Medication deviation... Patient right to know?

There is an Institute for Safe Medical Practice (ISMP) organization that may cover some of these issues. They do have an Internet site. I don't know if you are being too "picky" about 1/2 hour deviations, or there are constant 2 -3 hour deviations?

Honestly, it would depend on the medication and how soon it was given for me. If I realized I accidentally gave a medicine 15 minutes early, what's the big deal? 15 minutes is nothing, especially for an oral medicine. Now, if the offgoing shift had just given a narcotic, and I immediately gave another one less than an hour after the first, yeah, the patient should know. It just really depends.

If you look at your facility policy, there is usually a time variance--ours for instance is a half hour before or after. Some facilities it is an hour.

I worked with all paper charting for years. (up until the last year or so) One of the best pieces of paper I used was a paper "brain". Each nurse should (and if you are new, you can get into this habit) of looking at the complete MAR of your patient, and noting on your brain medication times that are not "usual". Meaning, if you are giving meds at 8 and 8 or 9 and 9 but you have a med at 1400. then note the 1400 to remind yourself. Otherwise, you know that meds are due at 9am or 9pm. Same with noting antibiotics or any other non-usual timed meds. Also, when they last received a PRN and when they can get it again, should they ask for it.

If the meds are given within the facility policy time frame. then I am not sure what can be done about giving a med then giving it up to an hour early--if this is what the policy is. But not a great habit to get into. If it falls in the policy, there really is no need to say anything other than practicing your 5 rights, informing the patient of what you are giving them, and when they will get it next.

Good luck!

When I worked inpatient, we had an hour on either side of the time the med was due, so a two hour time window within which to give the med. If your facility has such a policy, then as long as the med is given within the acceptable window of time, a med error has not occurred and as such, there is no need to inform the patient.

Thanks for the input everyone!

A little more clarification.. At my facility, there is a 1-hour-before and 1-hour-after window for a scheduled routine medication. Most medication errors/deviations occur when a PRN is administered. Subsequently, the error is when the nurse incorrectly reads when a medication was last given.

The medication error that I was speaking to my DON about (That she told me not to inform the patient, as it may upset them) involved a combo of PRN hydrocodone and tylenol. As both involve acetaminophen, there are specific parameters so the client does not exceed 4g/day. First time I found this error, I privately explained to the nurse who made the error about the risks of liver damage when it is exceeded. She was receptive to to, however, repeated the same issue the following week. Since it was a repeated issue, I involved the DON (next in the chain of command). This is when she reviewed my charting and told me not to inform the patient of these errors. I just stood my ground and explained, ethically, I did not agree with it. Since this instance, I hear many other nurses saying that medication errors are not mandated to be reported to the client.

I guess, I'm mostly trying to find a black and white answer. I hate gray areas. I don't mind deviating from scheduled times by a little bit... but 2 hours too soon or too late, and especially errors that could have medical consequences, I'm most concerned about.

Thanks for the clarification. It sounds to me like this is a frequent enough occurrence that some process improvement is needed here. Do you have any ideas for how to change the process so that this does not continue to occur?

In my experience, notification about errors would handled by the physician and risk management/quality assurance personnel.

Thanks for the input everyone!

A little more clarification.. At my facility, there is a 1-hour-before and 1-hour-after window for a scheduled routine medication. Most medication errors/deviations occur when a PRN is administered. Subsequently, the error is when the nurse incorrectly reads when a medication was last given.

The medication error that I was speaking to my DON about (That she told me not to inform the patient, as it may upset them) involved a combo of PRN hydrocodone and tylenol. As both involve acetaminophen, there are specific parameters so the client does not exceed 4g/day. First time I found this error, I privately explained to the nurse who made the error about the risks of liver damage when it is exceeded. She was receptive to to, however, repeated the same issue the following week. Since it was a repeated issue, I involved the DON (next in the chain of command). This is when she reviewed my charting and told me not to inform the patient of these errors. I just stood my ground and explained, ethically, I did not agree with it. Since this instance, I hear many other nurses saying that medication errors are not mandated to be reported to the client.

I guess, I'm mostly trying to find a black and white answer. I hate gray areas. I don't mind deviating from scheduled times by a little bit... but 2 hours too soon or too late, and especially errors that could have medical consequences, I'm most concerned about.

Preferably you just don't leave the opportunity for that error in the first place, which is why combinations containing 325mg is now preferred. Taking 2 of these combination medications every 4 hours would total only 3900mg per day. If the patient requires more than 2 tabs q4 a "plain" analgesic should be added.

Since the med error wasn't your responsibility I think it would be inappropriate for you to inform the patient. Since your manager has asked you to back off I definitely wouldn't speak to the patient about it, leave the informing or not informing up to the boss.

If you personally make an error I think letting the patient know would be appropriate. I would consider that part of keeping them informed about their plan of care. I'd also check the facility policies about this issue. One hospital I worked in specifically stated that the person making the error should not be the person informing the patient...you'd want to make sure our actions are within policy, no matter what your personal opinions are.