should I fill out med error form?

[Ms.RN]

our unit manager does all the renewals of our unit. she does the mar and the physician order for the next month. the problem is whenever we start our new mar, we floor nurses find tons and tons of mistake in the mar, in which medications are not transcribed right, medications not being dc'd etc.. this month as i was doing med pass, it came to my realization that we made med errors due to transcription errors from previous month. patient missed synthroid for 8 days, patient is still taking medications that has been discontinued few monthes ago.. if you found these errors would you just correct it or do you fill out medication error? there has been no harm done but i dont want to ignore it either.

[locolorenzo22, BSN, RN]

it is your duty to bring it to someone's attention. DON, unit clerk, whoever transcribed. It is IMPARITIVE that you do this aSAP.

[mn_nurse]

I would agree with comment above. It is your duty to report any med discrepancy. The purpose of reporting should be to improve the process. From your posting it appears that the process definately needs to improve.

[PedsDrNurseTheo, ADN, BSN, MSN, DNP, RN, EMT-P, NP]

this month as i was doing med pass, it came to my realization that we made med errors due to transcription errors from previous month. patient missed synthroid for 8 days, patient is still taking medications that has been discontinued few monthes ago

first off, i would hardly call missing a week's worth of levothyroxine "no harm done." levothyroxine has an extremely narrow therapeutic range - the physician needs to be notified and quite possibly the patient's free t4 and tsh levels checked.

no medication is completely free of adverse or secondary effects, and giving the wrong meds, or inappropriate timings of meds can be disastrous. this is definitely a medication error and needs to be reported.

where i work (granted, it's not long-term care, but still), even being late with a medication by over 1 hour qualifies as a reportable medication error and leads to an incident report being generated. sometimes a root-cause analysis is performed to look into the event.

you have to take this issue seriously - you worked way too hard for that license.

[JessicRN]

Med errors should be reported but near misses in my opinion should not. In the case of the unit manager she should not be penalized. It sounds more like a systems problems then the Unit Managers problem. I have never heard of anyone doing month to month transcribing without a 2nd person rechecking. In our acute care facility when I worked on a very busy chemotherapy unit, the charge nurse checked all patient charts for orders written in the past 8 hours to make sure if there were any errors they would be caught early. In the non acute facilty the Nurse double checked all new orders. It was also a policy in both places all new orders needed to be cosigned by the first person giving it. If you have not done that much transcribiing you would not understand how very very easily it is to make a mistake. When that person is transcribing is she allowed to do it without ANY interuptions? If this is not happening what do you expect, she is only human. Instead of complaining be proactive suggest 2 people do the transcribing one to write and the other to verify, your patients will thank you as will the boss.

[BlkQueenLPN]

That would be a lot of incident reports. It should be brought to the attention of those who need to know and suggest a new method of renewals being done.

[mamamerlee, LPN]

Still doing these by hand???? Nearly every facility I have worked with, and the ones my MIL have been in are computerized !!! And they still get reviewed and double-checked.

EIGHT days without her thyroid meds? Definitely needs incident report.

Best wishes - when you talk to those in charge, offer some proactive suggestions. One might be to do a count of the actual number of meds the patient is receiving, and jot it in the corner of the out-going month, and then to count how many were actually transcribed.

[NurseNinaFla]

As I recall from my nurses training,if I as a nurse know of a mistake,error,or wrong doing and do not report it > I

[NurseNinaFla]

Correction;meant to type "make sure all old orders are out of the system"

[sethmctenn]

Oh Lord (clutches pearls)...yes, you need to fill out an incident report. It does sound like a systems problem rather than an individual person problem. If it doesn't get corrected, your facility is taking big risks that ultimately will cause big patient harm.

[SuesquatchRN, BSN, RN]

Your entire change-over system needs to be overhauled. This is dangerous and unacceptable. Not necessarily a med error, but a plan for someone to double-check the new MARs.