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?

[Horseshoe, BSN, RN]

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

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).

At first I thought you were joking. I don't care who it is (but really???? just approaching a random person for info-and taking their word as Gospel- just because they are wearing scrubs and a stethoscope???). YOU are responsible for every medication you give. If you don't know enough about the medication, you LOOK IT UP, you clarify with the doctor. If something seems fishy, you go to sources YOU KNOW to have the proper credentials. And in the end, you use your own nursing judgment to make the appropriate decision, and once you've done so, you own that decision and the consequences of it. "Well, so and so told me it was okay" will never cut it if something bad happens. It won't cut it even if it's a doctor, because it is your responsibility to investigate and refuse to give a medication, even in the presence of a written order, if it is inappropriate. Most of us have had to tell a doctor that we are not going to give a medication for such and such reason. In the case of outright physician mistakes, many have thanked the nurses profusely for not giving the med as ordered and bringing it to their attention.

[MunoRN, RN]

8 hours ago, Lovethenurse2b25 said:

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.

The only way to clarify how the prescriber intended for the order to be interpreted is to ask the prescriber.

That being said, there's no reason to assume this order was written incorrectly, and this is actually a pretty reasonable way to prescribe this particular type of muscle 'relaxer', which is an antispasmodic, not really a direct muscle relaxer.

Metaxalone is basically the same as the more commonly known methocarbamol. Both cause relatively minimal CNS depression including respiratory depression compared to true muscle relaxers or even other antispasmodics such as flexaril.

The primary dosage limitation isn't sedation or respiratory depression, but the ability of the liver to metabolize it, which limits the safe daily dose. In order to get reasonable therapeutic effect, it often needs a peak plateau timed to coincide with period of the day most likely to have muscle spasms, taking one every couple of hours for 3 doses to get it to work when it's most needed is unlikely to cause adverse effects, and actually a single Norco or Percocet is probably more dangerous in terms of CNS depression and sedating effects.

In a court of law, you're held to what standards a nurse is reasonably expected to abide by in terms of ensuring the safety of the patient, which would require it to be established that taking this particular medication 3 time a day but not evenly spaced out throughout the day is clearly dangerous, which it clearly is not.