Med Error Report

ktwlpn, LPN · Dec 12, 2008

Careplans depend on the problem. You have to do an assessment of the mistake. For example (true examples)
Assessment: Med given PG intended for one patient were mistakenly given to another. Patients beds are nest to each other. Names begin with "B"
Goal: Proper adm of meds
Intervention: Move beds to opposite side of room, not next to each other, consider moving one patient to another room, Instruct nurse to avoid multitasking at the time of med adm. (no answering phones, no talking to others, etc.)
label cup with meds with patients full name- first and given
Follow up in a month
Another example:
Assessment : Pt given antibiotic according to doctors orders . Patient with a known history of allergy to this antibiotic. Patient immediately developed rash and hives to both arms and stomach. Dr's order was written at 12:05 when the nurse was giving meds and monitoring lunch activity. Dr asked that the antibiotic be started stat . Pt was given med from another pts drawer in order to accommodate drs order. Pts chart was appropriately labeled with allergy warnings in 5 different places
Intervention: New policy- new doctors orders can not be picked up during mealtimes. In the event of an emergency, a second nurse who is not passing meds and monitoring the meal, should be brought to unit to help. Under no circumstance should meds be taken from one patient to another except under the approval of the DON or shift supervisor. Patient given antihistamine and cream to rash as per Dr. Order, Pts vitals to be monitored until stable for 3 days. No med can be given till it is properly signed for an transfered to the MAR (which incidentally also lists allergies on top in red)
Daily monitoring till stable. Follow up in one month. Inservice planned for this Tuesday to discuss the error.
Hope this helps.

This is an interesting thread-especially the cultural differences.We can never move residents unless they request to be moved.The state would call your example "staff convenience" We have a floor with 7 people named "Davis" As for multi tasking-our families/patients/residents are "consumers" and they are always right.If someone wants some attention they get it-no matter what else is going on and the administration allows this.

PsychNurseWannaBe, BSN, RN · Dec 12, 2008

Not a part of the patients record, silly!, but a part of the med error report. The way I figure it- it clearly analyzed the mistake, and plans how to prevent them.
I could care plan anything in my life. When my teenage son has a problem, I teach him to think of it in 4 step- assess the problem, decide on a realistic goal, come up with a plan of action,( obviously carry it out) then evaluate the effectiveness of your plan to meet your goal. Sometimes when its written it keeps you on track. but it doesn't have to be written.
I never considered a care plan to be limited to residents issues.

I see what you are saying. You are saying careplaning... I would call it, using the nursing process. The nursing process can be used for things other than nursing (as you mentioned before)

Where are you from?? You mentioned Russia, but your location says Israel

PsychNurseWannaBe, BSN, RN · Dec 12, 2008

I hear what your saying- as I explained - this care plan is for the incident report- not the patient chart, it gets signed by the involving parties themselves. It is an internal document. It attempts to solve an internally made error.
BTW _ discovered through this that a head nurse was making the night nurse prepare for her her meds!!! Couldn't get over it, I was so mad.
What happened is that the evening nurse discovered the pts morning pills in a cup in the patients pocket- a med error report was written, the pills came to me, I discovered 2 of the same pill in it and asked the day nurse who then admitted that the night nurse had helped her prepare them. She promised it would never happen again. The Dr. tells me that when I went on a 2 week vacation, it resumed. I'm thinking of rotating my nurses. What do you think?

I would love to be not interrupted. Gosh, I could be so productive. :) I would think a lot less stress as well.

What would rotating your nurses do? I would be upset if I was rotated because of my peers behaviors. (Punish the lot because of the few) I never agree with that mentality. It lowers morale and I find it quite passive-aggressive. You should confront the nurse(s). Be more proactive. If they can't improve with genuine help and training...then dismiss them.

What are you at this facility. You talked about the DON in another post... are you a unit manager?

nurselsteele · Dec 12, 2008

:idea: I guess i am confused on the question?

My medication error reports are graded:nurse: meaning, degree of error, example:

Error: Antibiotic ordered Ampicillian= gave = Amoxicillian

Intervention: inquired with patient on allergies

Goal: double check orders against medication when pulling.

We have the same report for every medication error, I'm not sure of what "number scale", our administrator keeps "number scale" because you can have 3 medication errors in a 6 mth period before they have a "teaching step" and send you to a seminar on medication administrations & medication errors...

Please explain what is this "number system?"

:confused:

CapeCodMermaid, RN · Dec 13, 2008

And I never consider myself to be silly when dealing with med errors.

achot chavi · Dec 14, 2008

This is an interesting thread-especially the cultural differences.We can never move residents unless they request to be moved.The state would call your example "staff convenience" We have a floor with 7 people named "Davis" As for multi tasking-our families/patients/residents are "consumers" and they are always right.If someone wants some attention they get it-no matter what else is going on and the administration allows this.

Re the room change- I never said to change rooms, just change bed positions in the same room. I agree that it would not be fair to the patient and family to change rooms for our convenience- just to separate the beds more (in the same room).

Re the "Consumers always right"- even in hopsitals there are hours that the medical and nursing staff are unavailable. If explained to the consumers that the nurse can't be interupted during med administration except for real medical emergencies but she will be available at say 10:00 am for phone calls- they understand. If the call is important,either the nurse comes to the phone or another staff nurse or even me or the DON can take a message and get back with an answer.

Consumers understand that when they call they can be told, the nurse can't come to the phone but will be available in half an hour etc. If not, they need to learn to appreciate the job of the nurse. Believe me when a med error is made they will be even angrier!!

SO whats better to make a mistake or to wait for the phone call?

Its all about educating the families. Cultural difference has nothing to do with it

achot chavi · Dec 14, 2008

i would love to be not interrupted. gosh, i could be so productive. :) i would think a lot less stress as well.

what would rotating your nurses do? i would be upset if i was rotated because of my peers behaviors. (punish the lot because of the few) i never agree with that mentality. it lowers morale and i find it quite passive-aggressive. you should confront the nurse(s). be more proactive. if they can't improve with genuine help and training...then dismiss them.
the problem is not with the night nurse who is just doing what her head nurse is doing- the problem is with the head nurse who is really wonderful but looking for an easier morning- she is going through some personal problems etc. we talked to her and she denied it then admitted but says it wont happen again. i agree that staff rotation lowers morale. i don't find it passive aggressive because i expect my nurses to be mature and honest. a patient is a patient they are all important and a nurse is expected to enter any unit and deal with it - in the hospitals they have new pateints every day etc. believe it or not sometimes a new nurse sees things differently and is able to solve a problem that others were unable to solve. but i respect your opinion.
what are you at this facility. you talked about the don in another post... are you a unit manager?

i am the adon

achot chavi · Dec 14, 2008

I see what you are saying. You are saying careplaning... I would call it, using the nursing process. The nursing process can be used for things other than nursing (as you mentioned before)
Where are you from?? You mentioned Russia, but your location says Israel

I'm an American, trained in New York - licenced RN from there, currently living , We have many Russian trained nurses .

achot chavi · Dec 14, 2008

And I never consider myself to be silly when dealing with med errors.

never said you were-

you had misunderstood my post about care planning a med error and it not being a part of the pt record. Sorry if I hurt your feelings.

achot chavi · Dec 14, 2008

I am copying and pasting a reply from YAHSALAG from a different post : Angry ER nurse...

I'm a med/surg nurse who has tried LTC on 3 different occasions. Both times were horrible. I will never do it again because what you explain is only a fraction of what seems to be the "norm". I will never do it again.

Med Passes were a nightmare, IMO. I saw so many med mistakes that nobody wanted to acknowledge. One nurse gave all the medications from 8am to 6pm for the patients, so she wouldn't have to do a repeat pass. It was insane. They also would document all meds as being give, even if they were refused by patients because they said "the state doesn't like it if they see meds as not admin'd". Absolutely crazy.

THIS IS WHY I DON"T ALLOW MY NURSES TO BE DISTURBED DURING MED PASS- ONLY FOR REAL EMERGENCIES.

Who are we fooling when we say that we can multitask during med pass? We are not SUPERNURSE, only human beings trying to do the job at hand