How many is too many? Medication errors

Elladora · Dec 30, 2015

I have several questions about this situation.

Do you do narc count after each shift? Are the narcs missing or is she just signing that she gave them but not actually giving them? (My previous facility had the same type of system, paper MAR, paper narc count). From reading your post, I'm gathering that she is possibly hurrying when she signs off on her meds and is signing that she is giving the narc, but not actually giving it, correct? So the narc count is correct but not the documentation?

As long as you have reported it to the powers that be, there really isn't much more you can do. I dealt with something similar and the nurse in question eventually quit. If you feel the client's rights are being compromised, you can always report it to state. This is a drastic step, but sometimes what it takes to make something happen.

To me, it sounds like she needs to slow her roll a bit, especially if extra pysch meds are being found. She's not taking the proper amount of time to give meds correctly.

Oh, and as a comparison, I was in charge of writing med errors at my facility. I wrote 52 in one WEEK on a nurse and she kept her job. Med errors were considered separate from disciplinary action (they were actually considered a "teaching occurrence" and the med aide/nurse was supposed to document steps to prevent the error from happening again). I wanted to bang my head on my desk multiple times.

fangirl · Dec 30, 2015

I have several questions about this situation.
Do you do narc count after each shift? Are the narcs missing or is she just signing that she gave them but not actually giving them? (My previous facility had the same type of system, paper MAR, paper narc count). From reading your post, I'm gathering that she is possibly hurrying when she signs off on her meds and is signing that she is giving the narc, but not actually giving it, correct? So the narc count is correct but not the documentation?
As long as you have reported it to the powers that be, there really isn't much more you can do. I dealt with something similar and the nurse in question eventually quit. If you feel the client's rights are being compromised, you can always report it to state. This is a drastic step, but sometimes what it takes to make something happen.
To me, it sounds like she needs to slow her roll a bit, especially if extra pysch meds are being found. She's not taking the proper amount of time to give meds correctly.
Oh, and as a comparison, I was in charge of writing med errors at my facility. I wrote 52 in one WEEK on a nurse and she kept her job. Med errors were considered separate from disciplinary action (they were actually considered a "teaching occurrence" and the med aide/nurse was supposed to document steps to prevent the error from happening again). I wanted to bang my head on my desk multiple times.

We do count narcotics each shift. The meds are signed out in the MAR, but not in the narcotic book and the count is corrrect. As an example, Sally is ordered Lortab every six hours routine at 0600 1200 1800 and 0001. I take the keys and count at 0700. When I go to sign out the 1200 dose, I see the 0001 and the 0600 doses aren't signed out. Where I work, medications errors will get you a "learning moment and a plan of improvement". Lately there have been so many that managers have started to give write ups.

Elladora · Dec 30, 2015

So she is signing them off and not giving them. Ugh. Hopefully they take notice soon. Maybe she will get written up if that's what they are starting to do. Believe me, I know it's very, very frustrating!

I don't know how much leeway you have, or how your relationship is with this particular nurse, but have you ever just asked her, "Hey Leslie, I see you signed off on Sally's Lortab but it's still here. What happened?"

(Where I worked, that was what we were supposed to do first. Question the person responsible, then start moving up the chain). Again, ugh.

ED Nurse, RN · Dec 30, 2015

Extra doses of psych meds have been found on occasion.

This is part of the problem "on occasion" is not a FACT. If you are reporting things you need the specifics- date, time, med, dosage, etc to file an actual incident report.

Nothing is going to happen without WRITTEN, FACTUAL incident reports. Just going to the manager is just a step- without documentation, it didn't happen. When I'm in charge and have issues, I put it in a written statement, verbal counsel in form, or an email to my higher ups so there is a paper trail. Again, you are not management so you don't know what is going on behind the scenes nor are you privy to the discipline of others. Do you lack that must trust in your management to do the right things? If not, why work there?

Elladora · Dec 30, 2015

When referring to a singular person, use "him or her," not "them." "Them" makes reference to multiple people.

I think fangirl used "them" to avoid identifying the gender (as the name is gender neutral and as she doesn't say "he" or "she" anywhere else in the post).

kbrn2002, ADN, RN · Dec 30, 2015

I agree with OP's frustration in this. While it is true that it is not her concern as far as discipline beyond notifying the powers that be that a narcotic med was missed I wonder if the person [OP or whoever it is that follows "Leslie" ] is the one responsible for notifying the MD that doses were missed. Then that person has to deal with that fallout, not to mention dealing with a patient that is under medicated and quite possibly in pain.

fangirl · Dec 30, 2015

I agree with OP's frustration in this. While it is true that it is not her concern as far as discipline beyond notifying the powers that be that a narcotic med was missed I wonder if the person [OP or whoever it is that follows "Leslie" ] is the one responsible for notifying the MD that doses were missed. Then that person has to deal with that fallout, not to mention dealing with a patient that is under medicated and quite possibly in pain.

Also, whoever finds it has to call the family.

TheCommuter, BSN, RN · Dec 30, 2015

Narcotics are serious business. Even the smallest thing is a "must report."

I completely agree. In addition, narcotics and benzodiazepines are governed by DEA federal regulations that could leave the facility and nurses involved in hot water if not carefully adhered to.

BuckyBadgerRN, ASN, RN · Dec 30, 2015

So they ARE (management) doing something about the missed doses, regardless of what you initially posted. It sounds as though they are creating a paper trail for ALL nurses, not just Leslie!

We do count narcotics each shift. The meds are signed out in the MAR, but not in the narcotic book and the count is corrrect. As an example, Sally is ordered Lortab every six hours routine at 0600 1200 1800 and 0001. I take the keys and count at 0700. When I go to sign out the 1200 dose, I see the 0001 and the 0600 doses aren't signed out. Where I work, medications errors will get you a "learning moment and a plan of improvement". Lately there have been so many that managers have started to give write ups.

BuckyBadgerRN, ASN, RN · Dec 30, 2015

Aren't you looking at the signout sheet as part of your count? You should be able to see then that Sally didn't have any lortab signed out for the 0000 and 0600 doses, correct? Why don't you call Leslie out on it as you find it?

We do count narcotics each shift. The meds are signed out in the MAR, but not in the narcotic book and the count is corrrect. As an example, Sally is ordered Lortab every six hours routine at 0600 1200 1800 and 0001. I take the keys and count at 0700. When I go to sign out the 1200 dose, I see the 0001 and the 0600 doses aren't signed out. Where I work, medications errors will get you a "learning moment and a plan of improvement". Lately there have been so many that managers have started to give write ups.

dishes, BSN, RN · Dec 30, 2015

What is the med pass like in your workplace? Are most nurses signing the MARS at the time they give the medication? or are they pre or post-signing?

NurseSpeedy, ADN, LPN, RN · Dec 31, 2015

Isn't an incident report the next step, along with notifying physician? Also, if this nurse is missing narcotics I am wondering about other missed meds such as BP, DM, antibiotics that have been missed. Are you finding extra doses of these meds?

This is what I would be wondering too, and if the pills are in bottles from each patient's individual pharmacies and not a facilities own with monthly punch card meds, then it's really hard to determine.

I agree with what others have stated. If you've brought it to management's attention then you have done what you have to do and should let them handle it (which they may already be doing, or not). I can also see where you may be concerned for the patient/resident's well being since they aren't receiving their meds. It may be necessary for management to look at the situation in which the meds are being administered. If the nurse is constantly being distracted, this could lead to omissions that she doesn't even know are occurring. Yes, it shouldn't be signed off until it is given, but this is probably not happening in this case since there are additional meds left over. I worked for a facility that was constantly understaffed and sometimes the nurse would have to give meds all day for over 100 residents, plus act as supervisor to aide staff, answer the main line since there wasn't always a receptionist, and handle all the other responsibilities as nurse. Add going over to the memory care unit where they stand around your cart wanting to talk to you and/or are confused/agitated or you have to stop abruptly because you see someone take off without their walker ready to fall, well, it's really hard to do it all and stay on top of everything. I'm not saying this is the case, but sometimes the system itself is the issue contributing to the errors.