med error?

[Medsport, LPN]

For information purposes only say during count there is one too many meds of one kind and one short of another for the same resident that the nurse passed pills to the night before. The nurse could not find the missing med and assumed he/she gave the resident two of the one and not the other. There was no report by the resident it was wrong (this resident is aware enough that they usually would know if it was wrong), but you are not sure. Would you do an incident report or med error sheet or just put "error" or "wasted" in the narc count book in the appropriate place? This would be at an assisted living facility so rules are not as strict as say a nursing home, but this has never happened like this before and the other nurses don't seem to know the correct procedure as to what you are supposed to do either.

[rnlately]

Working in LTC, I would say it's an error. Let me see if I understand you correctly; Example: Patient is scheduled for Lortab @2100 and I mistakenly pop and administer Ritalin @2100 which she also received @1700 and is a QD med only. When it's time to count at 2300 I'm short one Ritalin and have 1 too many Lortab then yes it is an error because I double dosed one med and didn't give the proper one at the proper time. I don't know if or how guidelines differ in ALF but this is just my opinion.

[TheCommuter, BSN, RN]

It is a med error, but I wouldn't write it up as an incident report without at least privately approaching the nurse who was responsible for the error and informing her/him and giving them the chance to explain what took place.

I think it's so very passive-aggressive and counterproductive when people write up med error reports and incident reports without first consulting the nurses who were involved.

[OgopogoLPN, LPN, RN]

It is a med error, but I wouldn't write it up as an incident report without at least privately approaching the nurse who was responsible for the error and informing her/him and giving them the chance to explain what took place.

I think it's so very passive-aggressive and counterproductive when people write up med error reports and incident reports without first consulting the nurses who were involved.

ITA!! I missed giving a dose of valsartan to a very stable, low risk LTC resident one day. The resident suffered absolutely NO ill effects from this error.

The nurse who came on shift after me discovered the med in the residents drawer on the med cart and reported it to the DON who in turn emailed me and asked me to do an incident report. I have NO PROBLEM doing that and admitting my error, but really? REport it to the DON instead of letting me know first?

There are times when I see missed doses and will always let the nurse know and usually don't take it any further. Unless it was a critical med like chemotherapy.

[Medsport, LPN]

Ok, lets say it was yourself that made the error, but nobody else really knows (ex. maybe the person you counted off with) and the patient showed no ill effects. Would you still report it? btw, say there are no real guidelines on what to do at this place and when meds come up missing once in awhile (not a bunch, just the occasional one) two nurses sign off and sometimes just one does and sometimes they right "missing" and sometimes "wasted" or "error".

[rnlately]

Ok, lets say it was yourself that made the error, but nobody else really knows (ex. maybe the person you counted off with) and the patient showed no ill effects. Would you still report it? btw, say there are no real guidelines on what to do at this place and when meds come up missing once in awhile (not a bunch, just the occasional one) two nurses sign off and sometimes just one does and sometimes they right "missing" and sometimes "wasted" or "error".

I would still report it. Assuming that you won't be working in this facility for the rest of your life, you wouldn't want to develop the practice of sweeping med errors under the rug. You will run across many drugs or combination of drugs that will produce no ill effects, even when administered incorrectly; but that still doesn't make it okay. Once we develop bad practices in one area of nursing it's hard not to carry them with us when we move on to different areas. I hope this helps.

[Lorrie34]

It's a med error. If you didn't give what was scheduled and double-dosed on another med, that is a med error. If this was your own mistake, I think the moral action to take is to report it to the DON and let him/her make the call if an incident report should be filled out. Many times, if the medications given and missed were not meds that could result in serious consequences for the resident, the DON will simply give a warning or write up the nurse responsible, without doing an incident report.

We are human and mistakes happen because we can't be perfect all the time. But I believe that nothing entitles us to ignore our imprefection. We learn from our mistakes.

ALF are different because the residents are more like if they were in their own home and taking the meds themselves, and in that case, how many doses would a person miss on their own for different reasons? It isn't the misssed dose that is the issue, rather the double dose that is the concern.