How many is too many? Medication errors

Nurses Medications

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I work with a nurse, we'll call them Leslie, (not their name btw). This person has had a ton of medication errors, mostly not giving narcotics. We still use the paper sheets for narcotics, not a computer pixys system. The MAR will be signed, but not the narcotic sheet and therefore, if the count is correct, the med wasn't given. I know of at least 19 medication errors in a few months. Myself and others have gone up the chain of command to the director of nursing and administrator. Leslie has had several write ups by their own admission. How many is too many? I'm in no way implying that I am perfect. I have had a medication error or two in my career. Some staff dread seeing Leslie on the hallway, because we can almost bet there will be mistakes. I could totally understand one every now and then as we are all human, but 19? I'm not understanding how Leslie still has a job and a nursing license.

Specializes in CVOR, CVICU/CTICU, CCRN.
To be honest- that's none of your business. If you've presented the FACTS to management then it's out of your hands. You need to stay in your lane and not speak about this nurse on the floor to other coworkers, that is gossip- you can find yourself in hot water over that.

Agreed. This sounds like an issue for the OP's DON/Risk Manager. I'm out.

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

Incorrect. "They" is the gender-neutral choice. I worked as an editor and writer for over 15 years before going into nursing. It is obvious me that the OP didn't want to divulge in this person's gender, which I think is very considerate.

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Incorrect. "They" is the gender-neutral choice. I worked as an editor and writer for over 15 years before going into nursing. It is obvious me that the OP didn't want to divulge in this person's gender, which I think is very considerate.

Exactly! I said the same thing. :)

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It would be frustrating to follow this nurse especially if you are trying to manage the patient's pain and you are playing catch up. I'm willing to bet this is LTC? It sounds like our system. I'd also bet they are probably not giving other meds. The med passes are overwhelming!

Ask Leslie what happened.

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When asked, Leslie says, "how did I miss that?" My thought is as you are flipping pages of the MAR, you see a narcotic and think you'll finish popping the other meds out of the cards and then go back, sign the narcotic book and pull your narcotics. Then you get distracted and forget. The facility is a LTC center with a ton of behaviors, frequent fallers, dementia and alzheimers patients. We all have a system for passing meds. Some people check every page and write down medication pass times. Some write down who gets a narcotic, some check their narcotic book after every med pass, some use post it flags, some flag our pages in the MAR book, some put straws in the pages of the MAR. It's whatever works for you. I have suggested we all be given a refresher on medication pass. How to do everything correctly, so it brings it to the front of your mind.

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How do you know she isn't signing them out and then the patient is refusing them? There could be lots of different thugs going on here.

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How do you know she isn't signing them out and then the patient is refusing them? There could be lots of different thugs going on here.

The narcotics are signed out on the MAR, but not in the narcotic book and the narcotic count is correct. Therefore, they weren't given. If she signed the meds out and the patient refused, the count would be correct or over by one. If a patient refuses a narcotic, you waste it and have another nurse waste it with you and sign it.

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I think this is an ethical issue. If you feel that the patients on your floor are endangered and management isn't doing enough, it might be time to blow the whistle!

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fangirl, there is not much you can do unless you suspect this nurse might be diverting. Is there anything other than the incorrect counts causing you to question their abilities? Does the nurse appear impaired? Take more breaks than normal? Personality or mood change after breaks? If this is truly a cause of concern for you, I would suggest reviewing your state board's site and make the appropriate call. In terms of patient safety, does this nurse pose a risk to the patients?

Check it out and then move on... Everyone has their opinion, this is mine... :laugh:

Best wishes!

Link to an article you may find interesting: The High Cost of Drug Diversion

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fangirl, there is not much you can do unless you suspect this nurse might be diverting. Is there anything other than the incorrect counts causing you to question their abilities? Does the nurse appear impaired? Take more breaks than normal? Personality or mood change after breaks? If this is truly a cause of concern for you, I would suggest reviewing your state board's site and make the appropriate call. In terms of patient safety, does this nurse pose a risk to the patients?

I don't think Leslie is diverting. I would never accuse anyone of such a serious thing without rock solid black and white proof. I know we all worked our butts off for our license.

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I am extremely concerned that it seems acceptable for a medication error. One medication error is too much. What about the patients? Have the patients been harmed?

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Is she judgmental? Is she not giving these two types of meds because, in her opinion they aren't "needed"?

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