Operating Room Narcotics

[poolnurse]

There was a standing order for dilaudid on the doctor preference card however morphine was given..morphine was verified verbally with the doctor ( while he was still working on the patient) and was given to the Doctor by the tech but it should have been dilaudid..morphine was given  intramuscular at the surgery site on the field by the doctor..who is responsible for the medication error?

[Rose_Queen, BSN, MSN, RN]

There’s a lot of hands in the cookie jar here, and the purpose of reviewing errors is not necessarily to assign blame- it’s to look at the system. I’m surprised your facility allows pulling of narcotics without an order being entered. But there isn’t really a single point in your scenario as presented  that blame can be assigned. 

[Maizie Wilharm, BSN]

Was the medication on the field prior to incision? If so did the tech say that was the medication on the field? While I want to say it’s the doctor’s fault because he perhaps didn’t hear the change, I can also emphasize knowing they are also doing a lot in the moment. I’ve had a doctor lash at me after giving a medication that contained epinephrine when it was said twice before injecting that it was the local anesthetic given to the field. I’d write of a safetyzone event stating exactly what happened, but ultimately everyone needs to stop and listen to the medications more carefully.