Med error~Hard to explain on paper!

[jaxnRN]

i made a medication error. i was filling out the form and need some input.

working in a ltc on monday, and the nurse who was reporting off to me and counting narcs mentioned that it was "patch day". which means that in the hall we were on it is the day to change the duragesic patches on residents. (actually two residents).

well, i signed a patch out for each resident so that i could apply them that morning.

this is a very busy hall and a lot of acuities for ltc. i had one resident in severe distress and several others with acute serious needs. not that it is an excuse, i am just trying to paint the picture in the real world. the nurse that told me that it was "patch day" is an excellent nurse and i can never remember her making errors herself.

so, i applied the patches and then went to put them on the medication administration record. i then read that it is not "patch day". patch day was yesterday. :doh:

so, in reality i had removed the existing duragesic patch and replaced it with a new in 24 hours instead of 72 hours as ordered.

the order for the patch reads: duragesic patch 25mcg q72h as needed!!!!

first of all, we never write these patches as needed. so, at least looking back at the order i did catch this pharmacy error. but, still changed it too early.

anyway, the duragesic patch is a continuous release. this error would not be considered "double dosing", right? and when the patches fall off or will not stay adhered for whatever reason we replace with a new patch. no med error occurence has ever been written up for that!

my don isn't upset with me at all. i am upset with me. when i worked with home health and hospice if the patches fell off we were to tell our clients to apply another. i am just so frustrated that i could have been so busy that i made this error.

when filling out the medication occurence report i tried to logically think about how this is an error. of course, it was put on too early. but that doesn't increase the dose. plus, the pharmacy and the physician's order for the month actually states to use as needed!!! this resident is never in pain so either the duragesic has done its job or we need to decrease the dose. there is no documentation that the pain patch is needed.

so, it's actually a good thing that this happened. it definitely made me slow down and it revealed the pharmacy/md error for prn dosing. for a couple of years the dose was q72h routine. and the med was listed on the medication administration record under the routine meds when it even reads "as needed".

:zzzzz if you are still reading and following me, my question is this: how would you word this error? there were no adverse effects. does changing this patch in 24h actually give a med dose error????

i've been working way too many long hours. :stone:smilecoffeecup:

thanks for any input and ideas. sorry this was soooooooo long!:redbeathe: i just feel really stupid for making such a dumb mistake.

:urgycld:

[Psqrd]

We date and time application on the patch itself...I was taught this in nursing school, if this was done you would have seen that the patch wasn't ready to be replaced...not just our pain patches but our nicotine and hormone patches as well.

P2

[SixFive]

If you have your MAR with you when getting the narc out of the machine, lockbox, cart, or whatever you have and have it with you at the bedside, it's hard to make med errors. Like you said, this one wasn't a biggie since you took off the old patch when u applied the new one.

The biggest error made with Duragesic/Fentanyl patches is covering them with a tegaderm. Lots of nurses don't even know that's a big no-no.

Don't waste too much time doing your incident report or "explaining" the error. We all have made errors in our careers!

[jaxnRN]

the really stupid thing that doesn't make sense to me is that i actually checked the mar before putting this on! we write down the location of the existing patch so that we will be sure to find it and rotate sites.

i saw that it was put on just a day ago! i looked at it and still went ahead and did it!

!

we also write directly on the patch our initials and date and time.

i have oriented a lot of nurses through the years and stress to them that you have to pay attention and not just go through the motions!! we even are enforcing a policy not to interupt nurses during med pass unless it is something urgent! it's way too easy to get distracted on some days.

i am glad that something good came of something bad though.

we did find that the order should have been routine and somewhere along the line it got changed to as needed on the physician order sheet.

i cringe at that fact that the physician i have to report this to really frowns on med errors. one of the least understanding of them all. and as you know, we have all caught med errors that physicians write. we are all human.

thank you all!!! :bowingpur: i love nurses who really understand. :redbeathe: and support each other. you are all awesome!