med error

[malka]

I made a med error last week. I wrote for Amoxicillin which was the ordered med but instead I wrote on MAR and ordered from pharmacy keflex. I had just taken another order for Keflex on another pt., was stressed, only nurse for 90 pts, orders coming boom, boom, boom on phone. The next oncoming nurse did not check until 6 days later doing change over. Used to be that the noc Cmt lead would check orders p my shift 3-11, but not any more. I just feel really bad and don't know what will happen. I wrote up a med error form, MD was notified. Thanks for any replies.

Malka

[classicdame, MSN, EdD]

it was a mistake. I would recommend to your DON a review of the entire process leading to medication administration. For instance, if the facility is aware of the time demands and limited resources they are partly responsible for the results.

[malka]

Thank you for the quick reply!!! I have never had a med error like this before in my entire career and I have been an nurse for over 35 yrs. I did write it up. Pray for me. I go in to work soon. Thanks again.

[Sugarcoma, RN]

This is another example of a systems error. Yes you wrote the wrong med on the Mar and ordered the wrong med from pharmacy. I can understand how bad you feel about this. No one wants to purposely harm a patient. However before you beat yourself up too badly I would like to ask a couple of questions.

When you got the order did you write the order for amox or keflex? Does the pharmacist typically only check the mar and not the actual order? Why are you the only nurse for 90 pts? Is this norm or are you short? If this is the norm I would run!

First, you were EXTEMELY overworked and busy and I will bet your head was spinning in a million directions. Second, the doctors should really be entering their own orders (Just moved to a facility with provider ordered entry I cannot tell you how much I love it!!!). Third, the pharmacist should have been checking the order, not the mar if you wrote the order correctly. And then finally every nurse who followed you afterwards dropped the ball. I find it very hard to believe that every nurse who had that patient after you is lazy or not paying attention. The fact that so many missed it leads me to believe that you guys are way too busy!!! That is not your fault that is your manager/facilities fault!!!

We are human and none of us can claim a 100% error free rate! It is impossible. Do not beat yourself up for what was clearly many peoples error. Thank God no harm came to the patient. You have already acknowledged your part in the error. That is all you can do. I can tell from your post that you feel terrible! In the future when writing orders I would keep the doctor on the phone until you have written the order and transcribed it to the mar! Try to get another RN to verify via phone! If the docs balk tell them too bad. Do not allow any interuptions while writing orders! Let your phone ring..they will call back. If someone is trying to talk to you put your finger up to show them in a minute.

I am sorry for writing a book but this is an area I feel very passionately about. Every manager/facility gives so much lip service to preventing med errors, but no one wants to pay for the work environment that would help reduce them! And in the end it is always the nurse they hang out to dry. I watched my best friend and a great nurse get hung out to dry for a med error. It is disgusting to me. Provide a safer work environment with less distractions, rest, meal, and bathroom breaks and error rates will drop!

[eslvn]

What do they expect being the only nurse for 90 patients thats insane and impossible!! I would find a new job and report to the state because I dont know what state you live in but that doesnt sounds legal.

[bill4745, RN]

In most hospitals I have worked in, a carbon copy of the order is sent to pharmacy, so that they can see exactly how the order was written. Apparently your facility doesn't do this?

[xtxrn, ASN, RN]

What do they expect being the only nurse for 90 patients thats insane and impossible!! I would find a new job and report to the state because I dont know what state you live in but that doesnt sounds legal.

It's legal...

Most states don't care about (or even have) ratios in LTC...if there haven't been problems- repeated with the same situation , no changes- and I can pretty well guarantee that one med error won't cut it for new staffing...not good- but how it works.

But, the system for orders sounds nuts. Do you not fax the actual order to the pharmacy? If you have to re-write the MD order onto a fax form, that's a set up for errors. There are infinite ways this can go wrong.

Don't beat yourself up OP- you made a mistake- didn't sound like the patient had any adverse reaction (was the original condition requiring ABTs 'fixed'?).

If they do more than just acknowledge your own med error report with a "thank you- ok", they're nuts. JMO

[Esme12, ASN, BSN, RN]

I made a med error last week. I wrote for Amoxicillin which was the ordered med but instead I wrote on MAR and ordered from pharmacy keflex. I had just taken another order for Keflex on another pt., was stressed, only nurse for 90 pts, orders coming boom, boom, boom on phone. The next oncoming nurse did not check until 6 days later doing change over. Used to be that the noc Cmt lead would check orders p my shift 3-11, but not any more. I just feel really bad and don't know what will happen. I wrote up a med error form, MD was notified. Thanks for any replies.

Malka

:hug:.....you're human. Sounds like a systems error to me, takling orders on 90 patients is a set up for failure and a sentinal event. At least it was an antibiotic for antibiotic;). FOrgive yourself!!

[Isabelle49]

This is not a human error, it's not an accident. The problem here is 90 patients! Are you kidding me? The bigger problem is if harm comes to one of the patients because of your staffing, you will be held responsible and understaffing will NOT clear you. Your license is on the line Big Time and it's only a matter of time before you get burned. When will nurses ever learn? Just sick of this kind of stuff.

[tyvin, BSN, RN]

The cold hard reality is that they won't care and nothing will change. I have unfortunately worked under more stressful conditions then that (267 bed facility as a house supervisor) ah ha, talk about stress. But the only thing you can do is be more proficient. Make notes and keep list and follow through. I never relied on my memory especially with med orders, I wrote it all down in scratch and then transcribe, checking and rechecking. Unfortunately that is the only way to survive in some of these places ... it is what it is.

Who knows, perhaps we're all in need of a miracle and they will change the patient load ... let's see.

[jujuseah, RN]

A SRN caring for 200 patients serving medications and she had a medication error and she was up in trial but was acquited with a verbal warning. THEY HAD TO LET HER OFF caring for 200 patients THATS CRAZY! My eyes would have been crossed not mentioning how many million meds one geriatric pt can have.. imagine 200 geri pts. life is f u c k e d up.