Is this a med error on my part?

Published

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???

Specializes in Emergency, Telemetry, Transplant.

I get kinda tired of trying to decide who is to blame for med errors. It's a common theme on here, and, if a nurse has to ask then are probably at least partially responsible. My opinion, both the nurse before you and you deserve some of the blame.

The bigger issue here is why did you not question what was being done for this low Na? Even if the med was not delivered you should have questioned why a pt is here with a sodium in the 120s and nothing is being done about it (or so it appeared to you). Even if the salt tab was not there, there were other interventions that could/should have been done.

+ Join the Discussion