Medication transcribed then immediately d/c'd now boss write up transcription error

Published

I was verifying admission orders and transcribed a medication that had been dicontinued. I immediately d:c'd the medication so no harm no foul. Now my boss wants to write me up for transcription error. Can she do this? The pt never recieved the medication.

Specializes in Med/Surg, Ortho, ASC.

"They" can do whatever they want in terms of writing you up. It does appear that you made a transcription error.

How did you transcribe a med that "wasn't ordered"?

I was looking at medications from hospital then we found original d/c orders. Then had the RN to verify. It was never given.

Specializes in Registered Nurse.

They can do whatever they want. Employers make the rules, unless there is something that specifically states you did not make the error per policy or procedure or you have a union representative who can appeal this for you.

I work with a group of ten physicians. Typically medication list are NOT updated during office visits. Most days, there are no RN's in the clinical area. Medical assistants do most of the clinical aspects in office settings. Nurses have to go through the office notes to make sure a change did not occur before sending out an electronic RX where I work. I and sometimes the MD or APN has actually caught medication errors sent by prescribers (MD, APN), but called pharmacy to stop an order that was entered inadvertently. I've been lucky with my data enry, but see the potential for errors. EMR's have drop down selections for medications and one quick move or click and out goes the wrong medication. Nurses are expected to reply promptly to request for medications and the volume of incoming request is excessive. I have started to slow down, but still get pressure from management and others to speed up the process. I feel your pain. IMO, they penalize nurses far more than they would penalize an MD or APN. If the patient DID NOT receive the medication, I feel there is no need to write you up for this. However, Your employer can do whatever they want and they are not likely to listen to me.:banghead:

Specializes in Med/Surg, LTACH, LTC, Home Health.

Your supervisor can do whatever she wants...right or wrong. If you feel her actions are not justified, just remember, she has a 'boss', too.

But, what exactly is the reason for the write-up? Is she wanting you to pay closer attention to orders? Is she wanting you to be more aware of the potential for harm? Have you been the recipient of other warnings? Who called the error to your attention, and how long was the error on medication record?

The scenario you described is described as a near-miss at my facility. When they are discovered, we report (write-up) those, not as punitive indications, but as continued learning and patient safety awareness needs.

What was the nature of the D/C? Was it a med that the patient had been on but it was already D/C at the admission, or was it actually an error in transcription where you invoked "D/C" to take care of the error? If it was the latter, I can see the write-up, but if the pt had actually been taking the med but it was already D/C, no problem, as I see it. "Left over" entries are frequently carried over and resolved by writing "D/C on (date of D/C)". In one case, the boss is being finicky. In the other case, she probably wants you to pay better attention.

I had the same scenario happen to me as a new RN. The nitpicking in nursing is just atrocious. If you found the error yourself and discontinued, and it was never given to the patient, medication returned to pharmacy, I do not understand the commotion.

I caught the error myself when I futher examined all the paperwork sent from the hospital. Even put a comment on the order "Admission order clarification- not on discharge medication list". Our ehr prints all the meds active and discontinued. No I havent been written up for any medication errors.

Specializes in Hospice.
I caught the error myself when I futher examined all the paperwork sent from the hospital. Even put a comment on the order "Admission order clarification- not on discharge medication list". Our ehr prints all the meds active and discontinued. No I havent been written up for any medication errors.

If your supervisor does end writing you up for this error, I would place the information you stated above in my response if it was me. The key is keeping your response (verbal and written) professional.

Specializes in Pediatrics Telemetry CCU ICU.

This is no different than when a preprinted MAR is sent to a facility from a Pharmacy. If your supervisor is that nitpicky, then she would have to write up the Pharmacy for every entry you have to discontinue manually on the MAR. As long as it was not given and it was clearly and completely discontinued, then why should it be a problem? SMH...nursing never changes.

I was verifying admission orders and transcribed a medication that had been dicontinued. I immediately d:c'd the medication so no harm no foul. Now my boss wants to write me up for transcription error. Can she do this? The pt never recieved the medication.

She can do it.

However, she has apparently failed to convey the lesson she hopes you will learn. Personally, I do not comprehend exactly what you did wrong.

Why shouldn't all of the discharge orders be in one spot? Why should you have to look at the entire set of papers coming from the hospital before spotting all of the med orders?

This is part of the insanity created by electronic medical records.

Best wishes in dealing with what I see as ineffective teaching and guidance, and as nitpicking by your boss.

Ummm,.....you might point out that the very purpose of verifying orders is to check for mistakes and correct same. Sounds like you did just that. If you transcribed the med incorrectly and didn't catch the error immediately, that's another thing altogether. She should be happy you correctly entered the info in the end.

+ Join the Discussion