Medication error scenario

ckh23, BSN, RN · Jan 31, 2012

Everyone is wrong. I personally think the nurse that discovered the error is more culpable because he/she is actually aware of the error and continued it. Although the patient is getting the 10mg with two tablets, they are also now getting 650mg of Tylenol. The order needs to be clarified and the proper meds need to be obtained.

PinkRocksLikeMe · Jan 31, 2012

I would say since it is YOUR responsibility to do the 5 rights it is every single nurse that gave the wrong dosage.

psu_213, BSN, RN · Jan 31, 2012

Both sides are wrong. The order is for Norco 10/325. The nurses that gave 5/325 didn't give the prescribed dose. Nurses who gave two 5/325 pills gave the correct amount of the narcotic, but twice the prescribed dose of the APAP. Is there even a 10/325 combo of Norco? If not, they would need to give one 5/325 Norco and one 5 mg hydrocodone. I know I have had to do that with oxycodone when 10/325 Percocet was ordered. I really don't see where the clarification for this is needed...it was a pretty simple order that two sets of nurses didn't do correctly.

Who should write up the med error? Whomever caught the mistakes. Could be the nurse who made the error, it could be someone who came along later.

NurseOnAMotorcycle, ASN, RN · Jan 31, 2012

I agree with psu_213. The order was clear. The nurses who administered made the errors. I would have called pharmacy to send the new dosage (10/325).

I also thought this:

Norco "2" 5/325 q 4 hrs AND Norco "1" 10/325 TID

Was one of those d/c'd? Was the patient supposed to get one of them PRN? If the first was d/c'd, was it yellowed out and noted? How could the administering nurses sign for it if it was?

KelRN215, BSN, RN · Jan 31, 2012

Quick scenario: Pt returning to ltc from acute care with new medication orders.
Norco previously ordered number "2" 5/325 q 4 hrs, packages labeled hydrocodone 5/325.
New order written: Norco "1" 10/325 TID.
3 different nursing staff was giving "1" 5/325 TID .
Nurse that discovered those errors gave "2" of the 5/325 hydrocodone so pt receive the 10 mg of hydrocodone as patient was in severe pain, in middle of night, and left note requesting order needed clarification from Dr.
Whose error was this and who should be writing med error documentation?
Should the Dr. have written Percocet 1 TID or just hydrocodone 10/325 1 TID?

I agree with what everyone said. No one gave the ordered dose of medication. The patient was ordered for 10 mg of hydrocodone + 325 mg of Tylenol as Norco, which does come as 10/325. (I'm used to Vicodin which is 5/500.) Everyone who gave one 5/325 pill gave half the ordered dose of hydrocodone. The person who gave two 5/325 pills gave double to dose of tylenol.

Percocet is tylenol and oxycodone, which is not the same as Norco, which is tylenol and hydrocodone.

mazy · Feb 1, 2012

That order is a complete mess. I can barely make sense of all the mistakes that led to such a fuster-cluck of med errors.

It almost sounds like people were confused about the dosing of percocet 5/325 and not understanding that Norco is hydrocodone. Everyone was wrong. No one knew their meds.

And Percocet is not Norco. Two completely different meds.

The person who gave the med and requested clarification is probably going to take the hit though.

Vespertinas · Feb 1, 2012

and percocet is not norco. two completely different meds.

i know! i thought, "is this a trick question?" were we supposed to identify the third hidden medication error in your post?

i guess this sums it up:

everyone was wrong. no one knew their meds.

Kashia, ASN, LVN · Feb 1, 2012

No one gave Percocet:-) But I do agree it is a complete mess. Not only this scenario but

the whole dynamic going on there.

Jamie73 · Dec 23, 2013

The question still remains should Percocet 1 TID have been ordered rather than the Norco??? How and why would this benefit the patient?

Emergent, RN · Dec 23, 2013

Should the Dr. have written Percocet 1 TID or just hydrocodone 10/325 1 TID?

Percocet is Oxycodone and Tylenol, NOT Hydrocodone and Tylenol.

LPN_FTW · Dec 25, 2013

The finding nurse would write the report, but the doctor, the transcribing nurse, and every nurse failing to exercise their medication rights should be informed of their errors. I hope this pt had PRN medications and that he/she received them.