I've seen patients who had meds scheduled for 0900, 1000, 1100, and 1200. Why can't some of those, especially the ones given once daily, be combined and given together? As for EMARs, I personally think there is far too much reliance on technology- when it goes down (and it is when, not if), it's like people can no longer think for themselves.

[txnursetrb26]

I agree with some of this being a computer/pharmacy issue. Ex:pt is admitted at 2300, new orders start coming in to give metoprolol 25 q 6. First dose is put on computer for 0245, all other doses are at 45 on the hour. Pt has scheduled pain med at 0300 and antibiotic at 0400. Guess what? One is going to be given early/late because I'm not going back in 15 min later to wake him up for the 15,000th time. Sometimes our pharmacy can be accommodating about changing times on eMAR if it's daily or q24 to suit pts needs, but some of our pharmacists will tell us we have to call the doc in the middle of the night to change the time, even by an hour. Nope not that important, I'll wake them up. Again lol

[brownbook]

The Institute for Safe Medical Practice, ISMP has a good website about passing meds. I don't know if it addresses BCMA or Pyxis issues.

[CBlover, BSN, RN]

First of all, I don't feel like if a med is due at 0800 and I give it at 0910 because I'm slammed that that is an "wrong time" med error. It happens on a weekly/daily basis with me and everyone I work with probably. Now a wrong time med error IMO, is say, a beta blocker was to be given at 7 a.m. within 24 hrs after surgery and it wasn't given until bedtime or say, maybe IV abx were due at midnight but not given until 6 a.m. when they are ordered Q8H. These two examples, to me, are incidents of wrong time medication errors. Now many times for me, I have to give meds an hour late because the ole pharmacy didn't bring them to me on time. Happens too much and is frustrating. Really though, for the most part, I am able to give my meds within the hr time span that they are due.

[benegesserit]

Don't know if you're interested in anything other than acute care, but from a (mostly) LTC context...

From what I've seen, "Too early" errors are most often a conscious choice - starting the med pass early in order to get through it in time. Sometimes the "Too early" popup has prevented me from giving a PRN too early when I didn't notice that one had been given by the previous shift. Sometimes it happens because a patient is due for meds soon, but is going to be unavailable at that time.

"Too Late" most often happen because there are simply too many meds due during the med pass for that nurse to handle. Interruptions, needing to go get things from the pyxis, and so forth contribute to this (bottlenecks at the pyxis are rare, but it changes what is normally a 30 second process into 5 minutes). Some of it is UI design of our eMAR - patients who have meds due will be highlighted, but there isn't any way to easily distinguish those who are near the end of their two hour window from those who are have a while to go, so it's difficult to prioritize, and, as there is no easy way to look at the whole day at a glance, it can be easy to miss oddly timed meds.

User interface can also cause lateness if the interface is excessively complex, the user is new to the system, or there are computer/network problems. I was shocked when a med pass on three patients (acute care environment) took nearly the full two hours because the eMAR was so obtuse and difficult to use.

For most meds timed daily or twice a day, minor "Wrong time" is not going to cause any harm. I've seen recommendations that less time-sensitive meds be given a wider window.

[pc2801]

In my facility, the patients meds will be ordered for first dose when the order is input in the computer, often the patient is still in the ED, so the meds are already late by the time I get the patient in the room. It can take me 5 minutes to get the meds or over an hour depending on what part of shift the patient arrives. When ED send patient at shift change I haven't even peeked at orders and unless they are in distress I am going to settle them in, check on all my patients then return to review what meds patient has already taken that day before pulling meds. Often a.m. meds were taken at home but pharmacy will put in 1st dose at 7 p.m. and again at 7 a.m. for daily dosing. I usually end up not giving half the first dose meds because they are medically contraindicated. If I do give the meds they are late because of patient care prioritization or patient off unit.

[kbrn2002, ADN, RN]

Strictly from a LTC perspective, wrong time errors are so common as to not even be considered errors anymore. There is a two hour window to complete a med pass. Now imagine passing a whole bunch of meds that you have to get from pyxxis supply, med cards, OTC bottles, liquid med supply and maybe the refrigerator. Also imagine that many of these people take crushed meds and several are not so compliant and require quite a bit of coaxing to get these meds in them. Now throw in a few dressing changes or some other treatment.

I can do this in two hours only because I know these residents, how they take their meds and where all their meds are so well. If I get bumped to a wing I am not so familiar with, no way am I getting this done in the allotted time frame. Frankly I think that since nobody I know is Supernurse if anybody claims to be able to complete this impossible task I wonder what corners they are cutting to accomplish it.

When we switched over to EMARS the impossibility of signing everything off on time was brought up as a major concern by the nurses and we were told not to be too concerned about it. I guess administration was right as not once has the issue of meds being given late been brought up by state surveyors.

[benegesserit]

When we switched over to EMARS the impossibility of signing everything off on time was brought up as a major concern by the nurses and we were told not to be too concerned about it. I guess administration was right as not once has the issue of meds being given late been brought up by state surveyors.

Same here. We've had and eMAR for two years now, have been through both state and federal surveys, and late meds have not been an issue, even when we had people being followed by surveyors while giving meds late.

It's still a worry. If they did decide to focus on that, it would be a major problem.

Ideally, administration times should be looked at, and either the administration policy changed to a more liberal window, or the patient/medication load adjusted so that it's manageable within the existing window.

[Here.I.Stand, BSN, RN]

Agree completely with the previous 2 posters. I've never worked LTC as an RN, but have done subacute rehab in a SNF. I had 10 pts compared with LTC's 25-30+, but this wing was very high turnover. Among the ones who I didn't get to before breakfast was over, I had to compete for time w/ PT/OT. They billed by time, so would NOT let me give meds during their sessions. Sometimes i'd have to help w/ 2-person transfers, I'd have to get prns, I'd have to prep meds and call pharmacies in prep for 1100-1200 discharges, I'd have to intervene for confused pts, I'd occasionally have to take calls from the lab, every so often a pt would fall, and of course the routine need to call providers and respond to families' concerns. The 2 hr window ended at 1000, and I very rarely finished by 1000. I usually felt on track if I finished by 1030.

I also worked in an LTACH, which I like to describe as med-surg on steroids. I typically had 4 or 5 pts, many of whom were NPO/tubefed. Of those, they either had a PEG (yay!!!) or these tiny bore NJ tubes (boo!!! Those things would plug up with meds if you so much as looked at them cross-eyed.) Now this is hospital nursing, and very sick pts at that. They were actually sicker than my current hospital's stepdown pts. They needed more comprehensive assessment first thing, plus VS prior to meds, etc. We'd find pts declining, pts who were pressure supporting or trach doming but not tolerating it and needing their vent settings back, trached pts needing to be suctioned, wound vacs needing to be troubleshot (a lot of our wounds were very difficult to get good seals with), dressings that needed changing now b/c they were saturated and leaking everywhere, CNAs needing help with mobility because the pt was too big, too weak, or on the ventilator....

Not only all of that, but routine a.m. med time was 0800. Shift started at 0700, with report until 0730 (and sometimes going over, depending on how many RNs we needed report from.) With the bottleneck at the Omnicell, we might not even get to our first pt by 0800. Two hr window finished at 0900.

In other words, our working time really wasn't 2 hrs -- it was an hour and maybe some change.

As I said on another thread, I decided that I was just going to be okay with this type of "late" meds. I would much, much rather give meds a little late than rush and make a dangerous med error as a result.

As for true wrong time med errors, e.g. late because I missed seeing it on the MAR, or a prn given too early... I can count on one hand the number of times I've done that.