Med Error?

The right patient got the right medication, right dose, right route, at the right time. I don't see a medication error. Sounds like more of a facility policy/issue as far as drawing from the wrong card goes. It's pretty easy to see that everything was correct but the card. I wouldn't even write an incident report. I hope your supervisors aren't harsh about it.

part of me says not incident report worthy, however, part of me says yes. It was not a medication error as the patient did receive the correct dose, route, etc. But this could be a system error of labeling. This time it wasn't a big deal, but the next time it could be. There are holes in the system and sometimes these holes need to be patched up before something big happens, the Swiss cheese effect when all the holes line up leading to a potential centennial event.

I am glad that this was not a medication issue, but maybe something should be looked at in the system to prevent events in the future.

I do not see a medication error here. If you gave a dose labeled for prn use instead of a dose labeled for a scheduled dose and all things are equal there is no mistake unless the scheduled dose needed to be used first or at that time due to an expiration date.You could easily take the dose placed in the scheduled bag, to use your words, and place it in the prn dose bag. That is if I am understanding your scenario correctly!

Did you document somehow that you gave from the PRN instead of the scheduled? Since the doses are the same, not a med error. You have now learned to watch carefully which one you pull the med from though and will be more careful going forward.

Did you document somehow that you gave from the PRN instead of the scheduled? Since the doses are the same, not a med error. You have now learned to watch carefully which one you pull the med from though and will be more careful going forward.

True it is not a med error. But I think an incident report may help to demonstrate a potential area for an error. It could prevent someone from making a bigger error. It is about a system process and there is a hole in this process. The next person may not be so lucky.

Unless incident reports are treated as major only in your facility, deserving of punishment, I would fill it out. There's no medication error but there is a narcotics control issue. When one bag comes up short you could be asked to account for it, and either they may not listen when you point out that Bag B is up one, or the extra dose could go missing somehow and you'd be held accountable. If it weren't narcotics, I would say not to worry about it.