med errors

If anyone is using a point system for medication errors, would you please share?

[Cubby]

Would you explain what your point system is? At my facility we use a non-punitive med error. Meant to fix the problem, not point fingers! Pretty effective I think.

[ltc]

There are points assigned to four categories. Points based on type of error ie:(omission, extra dose etc.), route (po, iv, sc, im), class of drug (narcotics, cardiac, anti-histamine etc.) and why error occurred (transcription, did not verify MAR, did not follow admin. procedure etc.) Each are given a different point value.

Based on the total points determines discipline. For example 1-15 pts would be a verbal. 16-34 written counseling, 35-45 final written counseling, 46-60 suspension, over 60 termination. For the nurse who makes an occassional error the points are cleared when none for 1 year. If continues, points are cumulative. Each level has education involved ie: having a med pass observation done, observed doing a transcription, referred to education for assistance based on types of error. I was suprised at the responses we received from nurses as to why they made errors. The nurses with reoccurring errors took this very lightly and didn't understand why we were so concerned. As new nurses emerge from nursing school, I am amazed at the lack of knowledge and understanding about medications. I believe some nurses consider giving medications a task instead of a process. It's pretty scary when nurses don't even know why they're giving a drug let alone the side effects to observe for. While agree I wish this could be done is a less punitive way. However, it's frightening when you're in charge of nurses that don't take it seriously and what could happen to the resident. For these nurses there needs to be some accountability.

[kids]

I have worked with a point system similar to the one described by ltc.

I know it's not a popular opinion but I think med errors have to be tracked both as a learning and a potentially punative tool. If you have a Nurse who repeatedly makes errors in the in the med admin process then you need to educate, if the errors continue then you need to disipline.

I have done big med passes in SNFs, you have to follow the process. Errors still can happen, giving meds late or missing an incidental med (ie DSS, multi vitamin) is not potentially lethal and is therefore less serious, but what about giving the wrong IV antibiotic to the wrong patient or the wrong type/dose of insulin which is potentially lethal? These are very serious errors and Nurses who repeatedly make serious errors need to be delt with.