Medication Error Question

[BonnieSc]

I'm a unit nurse educator and have a medication error to deal with: dexamethasone clearly prescribed for one day (3 doses) but it stayed on the MAR and the nurses continued to give it for four days.

Now, obviously there is a pharmacy error here in that they continued to supply it, but apart from that, the nurses all should have seen clearly that it was to be stopped after three doses.

I want to do some education regarding this, but can't decide which of the Five Rights this error might fall under. Right Time? or Right Dose?... The takeaway is really "read the damn order", but I'd like to put it in the Five Rights framework.

[CTnewgrad826]

Right time seems to be the most applicable here but if it were to be stopped after 3 doses why did it continue to show up in the MAR for days after the fact? As you stated multiple people involved in this error

[Dachshund9]

The pharmacy should have taken the medication off the MAR since the patient was no longer taking it. Things like this do happen though, I have had it happen to me many times. If I'm doing my 5 checks before giving the med, it's then that I realize I'm giving a med I'm not suppose to be giving. I think both wrong time and wrong med would be appropriate in this situation since the med shouldn't have been given at all. The med error started with the pharmacy, and we all know well enough, if we,, meaning nurses give any med we will be held accountable.

[blackribbon]

We almost need to include "right computer program" or safety program in place. Both hospitals (one very small and low budget and the other is the #1 hospital in our state) that I work at have programs that change colors and warn if the med is being given outside of the perimeters of the orders which includes "time". I was scanning a dose scheduled at 2100 at 2130 and it was a last dose..and the computer even made me verify that I wanted to give it since it was "past the ordered time".

People make mistakes...yes, lots of people made mistakes in this situation but where are the safety checks to help protect the patient?

[blackribbon]

Yes.."read the damn order" sounds like a simple solution but can I ask what is the patient load of the nurses on this floor and how many meds are they expected to pass within that hour "on time" window? If you want them to slow down and double check every detail of every order, then your patient load better allow them the time to do this. If not, then safety checks better be in place to help the nurse who is trying to get her job done in a timely which includes stopping med passes to get water for the patient to take their pills, answer questions the family has, and chasing down prn meds that the patient never indicated they wanted when you did your first pass through the room...all on the 6 hours of sleep that is all we can realistic get between shifts when working a series of 12 hours shifts.

[MendedHeart]

Right frequency