Medication Error

Nurses General Nursing

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Specializes in Telemetry.

I am an LPN working with an agency. Today was my first day at a facility I have never been to. The facility is a nursing/rehab center, so basically a nursing home. I was placed on the Long Term unit with 33 patients and 3 nurses aides. Besides a completely messy nurses station, I noted that there was not sufficient supplies and support. I had to pass medications and do treatments , vitals, and assessments on 33 patients. At this facility they use a computer MAR attached to the med cart. This computer kept turning off despite the fact that it was charged. It turned off about 10 times or more during the shift, but it would turn on after I pressed around. Bottom line it was an insane shift where there was no time but to pass meds, and complete my tasks as quickly as I could. When doing count at the end of the shift I noted I missed a dose ( narcotic) of a patient. The supervisor was notified and a report was made. I feel as if this was completely out of my control and unfair due to the circumstances, what do you think? Also, I wanted answers on where medication error reports go. Will I be contacted by the board of nursing? Will it show up on my license? What happens next?

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Missed it as in overlooked giving it?

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Specializes in Psych (25 years), Medical (15 years).
Missed it as in overlooked giving it?

Or, as in a narcotic dose was missing?

Discrepancies need to be resolved at the end of the shift, and if the dose cannot be found, a UDS is usually done.

I don't know of anyone who ever got in trouble for a missing dose of a narcotic, that was not diverted, but there is protocol that needs to be followed.

If it is as Sour Lemon asked, it's merely a med variance and the facility's protocol needs to be followed.

I don't think it's a big enough deal that you have to be concerned of putting your license in jeopardy, nerdynurse7. Mistakes do happen.

Good luck to you!

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Specializes in Case manager, float pool, and more.

Ditto what the above said. If it was missed due to not being given but the narcotic was still accounted for then I would not be concerned for your license. However, it does sound like this particular facility needs help. IMO 33 pts sounds a bit much. But maybe that is the norm nowdays. Last time I worked LTC I had 26 pts. Best wishes.

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Specializes in Telemetry.

The medication was accounted for, missed dose as in I never gave it. It was a narcotic.

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The medication was accounted for, missed dose as in I never gave it. It was a narcotic.

Incident reports are internal. No one at the BON would be remotely interested in this very minor oversight. You're fine :)

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Specializes in Psych (25 years), Medical (15 years).
missed dose as in I never gave it. It was a narcotic.

Med variance. Follow protocol, and if I'm not mistaken: end of story.

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Specializes in Case manager, float pool, and more.
Incident reports are internal. No one at the BON would be remotely interested in this very minor oversight. You're fine :)

Med variance. Follow protocol, and if I'm not mistaken: end of story.

Exactly.

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Specializes in Telemetry.

Thank you. It was my first time, I was extremely nervous. Definitely more careful now, still feel terrible about it.

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There are much worse meds to overlook giving. I don't mean to sound callous. I realize it's a mistake and it probably meant the patient was in more pain than they needed to be but they won't die from missing a dose.

The BON will not be interested.

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