Is this a Med Error?

[AllyRN, BSN]

I’m a new nurse and literally today was the WORST day ever.

1.) I decided to go into work while barely getting over a cold (I took meds, wore a mask, hand hygiene, etc.). I’m just overall felt fatigued.

2.) There was a patient running down the hallway and into the stairwell and it wasn’t even my patient but a CNA and I ran after her and tried to stop her (we’re on the 7th floor) so it took forever because she did not stop until she got to the door and security finally arrived and then I had to take time to call back up to see who was the nurse that had her and see what was going on to give answers to the security.

3.) I had a discharge right at the beginning of my shift that I had to get everything ready for and that meant that I would also get an admission (which I did).

None of these are excuses. I just know I was not in the right head space and now I’m confused about this med error.

My patient had a medication order written: TID metaloxone for muscle spasms.

Long story short, I basically gave it only 4 hours apart. And I did question it. So I asked someone who I thought was a nurse because she had a stethoscope on, a WOW, and she had been on the unit since change of shift. She said it was fine. BUT BIG SURPRISE, she’s a respiratory therapist and I didn’t discover that until after giving it(not saying that there’s anything wrong with RT’s, but I was looking for a RN). I am also a new float nurse, so I literally know no one. I ended up thinking about it again and I asked our resource nurse about it and she was shocked. She said that she wouldn’t give it less than 8 hours apart and to notify the MD.

I called the MD and they said to continue to monitor the patient. I ended up writing an incident report because I believed I was wrong after I heard what my resource nurse said.

I emailed by manager asking to meet with him and to let him know about my mistake and to discuss what happened.

But my main question is, are TID PRN medications every 8 hours? Do they mean the same thing? I’m confused because I felt like because it’s TID, it means to not exceed a certain dose in a day but we can give it when needed with nursing judgment . I’m not saying I would given medications 10 minutes a part or anything crazy like that. Was this a true medication error?

[Nurse SMS, MSN, RN]

What time did the MAR say to give the med? TID is not always the same as q8h but generally that is the rule of thumb. It definitely doesn’t mean “use your own judgment “

Who was caring for your patients while you joined in on the chase? Tip - nobody. Next time let the CNA handle it.

I hope your cold gets better.

[AllyRN, BSN]

3 minutes ago, Nurse SMS said:

What time did the MAR say to give the med? TID is not always the same as q8h but generally that is the rule of thumb. It definitely doesn’t mean “use your own judgment “

Who was caring for your patients while you joined in on the chase? Tip - nobody. Next time let the CNA handle it.

I hope your cold gets better.

Good point... I’m just too nice of a person and in the moment it was just me and the CNA, no one else saw it. And I thought the right thing to do was help.

And the MAR didn’t have a time. It only said TID....

[Nurse SMS, MSN, RN]

On 9/25/2019 at 2:22 AM, AllyRN said:

Good point... I’m just too nice of a person and in the moment it was just me and the CNA, no one else saw it. And I thought the right thing to do was help.

And the MAR didn’t have a time. It only said TID....

Generally speaking, TID is q8h unless it states with meals or some kind of additional instruction. Always seek clarification if unsure. Checking the chart can give clues as to when the patient usually gets it.

It is natural to want to jump in and help. You aren't thinking quite like a nurse yet is all. ? In leaving, your patients were left without care and nobody had a handoff on them. Calling it "abandonment" would definitely be too harsh, but if something happened you would have a difficult time explaining your rationale. Your floor also now had two caregivers gone instead of just one, leaving the whole floor more vulnerable. The best way to help in these situations is call security and hold down the fort.

Don’t be too hard on yourself. You will learn from this. Get some rest.

[AllyRN, BSN]

On 9/25/2019 at 2:26 AM, Nurse SMS said:

Generally speaking, TID is q8h unless it states with meals or some kind of additional instruction. Always seek clarification if unsure. Checking the chart can give clues as to when the patient usually gets it.

It is natural to want to jump in and help. You aren't thinking quite like a nurse yet is all. ? In leaving, your patients were left without care and nobody had a handoff on them. Calling it "abandonment" would definitely be too harsh, but if something happened you would have a difficult time explaining your rationale. Your floor also now had two caregivers gone instead of just one, leaving the whole floor more vulnerable. The best way to help in these situations is call security and hold down the fort.

Don’t be too hard on yourself. You will learn from this. Get some rest.

Thanks for the input! I appreciate! To be completely honest, I’ve been through these forums all night and I found one that states that TID prn is not the same as every 8 hours and it blows my mind because I could not find a definite answer. I will be talking to my manager today to review what happened and asked for the policy. Thank you again!

[JadedCPN, BSN, RN]

As a new float nurse the best advice I can give is learn your resources, ASAP. I realize you are a new nurse but it is slightly concerning that you asked a random person who you thought was a nurse simply because they had a stethoscope, and that you were going to act based on the advice from a stranger. When in doubt, go to the charge nurse.

One of the best things about being a float nurse is that you can use that to your advantage without "looking" stupid. I have floated for 5 of my 13 years and have no problems walking onto a unit and saying "hey sorry to bother you, I'm a float nurse and am not too familiar with this unit, can you show me XYZ or explain XYZ." Most people are very receptive of this.

[AllyRN, BSN]

Hello everyone! I just wanted to let you guys know that I absolutely did not sleep last night LOL. But I did go in to speak to my manager about it and he said that he did not have an answer for me and there was no policy. He even sat there with me and called the pharmacy and the pharmacy said “technically they could taken it at 9,10,13 if it is PRN TID”. So they did verify that PRN TID does not mean every 8 hours and that there is no policy. But manager said I did the right thing by calling the MD and that writing the incident report was correct. He also gave me more resources in case I question myself. Thank you everyone for being honest and giving me advice!

[JKL33]

On 9/25/2019 at 10:11 AM, AllyRN said:

He even sat there with me and called the pharmacy and the pharmacy said “technically they could taken it at 9,10,13 if it is PRN TID”. So they did verify that PRN TID does not mean every 8 hours and that there is no policy.

Yes, but yikes. And that would mean no more muscle relaxer for this patient from 1300 until the next 0900.

Orders like TID PRN or QID PRN are far more suited to patients at home than they are to sick hospitalized patients who might have additional needs and might be awake at any given time over the course of 24 hours.

But, let's back up if you will. ?

On 9/25/2019 at 2:04 AM, AllyRN said:

My patient had a medication order written: TID metaloxone for muscle spasms.

Get very used to looking up any medication that you aren't completely familiar with. Use your facility-approved reference such as one built into your EMR or a current year's hard copy. Direct questions to your pharmacist. This is important even though these resources aren't going to answer the particular question you have in this one instance. Any knowledge you can gain will be incorporated into your decision-making ability. I believe you are talking about metaxalone, a skeletal muscle relaxant that works by way of CNS depression.

On 9/25/2019 at 2:04 AM, AllyRN said:

But my main question is, are TID PRN medications every 8 hours? Do they mean the same thing? I’m confused because I felt like because it’s TID, it means to not exceed a certain dose in a day but we can give it when needed with nursing judgment . I’m not saying I would given medications 10 minutes a part or anything crazy like that. Was this a true medication error? 

Conceptually, TID and q8* are two different things, as are QID and q6* or BID and q12. I think it will help you to understand the concepts:

BID, TID, QID, in and of themselves do not specify times to be given, nor specific times between doses, although a spread of time that is convenient for the patient and generally makes sense is what might typically be suggested by a patient's provider. What I mean by "makes sense" is that one would sort of spread them out evenly over waking hours. So, with a TID med, a provider might say to the patient, "take it three times a day, spread over the course of your day - like maybe morning, early afternoon, and night." ((Or, don't necessarily confine them to "wakeful" hours but do make sure to spread them out so that they aren't being taken more frequently than that, and also you don't take more than the allowed # of doses over the course of 24 hours)).

But in the hospital we have to have some sort of consistency, so your pharmacy will have a policy that defines how they handle TID in that facility, or QID, or BID. Etc. It is important to understand that there is (in reality) some variation allowed by the way the order is written, but that facilities need things further defined (for workflow, for consistency, safety, etc.) and so they define them further by assigning times that that "TID" meds will be administered. (Same for QD, BID, QID, HS, etc.). HS is a good example of this: In the hospital HS is often assigned to the time of 2100. In reality, if an order is written "at HS" it just means that a patient would make sure to take it around the time they were retiring for the night; maybe they go to bed at 2000, but maybe they go to bed at midnight.

**

That ^ concept is different than an order that reads Q8*. In this instance, the prescriber wants the patient to more specifically adhere to a particular amount of time between doses; to take the medication as close to every 8 hours as lifestyle will possibly allow. The medication might not work as well by taking doses closer together or farther apart than the amount of time ordered to elapse between doses, or in some cases adverse effects might be increased. Q8* means just that: As close as possible to every 8 hours around the clock.

Understanding these general concepts gives you one more tool for giving good care and preventing patient harm.

On 9/25/2019 at 2:04 AM, AllyRN said:

But my main question is, are TID PRN medications every 8 hours? Do they mean the same thing? I’m confused because I felt like because it’s TID, it means to not exceed a certain dose in a day but we can give it when needed with nursing judgment . I’m not saying I would given medications 10 minutes a part or anything crazy like that. Was this a true medication error? 

Again, in general TID PRN orders are much more suitable as an outpatient order. They make sense for someone who is well enough to be at home with a somewhat higher likelihood of being well enough to have more defined period of waking hours and sleeping hours. The problem with TID PRN becomes that if the patient takes 3 doses during "typical" waking hours but then would like the medication sometime over the next, say, 12+ hours, they technically can't have any more. Or just like the example your pharmacist gave. That patient is going to go a long time without being able to take the med again.

Q8*PRN or Q6*PRN, etc., or some other more specific order are way more suitable choices for a hospitalized patient.

In your case (having read that you don't have a policy about all of this) it might be best to have the provider directly clarify the order.

[JKL33]

9 hours ago, AllyRN said:

Long story short, I basically gave it only 4 hours apart. And I did question it. So I asked someone who I thought was a nurse because she had a stethoscope on, a WOW, and she had been on the unit since change of shift. She said it was fine. BUT BIG SURPRISE, she’s a respiratory therapist and I didn’t discover that until after giving it(not saying that there’s anything wrong with RT’s, but I was looking for a RN). I am also a new float nurse, so I literally know no one. I ended up thinking about it again and I asked our resource nurse about it and she was shocked. She said that she wouldn’t give it less than 8 hours apart and to notify the MD.

What was your decision-making process for administering the doses 4 hours apart? Your pharmacist and manager have already noted that this was not technically wrong, but since you were unsure what you were supposed to do, I am curious as to how you decided what to do.

Was it that you asked someone first (the RT), or had you already administered the medication when you spoke with the RT?

[TheMoonisMyLantern, ADN, LPN, RN]

I don't think you were wrong for helping the CNA with the eloping patient. Patients that attempt to escape are often impulsive and unpredictable, had the CNA been by themselves and the patient became violent (which nowadays is not uncommon) no one wants to be in that situation by themselves, there is safety in numbers.

[LibraSunCNM, BSN, MSN, CNM]

Oddly enough, the computer system at the hospital where I first worked as a nurse scheduled anything ordered "TID" at 1000, 1400, and 1800 automatically. If it was meant to be q8h we had to change it (which happened frequently, because a lot of providers assumed that ordering something TID would schedule it q8h). Was always odd to me because there are very few meds where that administration schedule makes sense. Sounds like you've learned some lessons, try not to beat yourself up.

[Nurse SMS, MSN, RN]

1 hour ago, TheMoonisMyLantern said:

I don't think you were wrong for helping the CNA with the eloping patient. Patients that attempt to escape are often impulsive and unpredictable, had the CNA been by themselves and the patient became violent (which nowadays is not uncommon) no one wants to be in that situation by themselves, there is safety in numbers.

Well no, not really. Her legal obligation is to the patients she was assigned to. If she gives chase and a patient codes, calls, falls - then what? Or if she herself is hurt by the eloping patient and nobody has report on these patients still up on the floor? Then what?

The CNA should be well trained not to approach an eloping patient due to violent potential. If they are alert and oriented, then there is no reason to approach them either. They are allowed to leave at will. The only thing stopping that would be to retrieve a telemetry box or other such medical equipment.

I work in an inner city safety net hospital and we train EXTENSIVELY on this. Nobody should be getting close enough to an eloping patient to get hurt. Follow? Yes, at a distance too far to be struck. Never get in the elevator with them. Stay two stair flights behind them and have security on the spectlink (if you have that) with a description of the patient and where they are headed.

Violence against healthcare workers is on the rise and, trust me, if a patient is violently inclined, having two healthcare workers chasing them isn't going to make anyone safer. It makes both of them less safe, along with the patients the nurse left up on the floor who are now without anyone looking after them.