Med error or not

Nurses General Nursing

Published

This happened a few weeks ago. This facility is in a lot of trouble with the state for numerous medication errors that have been going on for months. They have medication techs that give medications on all areas.

This one day, a nurse was not told about any problems with a patient not getting coumadin or lovenox since her arrival at the facility. She did not work on that unit very often, but enough to know that there are problems there. She recieved a phone call from the doctor's office staff asking if the lovenox and coumadin had been given yesterday. There was no coumadin orders in the chart that she could find, but the lovenox had been given the previous shift and by her at 9 am. She called the PT/INR to the doctor office and asked for the coumadin and lovenox orders for that day and when the next recheck should be. She wrote the orders out on the chart. The ward clerk took off the orders and assured the nurse she had done everything to the order. The only thing the nurse had to do was note off the order. The nurse and the ward clerk both called and told the pharmacy and stressed how important it was that the patient get the medication. The nurse's shift was over and she gave report to the oncoming nurse. The coumadin and the lovenox is due on her shift. The nurse told her about the problems that they had encoutered. The charge nurse knew all about it and went in and told the rest of the story that the other nurse did not know. This conversation took place in front of the nurse coming on.

The next day the nurse that took the order and noted it off was called on the phone and fired on the sport. The medication had not been given. The ward clerk had not been honest and did not write it on the medication sheet. The med tech did not give the pill even though it was delievered in time.

Having said all that, my question to everyone is: Is that a medication error on the day shift nurse or the evening shift nurse? Should the nurse that noted off the order be fired, written up, or suspened or what?

i would say it’s the oncoming shifts fault. she gave report mentioned it still needed to be given, accountability was transferred. that happens often, maybe the patient is out, med has not arrived, doc ran away with the mar.

firing over the phone for a first time incident is not right. it sound like they were looking for someone to take the fall or some reason to get rid of this specific nurse. if the place is really so terrible then it might be a blessing before there is a really big error made that cost her more than her job.

Wait why is the ward clerk noting it on the medication record?

Specializes in Cardiovascular, ER.

If I read your post correctly, I would say it is an error on both nurses parts. If I knew there was such a problem with the pt getting their coumadin - I would not take anyone's word that it was on the MAR, I would double and even triple check it myself that it is indeed there. I would even chart, order rec'd from MD and noted on the MAR, oncoming nurse notified of med to be given.

The oncoming nurse has accountability to give the med too.

That being said, firing seems harsh unless it is a chronic prob for the nurse.

Specializes in LTC, Psych, Hospice.
Wait why is the ward clerk noting it on the medication record?

I'm wondering the same thing. :confused:

I am beng told by the nurse, that the way the facility does it. The ward clerk writes it on the MAR and that the nurse is suppose to check and make sure that the medication is written correctly. The problem with this is that the medication tech's usually have the med books some place else and the nurses do not always have acces to it. According to her there are a lot of problems with getting charts, medication records and other documentation a nurse needs. This is a common practice and everyone thinks you are being a ***** if you say anything about it. This nurse tells me of an hour and half that she looked for a chart in order to call the doctor a critical lab.

Specializes in psych, addictions, hospice, education.

I think firing over this is extreme, but isn't "noting" intended to verify that orders have been transcribed where they belong? Otherwise, what's the point to noting.

Sounds like the place had a lot of problems and they were looking for a fall guy. I hate that this happened to this nurse but it may have been a blessing in disguise. I'd hate to see a nurse have an action by the board against them for something that really is not their fault.

Specializes in Medical Surgical & Nursing Manaagement.

Being fired for not giving a med, I agree is somewhat extreme but I do have some questions.

What time was the ordered received, what time did the pharmacy get notification? Since the clerk entered the med on the MAR the RN is responsible for verifying it is correct and then give it. This is why I don't like anyone other than an RN writing on the MARs.

Specializes in Telemetry, ICU/CCU, Specials, CM/DM.

What type of facility is this? In the hospital where I worked, only the nurses wrote on the MAR when an order was received and it was not noted until the order was verified with the chart. Firing a nurse for this sounds very extreme though.

This sounds like a place that is cheaping out by getting everybody they can who is not really qualified to do part of the job of an RN. Also, would help them to be EMR. Even though there are times you hate EMR, here is one time you'd be glad to have it.

report this place stat to the state dph.:uhoh3: or you look like you're complicit.

can i get an "amen"??

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