Is this a Med Error?

[AllyRN]

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?

[FolksBtrippin, BSN, RN]

Our system has standardized TID to mean 9am 3pm and 9pm. BID is 9am and 5pm. Daily is 9am.

QID is 9am 1pm 5pm 9pm.

If you dont want it given as above, you5 need to write for hours or times.

Your hospital would benefit from a similar standard.

I wouldn't call this a med error because the patient did not get more than 3 doses in a day, but things do need to be cleared up.

[Golden_RN, MSN]

This thread is getting confusing because the original post said that the order was TID and later on the OP mentioned TID PRN. Please make sure you know the difference between scheduled & PRN meds.

If it was indeed PRN, was the pt asking for it or exhibiting signs that the med was needed, or did you administer it because you thought it was scheduled?

[NutmeggeRN, BSN]

I would say this starts as a transcription error, as no time was written into the MAR...and then follows into an adminstration error. If you did not follow the gazillion rights, which includes knowing the medication (had you looked it up you probably would have seen that it has a peak of ~3 hours so two doses close together might be unsafe for the patient) and then called for clarification and a new order for the appropriate times to be administered. That said, you could easily have walked away and not said anything. You reported and advised the MD. This is a learning experience, of which there will be many! Feel better

[MEINstudent]

I could see giving a muscle relaxant med ordered for TID PRN, closer together than 8 hours. Say, the patient takes one when he wakes up, but then likes an additional dose prior to physical therapy. But if a patient asked for a second dose less than 8 hours from the first, I would page the provider to verify it's ok to give that close together. If the patient will be in the hospital for a while, and this is his habit, then I would suggest to the provider to add or amend the med orders to say it's ok to give close together for PT. Otherwise, I would page every day to confirm it's ok, just to cover my butt.

If you had other patients assigned to you, you shouldn't have left the floor to follow the escaping patient. You should just notify the charge nurse, call security. I'm not sure it's ok even for the CNA to follow alone. Your hospital should have policies and training on that. Safety first.

[mmc51264, BSN, MSN, RN]

I hate those kind of orders!!!! I don't believe that it was a med error. TID can mean anything. To me, that Q8H. Some are TID w/meals. Some are 8 12 2100. They need to be more specific and I will ask that orders be clarified and/or timed to avoid such a situation.

[MunoRN, RN]

TID is not the same as q 8hrs. For scheduled medications, TID means the medication is scheduled for the defined times for that medication, which might be 0900, 1300, and 2100, as an example.

TID prn means it can be given 3 times in a day.

[choksantos, BSN, RN]

Technically It is not but, think about it this way, if you get an order for Oxy 10 TID PRN, are you going to give every hour x 3 just because the order says TID PRN? I guess you won't. Orders like this needs to be clarified unless you have a hospital policy or unit policy about it. Also please make sure you clarify with appropriate people. If it's an MD get their name and put it as comment in MAR or write a nursing communication order.

[Orion81RN]

I was in a facility as a patient where I had Xanax prescribed to me 4 times a day. I was confused when they tried to give me my 2nd dose of the day just 4 hours after receiving my first one. I told them I just got my Xanax a few hours ago, that I didn't need it. They said their policy was different in that facility. They divided the doses up over a 12 hour period during the day. So I don't think this is a cut and dry case. It is definitely confusing as to if it is a med error.

I have had prescribers give instructions for cases just like this. Ex. Order may be TID with a note stating med should be given no less than 4 hours apart. That gives nurses the legal leeway to use nursing judgement.

[Kooky Korky, BSN, RN]

On 9/25/2019 at 8:29 AM, JadedCPN said:

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.

I have a problem with you apologizing for needing information.

[Kooky Korky, BSN, RN]

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

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!

What was the RT's answer?

[JadedCPN, BSN, RN]

On 9/28/2019 at 10:24 PM, Kooky Korky said:

I have a problem with you apologizing for needing information.

Word it how you want, it was just an example. Point being you are likely going to be received well if you approach it right.

[Lovethenurse2b25, ASN, BSN, CNA, LPN, RN]

As a new grad myself i would certainly question the medication order. I work for a rehab hospital all of our PRN medications usually have a frequency written behind it. Given the fact that this medication is a muscle relaxant i certainly would not give this medication at 9 10 13 like you said the supervisor mentioned.

Keep in mind you always have to CYA.

My question to the senior nurses if this patient would have gone into respiratory distress or coded how do you think this situation would be in a court of law? Im sure you cant say the medication order was written TID PRN so i could give it whenever.

It sounds like a recipe for disaster.