Medication errors

VANurse2010 · Dec 3, 2015

Medication errors are not treated punitively at my facility as long as there's some systems element involved in it, which is the case 99% of the time. In fact, I'd say the majority of the time minor medication errors are covered by a physician agreeing to give an order for what is given. Patients are not generally informed of errors, but it just depends on what it was and the situation as a whole. LTC is a different beast, however. You can't wipe a patient's @ss without an order, 15 pieces of paperwork, and informing the family and the doctor.

fangirl · Dec 3, 2015

I completely agree about the paperwork. It is absolutely ridiculous! As an example, if someone has a small scratch, self inflicted, this is what is involved: call family, call doctor, call unit manager, put in treatment order, print Treatment recored, print order, fax pharmacy, make out skin sheet, pain assessment, change of condition skin, Braden scale, investigation and risk management, update the care plan and come up with and implement an intervention. It's ridiculous.

fangirl · Dec 3, 2015

The most common are orders that are misinterpreted and transcribed wrong, and people signing out narcotics in the medication administration record, but not in the narcotic book, which means they're not given. We still have paper MARs and paper narcotic sheets.

RiskManager · Dec 3, 2015

There is still a lot of discussion in the risk management world about error disclosure, especially if the error either did not reach the patient and/or did not cause any harm. I myself lean towards the philosophy that if the error did not reach the patient and/or did not cause any objective harm, to not disclose that. This is based upon the opinion that disclosing every error that occurs is not good for the patient's peace of mind and the therapeutic relationship. I recognize that there are many competent and experienced people who disagree with this and believe that from the patient autonomy perspective, all errors should be disclosed.

mmc51264, BSN, MSN, RN · Dec 3, 2015

when i worked LTC, we had to notify MD. Monitor if there was an issue. In the acute care setting, we have a "Just culture" where we file an internal report,, notify MD, but they look at why error occurred and what can be done to keep it from happening again. Like a PP, a non-punitive system, although if it was REALLY bad (sentinel event/death) there would have to be more serious investigation.

fangirl · Dec 4, 2015

That's the annoying part of where I work. You have to disclose everything. It sucks for building rapport with families. And it's almost always narcotics. I dread hearing the words med error.

vintagemother, BSN, CNA, LVN, RN · Dec 4, 2015

At my last place of employment, you weren't penalized or written up for a med error. Instead, we had to notify the MD, tell the pt (I think) and explain why it happened. Monitor the pts Vital Signs for awhile, take appropriate action to assure the pt wasn't compromised.

At another place, my first employer, they fired me during orientation for not transcribing an order for robitussin correctly. I didn't write the DM after it. Other nurses transcribed Coumadin incorrectly and it was never even corrected in the MAR.

I personally think that we all can learn better how to avoid a med error when the person isn't penalized, but the facility teaches all nurses about the flaw in systems and how to avoid it occurring in the future.

fangirl · Dec 4, 2015

We didn't used to get written up unless the error was major or caused harm. Lately, we are short staffed, so more errors, so here come the write ups. Nobody wants to turn in a medication error because of the paperwork and someone will be getting a write up. However, we still turn them in and do the paperwork, but it almost makes you afraid to admit a mistake. I own my mistakes. When I make a mistake, I admit and own it, just tell me how to not do it again, so I learn something. We are all human.

mmc51264, BSN, MSN, RN · Dec 4, 2015

we are short staffed, so more errors, so here come the write ups.

Why should ya'll get written up when the reason more mistakes are made is because of the understaffing. All that does is cause more stress and more mistakes. Self-fulfilling prophecy. UGH.

sjalv · Dec 4, 2015

In no particular order:

1. Tell the patient

2. Tell the attending

3. File an incident report

4. Tell your charge nurse

5. Meet with unit manager to discuss how it can be prevented in the future

Med errors are not treated punitively unless it is a recurring issue.

Elladora · Dec 30, 2015

I realize I'm a little late to the game here, but I'm guessing this might have something to do with your other post, so I thought I would answer as well. :)

I worked in a psych facility, so we handled med errors a little differently.

If a client was given the wrong meds but there was not known contraindication or allergy, they were not necessarily told about the mistake. A set of vitals was completed every 30 mins until the nurse called it good. Seriously.

If there was an issue with a med (contraindication, allergy, etc) the severity was judged. If it was something that could harm the client, they were transported to the ER (and of course told about the error). If it was something that could cause funky side effects, the client was monitored. Depending on the client's mental status, they may or may not have been told.

Insulin errors - too much, always went to ER, client was made aware. Too little, adjustment was made.

Our med errors were not considered disciplinary, rather teaching moments. There was a rather lengthy form that was filled out the QA person (me) that was then given to the DON. The nurse responsible for the error had to complete the form, documenting what steps they were taking to prevent further errors. I firmly believe a lot of these forms were shredded and never again saw the light of day. The only time it turned disciplinary is if there was a pattern of errors. (I never saw that happen in all the time I worked there).