I have been nursing for 3.5 months now and in that time I have had over 7 medication omissions, and 1 med error where I gave the a med to the wrong person. I have been counseled a couple times and I'm worried that I may be terminated soon if I can't get my act straight. I work in a LTC on the rehab unit. We can have up to 25 patients on the floor at times, but I've never had more then 19 since I've been with them. I work overnight with one aid and I am the only RN in the building, the other staff are LPN's and sometimes they can't answer my questions. When I was hired I was given three weeks of pseudo-orientation where I was working most of the time and not being trained, and my position is on weekends. Sometimes I can get an extra day in but most of the time I'm only there TWO days a week.
Now my first big omission was PO vanco dosing for 10PM and I didn't give it two days in a row, and the next time I came in I didn't give it again. Thats three times in four days that I missed this order. after I was counseled I started sitting down with the MARs and doing a thorough check, or so I thought... This last big omission was for 6Am dose of valium and again three times I didn't give this med. After my review last night I finally registered it and put an incident report on my supervisors desk. I was so scared when I saw that I had missed a med this many times in a row again. I had a panic attack. We put a red dot next to the meds that the night nurse needs to pass, but somehow I passes by it 50 times without "seeing" it.
The wrong pt with a med was when I was on another unit orienting. It was my second orientation day and I had the whole floor passing meds. I thought I knew a resident and gave her a bite of applesauce with metoporol in it, the pt was demented and non-verbal. The orienting nurse saw and stopped me thank god! This was my bad. I have gotten out of the habit of asking people their names and looking at their wrist bands since working here.
Now I know that I needed to straighten out my act, but this last omission killed me. I'm not sure what to do? Or what to say to my supervisor? Is there no excuse for me? Between passing meds and answering call lights, helping people to bed, toileting people, answering the phone, getting meds from pharmacy, and completing treatments I feel so out of my body that when I do review the MAR I don't see things. I don't like that we have a manual system at all, and I take responsibility for what happens, but I can't help resenting the facility for the lack of support as a new nurse and lack of employee safe guards when it comes to passing meds. I also feel like everyone else is doing it right so whats wrong with me? Isn't the med pass supposed to be the "easy" part of nursing? At least I wasn't thinking that it would be one of my greatest challenges. I don't feel like a nurse. I feel like a fraud when I even tell people I'm a nurse.
I want to be excited about my work, I want to be a hospice nurse and I thought I should have a bit of experience with pt care first before I did, I thought rehab nursing would be easy. Now I don't have any confidence with my work, I feel worse then I did when I was in clinicals in nursing school. Is it possible for me to get a job at a hospital with a REAL orientation if I have fudged it up so bad at this place? Can I even use this place as a reference if I've made so many mistakes? Who will hire me with this track record?
I'm also worried that this anxiety and failure is going to follow me to the next place.
I just moved here and I don't really have anyone to talk to please provide any advice.
I think it's a great idea for you to look for a new job before you get fired. This position dosen't seem like a good fit for you- Some new nurses can handle that med load- but not many. The time to get out is before they fire you- or worse yet- make a report to the BON. There may be few options in your area, but even if you have to make a geographic change- find a place you can do a good job and be safe doing it. After what you described I don't think that will ever happen where you are.
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You should always ask the patient identifiers. Please don't get out of that habit. The patient tells you their name and birth, you don't ask them if they are Martha Stewart or whatever. Print the MARs and color code as was mentioned. One patient at a time and don't allow yourself to be distracted.
Agreed.
While it's not unusual for a confused, sedated, or HOH patient to answer to the wrong name, but I've never had anyone give me another pt's name and DOB. And they could have the wrong ID on. There's always the chance that a worker thinks they know who that old lady without the bracelet is, and slaps on the wrong replacement.
You work on nights and have 2 major med passes, right? 2300 and 0600? Sometimes it can be easy to miss a med if it's irregular (like the occasional 0200) but even if you just scan the Kardex and see that something is ordered TID or Q6H or is a "before meals" med, like Synthroid, Protonix (really most of the PPI's/GERD meds), Flomax, you can see what you should be giving. Residents on ABT is something you should honestly be getting in report and charting on anyway, so I'm not sure how you missed that. When I work a cart on 2300-0700, I flag all 0600 meds after giving the 2300 meds. We also highlight the night shift meds in pink, and the same goes for the treatment books. We have up to 34 beds on a floor in my facility, and each floor is a mix of rehab and LTC. Most of our units have ~ 30 residents right now. It sounds like a lot, but it really is do-able on nights. I can count on one hand the number of residents who get 2300 meds and I'd say maybe 50-75% of them get 0600 meds. Also, it can be helpful to organize residents' drawers in the med cart, say by putting the 0600 meds ahead of the daytime, bedtime, BID meds.
I'm not saying I haven't made med errors, but it sounds like you're repeating your mistakes. If you find yourself rushing, stop and ask yourself what's more important, getting all of your meds out between 0500 and 0700 or getting the right meds to the right residents? If you're getting caught up in doing things at 0500 consistently, make it a point to get certain things done early in the shift, like changing tube feeding flushes or O2 humidifiers or Q shift vitals on someone who otherwise doesn't get anything med-wise from you.
I hope this helps. When I was new to my facility, I made a few errors of omission but I quickly learned how to avoid that problem. Figure out what works for you and stick to it. Have you asked your colleagues how they get their med passes down or manage their time? If you need a question answered, like what does a medication do, Google is your friend in a pinch. Don't feel bad asking for help. Do you have a night shift supervisor who could be of assistance or are you considered as such because you're the RN in the building overnight?
1 GNA to 19 residents seems like a really crappy deal. Our units have 1.5-2 GNAs a piece and even that can be hard.
2300 is a common med pass? I do a 12 hour shift, the 2000 is a big one and then we catch the 0600 before we go home. Personally I think a 2300 pass is ridiculous, as a resident anyway! I'd be ticked to high heaven if someone woke me up every night to hand me pills. Of course I totally understand the occasional med that needs round the clock scheduling, etc but what facility schedules an entire med pass that probably doesn't end until midnight?
2300 is a common med pass? I do a 12 hour shift, the 2000 is a big one and then we catch the 0600 before we go home. Personally I think a 2300 pass is ridiculous, as a resident anyway! I'd be ticked to high heaven if someone woke me up every night to hand me pills. Of course I totally understand the occasional med that needs round the clock scheduling, etc but what facility schedules an entire med pass that probably doesn't end until midnight?
I mostly find myself handing out blood pressure meds, like Hydralazine or Dilatizem. And the pass time is actually 12MN. Sometimes the TID meds are ordered to be given at 12MN though, like Neurontin or Baclofen, which is just kinda weird.
I wonder why they aren't scheduled for 6a-2p-10p but sometimes they're scheduled at 8a-4p-12MN. Pharmacy prints them on the MARs like that though, so most of the time they're not adjusted for 3-11 to give them at 10p although it's much easier for them to add a pill to their pass than for us to wake someone up for one pill and vitals. When I do turnovers, I will shift the med administration times to 6a-2p-10p because it just make more sense and it's still the right timing, but not everyone does that. Sometimes I see a PC med scheduled for 8a-5p-12MN when it should be 8a-12N-5p but not everyone catches that, because it would be nice to trust the pre-printed MARs from Pharmacy, created by the order sheets we fax to them, but that's a different story.
This makes me so mad. I see soooooo many posts on this site about LTC nurses making med errors. Clearly it is not the fault of the nurse. While we all know that floor nursing is overwhelming, there is something extremely broken about the LTC system. I don't care what the acuity level, 20+ patients to one nurse is ridiculous and grossly unsafe. How the hell can they expect one human being to safely administer medications to two dozen people, more than half of whom are likely polypharmacy patients? I never have and never will work in LTC, but my god I can tell from the horror stories I read that there is something extremely wrong here. Does anyone know if California has established staffing ratios for LTC nurses?
If you never have and never will worked in LTC, then you really aren't qualified to state to unequivocally about the med pass practices of those of us who do. You know what? Sometimes it IS the fault of the nurse that med errors happen. I had one a couple of weeks ago, I gave someone Vicodin 7.5/325 when their Rx was for 5/325. The two cards were right next to each other and I pulled the wrong one (no harm done and the recipient rather liked the pill I gave her rather than her own!!). Why was that anyone's fault but mine?
I can honestly say that polypharmacy is not a problem in my facility, pharmacy reviews ALL MAR's monthly and recommendations are made if any sign of polypharmacy is found.
Unless you've walked in the shoes of us who do it, please do not offer your opinion as the end all, be all conclusion that ALL of us working in LTC are working in unsafe environments.
This makes me so mad. I see soooooo many posts on this site about LTC nurses making med errors. Clearly it is not the fault of the nurse. While we all know that floor nursing is overwhelming, there is something extremely broken about the LTC system. I don't care what the acuity level, 20+ patients to one nurse is ridiculous and grossly unsafe. How the hell can they expect one human being to safely administer medications to two dozen people, more than half of whom are likely polypharmacy patients? I never have and never will work in LTC, but my god I can tell from the horror stories I read that there is something extremely wrong here. Does anyone know if California has established staffing ratios for LTC nurses?
Well the fact that you made a med error because of 2 cards next to each other clearly indicates that you work in an unsafe environment!
Don't they follow EBP? Studies clearly show that Norco 5's and Norco 7.5"s should be kept in two different med carts. Sure, its more walking for the nurse, but then mistakes like that won't happen. Studies prove it!!
Seriously, though, it sounds like the OP just needs to slow down and think the steps through. When you pull a med look at it and compare it to the MAR and verify its for the right resident. Do your med pass room by room, in order, and don't cross a resident off your list until they got their meds or you've verified they dont get any meds with that pass. Know that you're not done till every resident is crossed off.
I know all that sounds overly-obvious. maybe even condescending, but its easy to overlook the basics in a LTC med pass. We become too focused on finishing and finishing fast, we forget the most important part of a med pass is administering the meds safely.
Well the fact that you made a med error because of 2 cards next to each other clearly indicates that you work in an unsafe environment!
You must be a very recent new grad. Once you learn the routines of the residents, you become quite efficient and then can handle med pass, accuchecks, wound care, trach care all while keeping everyone safe. I agree there are some unsafe nursing homes out there, but please don't judge other facilities because of the unsafe ones. And the above poster was correct. ..we are suppossed to do 3 checks to avoid med errors. He missed a step (it happens)
suanna
1,549 Posts
I think it's a great idea for you to look for a new job before you get fired. This position dosen't seem like a good fit for you- Some new nurses can handle that med load- but not many. The time to get out is before they fire you- or worse yet- make a report to the BON. There may be few options in your area, but even if you have to make a geographic change- find a place you can do a good job and be safe doing it. After what you described I don't think that will ever happen where you are.