Is it a medication error if...?

Mavrick, BSN, RN · Jan 21, 2018

There must be some "missed charge" involved or our Pharmacy wouldn't have such a fit when a dose of Ofirmev is removed from the Pyxis but not charted. We get nastygrams in our e-mail to "correct" the chart and if I don't do it in a timely manner (i.e. on a four day stretch off) my manager tracks it down and corrects the chart.

I also question the OP. Where have the "missing" medications gone? Not documented means not done. Theft is the least of your worries if other true medication errors are made because someone noticed a med wasn't given and gave it again.

Ambersmom, BSN, RN · Jan 21, 2018

At your hospitals is it considered a medication error if a medication is pulled from the omnicell but never given (or scaned for computer charting)?
At the hospital I work at the pharmacy department has been writing up more medications errors. When asked what these errors are they state that medications have been pulled from the omnicell but never scaned as given. Therefore they are considering it a medication error.
Is that a true medication error or just a financial error since they just want the patient to be charged if that pulled medication was given or not?

I don't think it fits the criteria for a med error, I do think it could be written up as drug diversion regardless of the class of med. If the med is pulled and the patient doesn't want it, why is it not returned to the omnicell (very easy and quick to do).

cleback · Jan 21, 2018

Speaking from my experience, most of the meds that nurses take from those machines are prn (pain meds, laxatives, etc). Aside from narcotics, I find it a bit overkill to demand tight control of tylenol or bisacodyl, for example. So a patient changes his mind and only wants one tylenol vs two. Honestly, I would have never thought I'd have to go back and waste the tylenol in the machine.... just seems a little much if everything is already documented. Anyway, I would hope an announcement was made prior to the policy change so nurses could adjust their practice.

klone, MSN, RN · Jan 21, 2018

OP, where have you gone?? So many unanswered questions...

FurBabyMom, MSN, RN · Jan 21, 2018

Um... I'm confused. You're on an inpatient unit like floor, stepdown, ICU etc, right?

When I worked an inpatient nursing unit, we could only pull medications for which the patient had scheduled or PRN orders. We could override the software to pull something emergently but that was for things like D50, narcan, etc. We could return the medication of refused or not given. If we hadn't opened the packaging and the patient refused, no problem, could be returned. There was still a "paper trail" albeit electronically in the machine.

I'm in the OR now. Primarily we pull a set of medications based on the primary service for the patient's case. Sometimes some extra stuff too. There are no order restrictions on our pyxis as all of our medication orders, except a very specific few, are verbal orders at the time the medication is needed (chemos, Exparel, and some other things require a written order). We usually have a name - real or fake, but sometimes we don't and override the system altogether.

BSN16 · Jan 22, 2018

I don't think it fits the criteria for a med error, I do think it could be written up as drug diversion regardless of the class of med. If the med is pulled and the patient doesn't want it, why is it not returned to the omnicell (very easy and quick to do).

would it really be "drug diversion" though? I pull out many meds that patients will refuse, which i will chart as so because theyre scheduled. but what about pulling out a PRN med? Ex my patient is having pain, or hasnt had a bowel movement so i pull out a prn tylenol or miralax. Patient ends of refusing, or for whatever reason i dont give it. these are not controlled substances so i dont need a witness to waste it. i return it if i can, but most cases just end up disposing of it because theyre in isolation

Meriwhen, ASN, BSN, MSN, RN · Jan 22, 2018

Depends.

If the medication was pulled but wasn't scheduled or PRN to give the patient, it's not a medication error. However, it is diversion, because why else are you pulling an unscheduled med?

If the medication was pulled and supposed to be administered to the patient and wasn't, then it's a medication error. Whether or not it's diversion depends on what happened to that medication you pulled.

If the medication was given to the patient but not scanned or documented...that's poor nursing practice because as you've already been told, if you don't document it, you didn't do it. And how would you prove in an inquiry that you did in fact administer the medication? Your employer sees a missed dose and considers it a med error. And they see a missing med and may also think diversion as well.

Of course, you could always say you accidentally pullied meds under the wrong patient's name. And that does happen to even the best nurses on the rare occasion. But when it's happening on a regular basis, it's both poor nursing practice and very suspicious behavior. Especially when those pulled meds can't be accounted for.

If this is you, you better start a. paying better attention to your MARs and at the Omnicell, b. document meds ASAP after being given, and c. return meds to the Omnicell ASAP if they're not given for whatever reason (refused, order change, no longer needed, wrong patient). If the patient refused or the medication was held for whatever reason (MD order change, patient condition, etc.) you better be documenting that as well. And yes, you can and should document the refusal of PRNs that you offer the patient.

Hope this helps. Best of luck in sorting this out.

Ambersmom, BSN, RN · Jan 22, 2018

would it really be "drug diversion" though? I pull out many meds that patients will refuse, which i will chart as so because theyre scheduled. but what about pulling out a PRN med? Ex my patient is having pain, or hasnt had a bowel movement so i pull out a prn tylenol or miralax. Patient ends of refusing, or for whatever reason i dont give it. these are not controlled substances so i dont need a witness to waste it. i return it if i can, but most cases just end up disposing of it because theyre in isolation

In my opinion yes, if you pull the med, the patient for whatever reason doesn't want it and you don't document the refusal and return the med to the omnicell, you've diverted the med from its purpose, whether you forget a APAP in your pocket (we all have) and take it home and either throw it out or put it in your medicine cabinet for later use its still diverting-the med did not go where it was intended. Diversion most often has the connotation with narcotics and people who reroute them illicitly but regular meds can be diverted too, in the technical definition.

kbrn2002, ADN, RN · Jan 22, 2018

I guess I'm a little confused about this. Why would you pull a med if you aren't going to give it? If for some reason you do pull a med and don't give it wouldn't it be returned or wasted? Or is this a case of the med being given and somehow not scanned or correctly documented when administered?

mmc51264, BSN, MSN, RN · Jan 22, 2018

Our pts don't get charged until med scanned. Any med pulled should be returned, but stuff like senna, I don't think they much care about. All controlled substances need a witness for return or waste (dropped, etc) I have been on my hands and knees looking for that little oxycodone that jumped onto the floor and rolled under the bed!

JKL33 · Jan 22, 2018

Couple of things:

1) You can waste a medication (through the dispensing machine) whether it requires a witness to do so or not. This is what I suggest. I go back to the machine and do a waste if I so much as drop a Tylenol tablet on the floor (or, say, the patient changes his/her mind after it's already removed from packaging). Take yourself out of the loop of these foolish "diversion" games!! See #2

2)

In my opinion yes, if you pull the med, the patient for whatever reason doesn't want it and you don't document the refusal and return the med to the omnicell, you've diverted the med from its purpose, whether you forget a APAP in your pocket (we all have) and take it home and either throw it out or put it in your medicine cabinet for later use its still diverting-the med did not go where it was intended. Diversion most often has the connotation with narcotics and people who reroute them illicitly but regular meds can be diverted too, in the technical definition.

I get what you're saying, but I disagree with the sentiment. My problem is that in the original spirit of the definition of drug diversion was the idea that the substance was being diverted for an illicit purpose (as you noted). In other words, if I forget about a Tylenol in my pocket, I probably haven't handled it exactly according to policy, but I have not "diverted" it according to what this word used to mean in context. I had and have no plans to use it for illicit purposes.

The general and everyday dictionary definition of diversion is simply a change of course or turning from course - it works well for talking about something like traffic. But if we're talking about drugs then the original definition of drug diversion is more apt.

What "some people in healthcare" want to do now, is define it exactly as you describe above, Ambersmom; they think they're so clever saying the same thing you said - meanwhile the rest of the entire world is still working on the old (in-context) definition of drug diversion. As in, "s/he was diverting fentanyl." The original definition of drug diversion involved intent. This new-fangled use doesn't address context or intent and instead steals old terminology in order to imply that there was nefarious intent.

I realize I'm making picky distinctions here, but this terminology inflation is occurring right alongside the acceleration of reporting to BONs (or at least increasing threats to do so). It looks worse, it sounds worse, and it wreaks more havoc to call this "drug diversion."

This makes a difference in a lot of things down the line, too, such as the way these issues are written about, talked about, and reported about - - and dealt with.

Ambersmom, BSN, RN · Jan 22, 2018

JKL33, I hear what you're saying and I think we are both correct but I do feel with the current paranoia on opoids this is going to evolve and broaden into other meds, maybe not now, maybe not tomorrow but I'm willing to bet on it, and the almighty powers that be will hop on it like flies on excrement because saying diversion is so much more powerful than saying med error, and if management decides they don't like someone, eventually they'll use that more powerful word, sure diverting apap, losartan, metoprolol,(or whatever) is not reportable to the BON or DEA but tptb do like their reasoning to be beyond question, its the same as the other favorite key word critical thinking, nowadays if anyone forgets a task, or misses a piece of charting, or whatever they are told "we question your critical thinking skills". Heck, my last facility all the nurses were written up for supposed pain scale violations, if the patient said they wanted apap only, no narcotics but pain was recorded at a 5, written up because the patient didnt get the narc, if the patients pain was a 5 and you gave 10mgs of oxy instead of 5 written up. If you failed to rescore pain in an hour written up, and there was no announced policy change or warning that went around telling everyone to clean up their act, and in most cases the docs didn't write the orders correctly in the first place but I digress... Our pharmacy even had charting changed for MAR for any med so if you pulled it, and didn't use it or waste it, you damn well better be able to explain what you did with it. For myself, I try to return/waste/chart every med, but others I've worked with not so much. And yes this is what I'm trying to say is that tptb will eventually start using more powerful verbage, its already happening in other areas because it makes it easier for THEM to defend their actions.