med error

Inaniel · Feb 17, 2014

- however this resident was, IMO, "snowed" from the previous shift. She was responsive/easily arousable but denied having any pain and had been given her PRNS -moprhine, ativan, haldol, tylenol - at every available

I say she was overmedicated because this resident generally is screaming out at night but this particular night she was sound asleep.

x19amanda · Feb 17, 2014

I understand your reasoning, but if it was scheduled it needs to be given. How often is it scheduled? If the resident is given other prn meds throughout the shift, than those prn meds should be ordered for Q so hours that does not interfere with the scheduled meds thus causing harm. Hopefully the MD took this into consideration before ordering the meds which I'm sure they did. This resident seems to be in severe pain, possibly Hospice? Always give a scheduled narcotic.

Momtomykiddos · Feb 17, 2014

What kind of documentation did you do when you held the med? There's a big difference between simply not giving a med (appears as if you just overlooked it), and thorough documentation as to why you held it--assessment of patient, nonverbal pain score, administration times of other PRN meds, your plan to reevaluate pain, notification of the doctor.

How often is it ordered? Is she maxing out on her PRNs? If this was a once a day med, and she is taking max PRNs, her pain might not be controlled throughout the day without it.

LTCNS, LPN · Feb 18, 2014

What kind of documentation did you do when you held the med? There's a big difference between simply not giving a med (appears as if you just overlooked it), and thorough documentation as to why you held it--assessment of patient, nonverbal pain score, administration times of other PRN meds, your plan to reevaluate pain, notification of the doctor.
How often is it ordered? Is she maxing out on her PRNs? If this was a once a day med, and she is taking max PRNs, her pain might not be controlled throughout the day without it.

This is pretty much what I was going to say. Thorough documentation, and reevaluation with follow up documentation is key. I wonder how her pain level is during the day?

KUDOS to you for offering pain medication prior to therapy! Being a chronic pain sufferer myself, I am a huge advocate for pain control. Although I'm sure many nurses give pain meds., too many just don't. A resident does not have to be verbal and alert to verbalize/exhibit signs of pain.

I hope the meeting goes well with your DON. I hate to say it, but if you didn't document why you held the pain med., she will either counsel you or give you a written warning. Sounds like you did a wonderful job overall and are a great advocate for your residents. Keep up the good work!

pinkiepinkPN · Feb 18, 2014

Do most med error incident reports result in a write-up? First post new grad, NOC charge nurse. Had a crazy night the other day...We were short -had 4 CNAs for 100+ residents, as well as three 9pm admits; I come on at 10p and have to get admit paperwork, observations, and my own full-body assesment b/c i don't "trust" the PM/admit nurse's assessment, plus TBs done ...I spent a lot of time helping CNAs with morning get-ups (hoyers) and completing several time-consuming day/PM TXs due to our wound nurse resigning..plus toileting/changing/turning residents during my midnight and morning med pass; more-so than usual d/t being short. Busted my butt and did a great job that night. Written up the next day for not giving a resident scheduled morphine cream - however this resident was, IMO, "snowed" from the previous shift. She was responsive/easily arousable but denied having any pain and had been given her PRNS -moprhine, ativan, haldol, tylenol - at every available time d/t her family being in the facility during the PM shift and requesting her be medicated even when not warranted. (This resident can be sound asleep and her family will request her Ativan/Haldol/morpine be given all at once). I'm worried about this med error/incident and kind of find it ridiculous that I might get written up for this. Comments/suggestions? I understand I was technically at fault for not giving a scheduled pain med, however this person was sound asleep and when I gave the AM meds she denied having pain. It's silly to me because there are long-term residents there that are non-verbal/non-mobile and probaly in pain but don't even have PRN tylenol?!? Despite e faxing MDs and asking the day nurse to f/u it never gets done. I DO understand pain management and when signing out my morning Narcs (I offer pain meds to my resident's in the morning b/c they go to PT early before breakfast and I don't want them to be hurting) I find that I'm usualy the only nurse they've gotten pain meds from that 24hrs.... Should I even make my case in opposition to this write-up or just take it as a lessoned learned? Meeting with the DON this week. Thanks.[/quote']
Sorry to have to regurgitate your quote but my phone won't let me just reply.
Anyhow.
My first reaction is that if we got 9pm admits I'd quit my job. I work PRN NOC and days and night are so jam packed with a 5 hour med pass for 50+ residents plus a craaaapton of paperwork- if we got late night admits on top of that I'd go postal for sure. The latest we take admits is 4:30 pm!
I think it's silly for you to get written up for this but of course we all work within a totally convoluted set of rules and regs. Be straight wih your DON- you used nursing judgment to conclude that his dosage of narcotic was not only unnecessary but could have been harmful. I would request that the DON speak to the POA (if the DON agrees with you) and educate them about the dangers of over medicating with narcs especially. Perhaps the family is really clueless about these meds and they're no aware that a different dosage or making some PRN would keep the pain under control adequately.
Pain management is some tricky shizz. Some nurses give every scheduled AND PRN and some are reluctant to ever give PRNs. And you never know which route will lead to termination faster.

DHawkinsrn · Feb 18, 2014

To OP: I completely understand your opposition in giving the scheduled med. If you find yourself in this situation again you should call the on - call MD and get a order to hold the med due to the patient being sedated. Place the patient on 24/hr report and you are covered.

ktwlpn, LPN · Feb 18, 2014

It's great that you get in there and help the cna's with the direct care but remember -you can do their job but they can't do yours. You can't work yourself to death like this and run the risk of med errors that could potentially lead to the loss of your job.

CapeCodMermaid, RN · Feb 19, 2014

Pinkiepink....you'd be quitting most places. We take admissions 24/7. It's not the best for the resident to get there that late, but, if

that's when they are sent from the hospital, we admit them.

LTCNS, LPN · Feb 20, 2014

Pinkiepink....you'd be quitting most places. We take admissions 24/7. It's not the best for the resident to get there that late, but, if
that's when they are sent from the hospital, we admit them.

This is so true, especially for a skilled rehab patient. I've also been witness to a nurse being terminated because she told a hospital they couldn't accept a patient during shift change.

pinkiepinkPN · Feb 20, 2014

Pinkiepink....you'd be quitting most places. We take admissions 24/7. It's not the best for the resident to get there that late but, if that's when they are sent from the hospital, we admit them.[/quote']
Lol well we don't. It's company policy ...none after 1630. There are 6 nurses covering 6 units during day shift...at night , TWO nurses cover three halls each. An admit would KILL you lol

pinkiepieRN · Feb 20, 2014

How did you document? Did you document that you held the med? Did someone else catch that you hadn't signed it off? Did someone say you were getting written up?