Possible Med Error?

[duncannurse429]

I work on a TCU and last night I was giving patient their scheduled dose of 0.5mg ativan (it's ordered as 0.5mg bid). I noticed that the day shift nurse had crossed out the 8a dose in error and it did not look like it was ever given that day. The patient had previously been on 1mg ativan bid and the card was still in the lock box, so i checked that page in the narcotics book and it had been documented that 1mg was given. I reported the incident to my supervisor and she notified the on-call NP. The patient was not demonstrating any ill effects. I'm now wondering if I should have held my scheduled dose of 0.5mg last night and if I've now made an error?! I'm just so nervous about everything I do lately! (I'm still in my first year!)

[Sun0408, ASN, RN]

Im kind of confused.. If the order was written for 0.5mg why would you be worried?? Sounds like the MAR was not updated in time for the earlier dose. If you gave what was ordered, you did nothing wrong. The 1mg dose was long gone before you gave the 0.5mg :)

[liveyourlife747]

I would say you are fine. I would have not held the Ativan unless the pt was overly sedated. Ativan has a pretty short duration compared to other drugs. It was a med error on the other nurses part, but you did catch that error and notified the appropriate people. I would not be worried as long as you documented the issue. As in how the pt was acting before you administered the Ativan and how the pt was after administration. I would also have made sure that an incident report was filled out. I'm not sure about how to write a note regarding the Ativan issue as it did not happen on your shift. I guess you could write "See emar and narc record regarding previous dose of Ativan. MD notified of possible medication error from prior shift and stated "blah blah blah." Pt awake, alert, and conversing well with nurse. Scheduled dose of Ativan given per MD order. Pt tolerated well and expressed that he felt "blah blah blah." Will continue to monitor."

I don't like putting stuff in notes that could incriminate other nurses or myself, but I think this issue needs to be addressed and a note stating what happened, what you did from that observation, and the effects of it are necessary to protect the pt and staff. Hope that helps!

[duncannurse429]

The dose of 1mg had been d/c'd weeks ago, but both cards are still in the lock box, it seems like them previous nurse just popped from the wrong card.

[liveyourlife747]

If the 1mg tab had been d/cd that card should have been removed from the box a returned to pharmacy or wasted. This is why I'm glad we have individually wrapped medications in our med select where you can only pull one at a time.

[KelRN215, BSN, RN]

You notified the provider who did not give an order to hold the pm dose, so why would you hold it? You administered what was ordered. Ativan doesn't hang around that long... that 1 mg dose was long gone by the time you gave the 0.5 mg.