Peaks and troughs...how does your unit remember?

[climberrn]

There's a situation in which a kid received an ototoxic drug. The doc wrote to check levels after the 3rd dose. It was never done. The doc realized it 24 hours later, re ordered it and the level was way too high. The kid is deaf.

My unit, when we get those orders will write the number of the dose on the mar (#1, #2, etc.) and when it's the 3rd dose will write that the level is due. This, in addition to verbal report. To my knowledge, we've never missed a level; our system works pretty well. What's your system?

[suni, BSN, RN]

The same as yours, and it also works well, the only issue is if we receive a transfer and mar needs recopied, we always double check those.

[mtwife]

We write the times and date on the MAR as well, and it is the responsibility of the MAR checker to transcribe the orders. Sometimes the pharmacy can add a comment to the med order, but usually there are restrictions on what the pharmacist can add. We've had trouble, too, and the main reason is because the MAR check was too hurried and didn't manually transcribe important info that the computer didn't print out. Sometimes, if it is a mtx level or something like that, the charge nurse will have it on her report sheet and make an effort to follow up on it (although we all know how busy it can get so can't rely on charge nurse to follow up on EVERY level). Something like a level should also be on your work order sheet (something like a Kardex or computer generated list) or in the computer as an uncollected lab with the time, so SOMEONE should have seen it, right?

[queenjean]

Our MARs are computerized.

The trough and peaks are a task on the MAR itself; also, the bag that is to run after the trough is not on the unit; it is sent out after the pharmacist receives the trough levels (We have 24 hour pharmacy). That way, if it is accidentally missed, at least there isn't a bag to run.

[climberrn]

Our MARs are computerized.

The trough and peaks are a task on the MAR itself; also, the bag that is to run after the trough is not on the unit; it is sent out after the pharmacist receives the trough levels (We have 24 hour pharmacy). That way, if it is accidentally missed, at least there isn't a bag to run.

Bolding mine:

Aw, man, that would have solved everything. The nurse would have called Pharmacy, most likely pissed that her med wasn't there, :chuckle and would have been told that a level needed to be drawn.

I'm beyond pissed about it; this kid was failed by so many system failures.

[Gompers, BSN, RN]

We have a computerized charting and medication system, that helps a ton. The docs will time the peak and trough order for when the third (or whichever, depending on the drug) dose is due. Nursing passes it on to make sure it's done. Half the time we're the ones noticing the levels weren't ordered or done and calling the docs about it because it's so routine for us. This is probably because we use it so much - almost every baby admitted to the NICU is started on Amp and Gent.

We do print out our MARs off the computer and when a baby is on Gent or Vanco, we'll actually write what number dose it is, to alert the oncoming nurse as well. If you have handwritten MARs, you should get into the habit of numbering each dose of these types of drugs - like I said, when it becomes routine, it'll be much easier to remember.

[climberrn]

We do print out our MARs off the computer and when a baby is on Gent or Vanco, we'll actually write what number dose it is, to alert the oncoming nurse as well. If you have handwritten MARs, you should get into the habit of numbering each dose of these types of drugs - like I said, when it becomes routine, it'll be much easier to remember.

That's what we do. Turns out the level was sent but the lab didn't run it. And no one noticed that a level wasn't back. So they did draw it but didn't follow up. Which is just as bad.