Performance Report -Med Error

Davey Do · Dec 25, 2017

I have a client that has his meds in a detachable blister pack that's individually labelled. I happen to give the meds one day ahead. The client told me that pharmacy put the wrong date on that is why it was one day ahead. It was the same meds that he takes every day as it says on the main label, I made a wrong decision of just giving it assuming the dates will get fixed

So, if I understand correctly everything was correct: patient, med, dosage, time, and route, but the date was off.

The situation sounds like a documentation error, not a med error.

I see no big deal here. Change the dates on the future meds and problem solved.

Right?

BTW: Welcome to AN.com, Mother nurse!

Davey Do · Dec 25, 2017

The Ghost of Christmas Double Post!

Mother nurse10 · Dec 25, 2017

Thank you. You're right but the on call supervisor's point is I didn't follow protocol. I gave meds at the wrong time and did not report it. It is still considered an error. This is stressing me out right now because I won't hear from my direct supervisor till the holidays are over.

Davey Do · Dec 25, 2017

I gave meds at the wrong time and did not report it.

Okay- the wrong time is a med error and it did need to be reported.

However, I'm assuming no harm came to the patient. We all make mistakes and have to deal with our feelings toward our fallibilities and go on from there.

Sorry you have to be on tender hooks during the holiday season, Mother nurse. I'm reasonably sure you will not make this mistake again. Something gained.

The very best to you!

Been there,done that, ASN, RN · Dec 25, 2017

Knock off the ashamed stuff. We are nurses that have decided to spend our lives taking care of sick people.

Somehow the pharmacy check was not only lost, but it caused you to make an error. Your supervisor has too much time on her hands . There are thousands of home care agencies begging for your labor.

Think about it, take care of yourself for a change.

cleback · Dec 25, 2017

Although I get some meds are only taken MWF, it sounds like you gave the appropriate meds, only you gave Tues's supply instead of Monday's. That's probably the smallest med error you could make. I would reflect, learn, and move on from this.

Workitinurfava, BSN, RN · Dec 25, 2017

Right pt and no overdose, not the biggest error.

K9lover, ASN, RN · Dec 25, 2017

I am SMH trying to figure out why it is a big deal if he takes this same medication every day. If that med was due in that dose on that day what were you supposed to do, wait and withhold the med until pharmacy got their label right?

Silly question on my part, as much time as we spent in those 4 years of college and emphasized we needed more brains than brawn it would appear current climate dictates we do not use critical thinking at all. A few years ago I was working a circulating nurse on step-down giving breaks and doing accuchecks etc...I had one patient diaophortic, slurring words et al, her BS was 30 so I gave her an amp of D50, told the primary nurse and going to recheck, primary nurse freaks out saying we need orders from the doc. I let her know we did not have to wait and that the patient could well die in interim. I do not fault the new nurse as she has been apprised by the facility critical thinking is neither required or desired.

When I was new to corrections I was not as rapid about going over all of the strips and blister packs and if orders were written on weekends/holidays we were not getting that med delivered from the hospital. What we did have was a lock-box chock full of non-narcotic meds from guys released, transferred and refusals. Many time i had to fish around lock-box to locate an anti-hypertensive, ABX etc...it was right dose, right med, right time, right patient excepting patient name. Even though the name on that strip was another I was not going to let inmates with hypertension stroke out because it was a 3 day weekend! I'd mark 'administered from floor stock' so pharmacy would be aware we did not have it. It is a jail, we get our meds when they are sent which is Monday through Friday. Now they keep more meds on stock in the little pharmacy but we do not have to fish around very often.

I have them show me their jail-issue wrist band; if name, DOB and booking number match they get the med. If we all stood around asking if they knew the rationale we'd have a riot from the guys at the end of the line waiting an hour...

Now that I have vented on the 'healthcare system' desire to turn us all into robots I am still unclear on your mistake if you gave the right med in the right dose at the right time to the right patient.

Mother nurse10 · Dec 26, 2017

Yes. I had the right meds, right patient , right dose and right time. It's just I gave the blister with the wrong date. There was no supper pills with the right date so I took out the one from the day after. They told me I can't do that and I should've not went ahead and decided on my own because it screwed everyone else. I only see client at supper and bedtime for meds and insulin. Her morning and lunch visits are done by health care aides. HCAs are not allowed to give meds unless it is packed in blisters or ATC rolls. They told me I did not follow protocols that when I realized that the meds were labelled one day ahead, I should've reported it to the office. When it happened the first time, I told the client how come your pills are dated one day ahead. She said oh "Pharmacy did that, I'll let them know." So I gave the meds thinking it was the right date just printing error. I didn't think of reporting it. It got corrected the following day. Someone relabelled the dates by hand. Then it happened again and I got used to it and so are the morning staff who are HCAs. I'm just the one being crucified because I'm the one with the license. I admit I made a mistake of letting it happen ongoing for a few days. =(

allnurses Guide · Dec 26, 2017

I would totally quit beating yourself up for this. Knowing that I was

giving a client the same meds that he takes every night... right meds,

and right doses, right time, right client... I would have done the

same thing you did.

I've had home health clients who had daily blister packs full of

pills sent from their pharmacy, just like what you are talking about

here. I can remember one client in particular. Since he took the

exact same meds every day, he never popped the packs out in

exact daily order, and I never would have expected him to.

TriciaJ, RN · Dec 26, 2017

Yes. I had the right meds, right patient , right dose and right time. It's just I gave the blister with the wrong date. There was no supper pills with the right date so I took out the one from the day after. They told me I can't do that and I should've not went ahead and decided on my own because it screwed everyone else. I only see client at supper and bedtime for meds and insulin. Her morning and lunch visits are done by health care aides. HCAs are not allowed to give meds unless it is packed in blisters or ATC rolls. They told me I did not follow protocols that when I realized that the meds were labelled one day ahead, I should've reported it to the office. When it happened the first time, I told the client how come your pills are dated one day ahead. She said oh "Pharmacy did that, I'll let them know." So I gave the meds thinking it was the right date just printing error. I didn't think of reporting it. It got corrected the following day. Someone relabelled the dates by hand. Then it happened again and I got used to it and so are the morning staff who are HCAs. I'm just the one being crucified because I'm the one with the license. I admit I made a mistake of letting it happen ongoing for a few days. =(

Let's see if I have this right: the correct med reached the correct patient at the correct time but the date was printed wrong on something? And you're turning yourself inside out about it? Shake your head and enjoy a good eye roll.

Next time, just remember to report it if the ink is a little smudged, or the corner of the blister card is bent, or a bubble is a bit smooshed.