Is this a med error on my part?

jadelpn, LPN, EMT-B · Apr 21, 2012

This is a sticky one. Nurse 1 should have called it into pharmacy if that is what you all do in the course of admitting a patient. If the patient was admitted for low sodium, when getting report, I would have asked what we were doing with the sodium ie: if you don't do IV's, then the only other choice is PO. Did NP order it? (then if the NP did not, you would have had to follow up with a phonecall.) and would have prompted to look at the admitting orders to clarify. You can't admit a patient for low sodium and not do anything to treat it. But here's the saving grace--If the order said "start today" that is not a STAT order, in my opinion. As long as the med orders went to pharmacy, and she was getting all of her meds at 11pm, (when the pharmacy delivers them) that IS "start today". IF the order said Daily, first dose NOW, then that would be a different story, but it just said start today--which I assume that nurse 3, who perhaps got the meds from the pharmacy at 11 did. If she did not, then that is where the error is. Being caught in sort of the same scenario, I always check over the orders myself when a patient is reported off to me, as then I tend not to miss what--after a long shift--someone may miss to tell me.

sapphire18 · Apr 21, 2012

Why would you not use the MAR when administering medications? As far as I'm concerned, that in itself is an error- and a JCAHO violation. For what it's worth, 2 salt tabs over 2 days is going to do NOTHING to help a sodium level of 124- or prevent it from going to 123. What the heck?

Esme12, ASN, BSN, RN · Apr 21, 2012

When I got to work, I find we are in the process of getting 3 admits. The nurse I
was relieving stayed late, and took the first admit. (THANK YOU!) I was busy doing the other 2 as they came in an hour apart. For the 1st admit, the NP was there and based on hospital labs, wrote an order for Na 1 Gm po Qd x 2 days. Start today. When the 1st nurse left, she did not tell me about that particular order, nor did she call the pharmacy to make sure it would be delivered STAT (within 4 hrs.)...they don't usually deliver until 11p.m.
While passing meds that night, I didn't look at pt.'s MAR because she had no meds delivered yet. I left at 10:30, and did not tell the oncoming nurse about the patient needing the med NOW because I DIDN'T KNOW. The med was NEVER delivered, and the patient went to the hospital for Na 123. We admitted the patient with Na 124 so WHY DID WE TAKE THE PATIENT IN THE FIRST PLACE?? We don't do I.V. 's in the Rehab Dept. I work in. AND there is no Na in the E.R. kit. My D.O.N. is asking all 3 of us to write up an incident report???

Unfortunately, everyone kind of dropped the ball. The first nurse should have assured delivery and told you, you and the nurse who followed you should have checked the daily orders, and you should have passed it on in report. A NA of 124....makes me wonder why it was low. They would also have to be on a fluid restriction along with the NA replacement. Why did the patient go to the ED were they symptomatic? Was that a current lab?

The sodium tab, fluid restriction, and a couple bags of pretzels or chips would do as well. We all make mistakes, the skill comes into play is what do we learn from them. :hug:

Maine · Apr 21, 2012

I agree that you should have checked the MAR, I have definitely had people forget new orders in report before. You understand how the error was made so you can prevent it in the future. Hopefully the DON will see that this guy's Na was the same at admit and hospital discharge, it's not like he dropped, so as far as the med error having an adverse effect on him... it really didn't, right? Or was their concern just him staying at that level for a whole day? Just be honest and accept responsibility for your part and education and it should be fine.

heynurse1971 · Apr 21, 2012

I did check the admit orders. The order for Na was given verbally to the 1st nurse. She did not pass it along. I did not look at pt. MAR because no meds had been delivered for her yet, therefore I had nothing to give her.

NCalLVN · Apr 21, 2012

The NP wrote the order is what you stated initially. I would not assume anything (no orders for meds because nothing delivered) pharmacy could have dropped the ball. It is our responsibility to follow through. I hope it works out.

TheCommuter, BSN, RN · Apr 22, 2012

Why would you not use the MAR when administering medications? As far as I'm concerned, that in itself is an error- and a JCAHO violation

1. I live in a large metro area of several million people, and the multiple SNFs/nursing homes around here are not accredited by JCAHO. JCAHO tends to be an acute care hospital thing.

2. The OP did not use the MAR because the remote pharmacy had not yet delivered the medications. Therefore, she'd be reviewing a MAR with no medication to give.

sapphire18 · Apr 22, 2012

1. I live in a large metro area of several million people, and the multiple SNFs/nursing homes around here are not accredited by JCAHO. JCAHO tends to be an acute care hospital thing.
2. The OP did not use the MAR because the remote pharmacy had not yet delivered the medications. Therefore, she'd be reviewing a MAR with no medication to give.

Oh, I didn't realize LTCs weren't JCAHO accredited. Also that all meds were delivered and there is no pyxis. My bad! :)

heynurse1971 · Apr 25, 2012

Update: The patient of course, is fine. :) It was decided it was not a med error on my part, because nurse #1 took the order, signed it, and didn't follow through by calling the pharmacy to notify them that we needed the med ASAP. I did not have a reason to look at the M.A.R. because no meds had been delivered. I reviewed the original orders, but this order was added after admit. The order was not copied and attached to the report sheet (policy), nor was I informed of it. HOWEVER...I learned a big lesson. LOOK AT THE M.A.R. !!!!!!!!! The lesson is the most imoprtant thing! :) And, glad the pt. is o.k. Although, I am still wondering WHY we accepted the pt. with those labs! I do not work in a LTC facility...I work in a private rehab and have patients that really should still be in the hospital. We don't do I.V. therapy, yet we are all certified. ???? ANYWAY. Lesson learned. Next time, I will simply send the patient right back to the hospital, and avoid this mistake altogether! :)

applewhitern, BSN, RN · Apr 25, 2012

Not all hospitals are JCAHO accredited, either. The hospital I work at isn't, but they are accredited by the state instead.

JenLPN001 · Apr 25, 2012

I've always followed one simple rule: DOUBLE CHECK EVERYTHING! A lot of times, we get admits either at shift change OR right in the middle of a meal when everyone's busier than one armed paper hangers. Having to rush through an admit is the perfect breeding ground for screw ups, as we all know I'm sure. I've gotten into the habit of having someone else double check everything I've done, from ordering meds to transcribing the MAR to.... just everything. I do the same for the person who was on shift before me also. We've all caught potential errors this way and it's kind of nice to have someone as a back up. Glad the error didn't come back on you since the original problem wasn't your fault but you can see how easy it is to have something simple domino into a world class disaster.