Med Error?

[navydad51]

I wrote myself up for a med error last night, but now that I have had the time to think about it, I may not have been the one who made the error.

A new admission (I work for a sub-acute rehab) was to receive MS Contin, 15 mg. 1 tab PO q 12 hrs. It was written correctly in the MAR, however only plotted for 10PM (should have been 10 AM and 10 PM) I work the 3-11 shift, so, the patient did receive the dose on my shift. This went on for about 3 days. During report the day nurse pointed it out to me as though it was my fault because it was my admission, however I did not fill in the MAR, someone else did who was helping me that night (we had 5 admissions, crazy night) so I wrote the med error. As I thought about it, did I make the error? Technically no, I gave my dose, it was the morning nurse that missed the AM dose and should have notified the ADON on the error.

I am not looking to escape responsibility here, I should have read the whole order just as much as anyone, but in actuality I gave the PM dose.

A domino affects here, the one that plotted the med, to the morning nurse not reading it, to me. I feel as though the morning nurse was trying to pass the buck to me by pointing out the mistake instead of writing herself up for the error. Oh well, I did the right thing, notified the Doc, wrote the med error report, did my job.

Thanks for any feedback on this!

[rn-jane]

I would bring it to the don's attention that the patient missed the dose on the am shift. Technically you should not be the one in question with the med error. The one filling out the mar and ultimately checking the mar and the nurse that omitted the med by not reading the full order.

[JomoNurse]

hmm.... well, at our hospital, it's the night nurse's responsibility to double check the MAR during the chart checks. i don't think it's that big of a deal, though. think of it as a harmless reminder of how important it is to double check everything. i'd much rather give one less dose than one extra dose, that's for sure! :-)