report or not to report med error?

[Ms.RN]

few days ago when i was working on the floor i caught a med error. pharmacy sends us a new mar for the next month with list of medications. this patient is not suppose to receive any kcl pill, but in the new mar, it is written kcl tid. patient was given 2 doses of kcl. but this patient is receiving lasix everyday.

my question is, if you saw a med error like this, would you report it to don or do you just correct the mistake and let it go?

[CoffeeRTC, BSN, RN]

Report it. There are quite a few things wrong here and a med error report helps track these type of errors.

First...were the MARs checked or double checked before the start of the month?

Even tho they are on lasix, they might not need that K+ ...the doc might want a lab on this person.

[racing-mom4, BSN, RN]

When you take a loop diuretic such as Lasix, it blocks this transporter, causing more sodium and potassium to stay in the urine. The high sodium levels in the urine draw water out of the blood and into the urine, thus causing water to be passed out of the body. However, when you increase sodium excretion, you also increase potassium excretion. This is why people taking loop diuretics, and some other classes of diuretics, need to take potassium supplements. Could there possibly be an order for the KCL that maybe you didnt see?

Either way, always report, as you would not want to NOT give the KCL dose in case there was an order written that you didnt see. As if you did that, then you would be the one causing a med error. When in doubt, always question.

[bollweevil]

Did you check the chart to see the original orders? Be sure to do that right away.

And in general, the best policy is to report all errors, according to your facility's policy and procedure, but also to immediately correct the MAR so the error is not compounded or repeated. The doctor needs to know, too.

[OC_An Khe]

Always report errors, particularly systems errors. It is the only way we can learn from them and to initiate corrective actions. Reports of errors should not be used as a means of dicipline or punishment.

[Rexie68]

please report it. it's not a disciplinary thing...it helps to prevent future errors. most nurses who've worked for a time have made or found a med error. i'll admit that i've made 3 in 18 years. i'm not proud of it, but you can bet that i'll never make those errors again. thankfully there were no adverse effects. our don said that the nurses she worries about are those who are there for a long time and never report an error. :icon_roll

[CapeCodMermaid, RN]

Report it. It might be a systems' problem that could be corrected. I hardly ever give meds anymore. I had to take the keys one day, didn't know the patients or the routine. It was 8:30 and I realized I hadn't given someone their Fosamax. I know,big deal, once a week, get over it..that was the advice from my co-workers. I wrote myself up and came up with a plan of correction to solve the problem. From that day on, there was an index card on the front of the MAR kardex with a list of early meds. The agency nurses and the nurses who floated through out the building really appreciated it and it cut down on mistakes. That is the reason errors should be reported.

[racing-mom4, BSN, RN]

The thing that makes me most nervous about this thread is that MsRn was considering not to report it-thus-not look into it. If she would take it upon herself and NOT give the med because she thought it was an "error" only to find out it was in fact an order. Then she would be causing the med error.

I know at the hospital I work at any time a handwritten med is placed on the MARs, we need to initial it. Ideally orders should be read with the oncoming nurse, but if that got missed at least you could see who wrote the med on the Mars and then back track to the date that person worked last and looked at the orders for that date.

Just because a pt did not take the med last month does not mean it is a mistake if they are taking it this month.

[UM Review RN, ASN, RN]

Because KCL is so often given when a patient is ordered Lasix, I would not only report to the Lab and the DON but I'd call the doc to "clarify" this order. That way, if he wants the patient to get it, it's ordered.

Sometimes the doc forgets to order the KCL when ordering Lasix or maybe the doc called the order in and someone was too busy to write it down or the copy got lost.