RN Student Help: MAR against MD's orders.

[Uncle Harold]

I'm a RN student with questions.

I had a med error today. That scares the CRAP outta me. I am very smart, and I am (and was!) very very careful and there is absolutely no excuse for medication errors.

Here's what happened:

I was assigned the role of LPN today. Each patient has about 20 pages of doctor's orders, with adding and D/C'ing meds in some sort of sanskirt they call "handwriting." Somehow, I'm supposed to check through this entire thing against the MAR and come out with the right orders in time to give meds at 0730. My first thought when opening those charts was "this is one big med error right here..." UGH.

Long story short. The patient's been getting Regan q4hr, and it was D/C'd four days ago. I gave it yesterday and I gave it today. I checked the MD's order yesterday, and I checked it today. I personally overlooked it because it was buried under ten pages of other orders and I had about 50 other meds to check. The night nurse signed off on it all four days, and the day nurse gave it too. Pharmacy even overlooked it. Ok, no harm done, but what if it was an antibiotic she was allergic to!? Holy crap guys!

Reasons for error:

1) Because the stupid MD's order was crammed at the bottom of page and very hard to read. It looked like the tail end of a dressing change order because of where it was.

2) Because I checked the MD's Orders against the MAR instead of the MAR against the MD's orders. I knew as soon as I did it I may not catch a D/C'd order and sure enough.:uhoh21: That is what the nurses and my instructor told me to do (cause I was taking way too long), and I trusted the night nurses to have checked properly.

SO:

This would have been caught if I had started at the very beginning of the chart, which is over a month long, and built the MAR from scratch. I simply CANNOT do that on every patient every day I show up to clinical! However, there is no other way that I can think of that is not foolproof. Even that is so complicated that I'm bound to overlook something -- I gave approximately 30 meds today and I only had three patients.

So what do you guys' suggest? Because if it's this complicated, I will not give meds because I will make errors and I guess that puts me out of nursing school...and well, I gotta get through nursing school.

Thanks

[RN1982]

Don't feel bad. We've all made med errors at some point in our career. I know a nurse who gave a a whole insulin drip. Talk about big OOPS. The good thing is is that the patient wasn't harmed and you caught the mistake with the MAR.

[Murse901, MSN, RN]

First of all, let's clear up one thing - you were not "assigned the role of LPN". You were assigned the role of student nurse, nothing less and nothing more. LPN is a licensed practical nurse, not Let's Play Nurse. I'm sorry if that comes off as rude or arrogant, but you cannot be assigned the role of a licensed nurse if you do not have a license. I am an LPN and also an RN student. When I'm on the job, I'm an LPN. When I'm in clinicals for school, I'm an SN. There is no crossover.

Secondly, as a student nurse, the responsibility for checking orders should not be your burden alone. Again, you do not have a license as a student nurse and cannot legally sign off on orders without a cosigner. Your unit charge nurse or instructor should have come behind you to ensure everything was legit.

Third, if the D/C order was from 4 days ago, that's on the charge nurse from 4 days ago, not you. While it would be nice to be able to go back and check the MAR against every single order written for the patient since day 1 of hospitalization, the reality is that you're typically only expected to check off the orders that were written since the last chart check, which should have been no more than 24 hours prior to your check, depending on facility policy. If the D/C order was indeed 4 days ago, you cannot realistically be held responsible for 8-12 different shifts missing the D/C order.

And finally, to address the point of possibly giving a contraindicated antibiotic, you should get in the habit of checking your patient's allergies and writing them down on a cheat sheet before passing meds. This will keep your butt out of court in the event that pharmacy slips up and doesn't catch the allergy first, which they should at any hospital worth its salt.

[mpccrn, BSN, RN]

med checks are done every night. doc's writing is atrocious but it is a fact of life in the real world. meds ordered should be dated so if there is a question, it's a bit easier to track down. there are several checks and balances in place but errors happen. it's human. you do the best you can. maybe someday, docs will type orders in on computers and get the guess work out of the system. it could happen!

[chiari_mom]

A LEARNING EXPERIENCE!!! Take this situation and learn from it....let others learn from it. We are all human and we ALL make mistakes, it is just that medical people are in a different environment where their mistakes can be detrimental. FIND the mistake. ADMIT to the mistake. LEARN from the mistake. I wish you good things for your nursing career, but there is going to bad mixed in there too. KNOWLEDGE is POWER. We are all constantly learning from life's experiences.

HUGS:nurse:

[Turtle in scrubs]

Personally I can't read most MD's "handwriting" and find this to be not only frustrating but dangerous. I waste so much time trying to decipher progress notes and often only get a vague idea of what they are saying . We are going to computerized charting for MD progress notes soon and I can't wait!

The system at your placement sounds like a nightmare. Once I survived nursing school and was searching for a job I chose a hospital that had computerized MAR's. It is not a perfect system and there certainly is room for error, but I have found it much better than the other hosp I was considering where med orders where scribbled on little strips - which seemed a bit like playing Russian roulette with medications. I know there are probably many seasoned nurses who will say that is the way it always was before computers and I know this, but today we have a better way and we have choices as to where we work.

As DonaldJ said, you are a SN and the ultimate responsibility is on the nurse in charge of this patient - period.

All the best to you with the rest of school and in your career as a nurse

:wink2:

[queenjean]

MARS are checked in the following manner:

Check #1: The nurse notes the order after it has been entered into the computer (we have computerized MARS) against the written order in the chart. She notes it in the chart that she checked it.

Check #2 Before the first dose of the med can be given, whomever gives the first dose has to review the written order in the chart. When the med is scanned, it prompts this, and you can't go forward in passing meds until you click that you have reviewed it against the physician's order.

Check #3: Every night, the night nurse does a 24hr MAR check. We look through all the written orders from the last MAR check forward, and check them against what is in the electronic MAR.

Hope that helps.

[pagandeva2000, LPN]

We also have computerized charting, at least for the MAR and to pick up orders. We have to print out medication sheets every 4 hours to see if there are any changes. In addition, we have a screen right on top of the medication cart that can be refreshed when necessary. I print out mine at the beginning of the tour, I also have to pull the meds from the pyxis, and I check off the meds I obtain on my print out as I go including checking for dosages, and when I get to the bedside, I am checking again, and then, after administration, I cross off the names administered. I also cross out the IVPB as I hang them (for people with several meds to hang). The med sheet lists allergies on it as well, so, I get a chance to even look up drugs on the computer before I give it for safety.

I have not been employed at a facility that has not used electronic means for checking orders. I wouldn't know what to do, because the handwriting of the physicians is horrendous. Even their notes on the computerized charting is filled with horrible mispellings and poor grammar. I have to laugh at this, because I study handwriting analysis occasionally as a hobby, and one of the authors said that people who purposely write illegibly usually are trying to cover up what they don't know. Must have been speaking about some of the physicians floating around.

[Dolce, RN]

This is just a great example of why MDs need to be doing computerized order entry. There is just no excuse for this second rate care. Its not like they can't type! They have had twice as much schooling as most nurses--I think they should cowboy up and use the computer just like everyone else. This is 2008. We need to be having MDs entering their own orders on the computer!

Sorry. End of rant.

[queenjean]

Supposedly our physicians will begin entering their own orders in the next year. The ER physicians already do for some of their orders in their own department.

I can't imagine how that will go over. There are several physicians on our floor who have thrown the biggest fits about using the computer at all. I'm sure several of them don't even know how to look up vitals and labwork; they'll hunt the nurses down and ask them. I can't wait; I'm hoping they'll just leave, as in, not practice in our hospital any more once they go to physician order entry. PLEASE turn your pts over to the hospitalists! Please!

[Uncle Harold]

Thanks for all the replies guys! Tests / clinical / paperwork / work, you know how it is. Still, I was rude not to reply again sooner.

I realize it's the nurses' responsibility and not mine, but I still don't like it. There were still consequences on the nurse, the patient, and bad "PR" for the hospital. It wasn't my fault, but if I'd been sharp I'd have caught it. Just trying to learn how to be sharp.

I don't feel bad about it. I'm just appalled that it's so dang easy to make a med error, and perturbed that there isn't better protection for the nurses. I was just hoping I was overlooking some "trick" to get around this scary little pothole and still save time. I've got a quality improvement report coming up, I just found my topic.

Thanks so much guys for your support!

[SunnyAndrsn]

What's Regan? Do you mean Reglan? Hmmm....

If you can't read the handwriting, then ask for help. I do, other nurses do all the time. It's our duty to make sure these things are correct. As you found out numerous other nurses missed it as well.

Having worked in LTC for a while now, the MARs get very messed up throughout the month, with changes and d/c'd meds. Last summer during my initial clinical in LTC I was extremely frustrated with this same sort of thing. The MAR was just a mess! Now that I see first hand how it happens, well, I understand a bit better.

This is a good example of why should perform the 5 rights x3 every single time, even on pts. we know well.

Also, if it was an antibiotic she was allergic to, I doubt she'd get it for four days in a row, BID, since she'd likely be exhibiting allergic symptoms. This is why we are supposed to ask about allergies every time we give medications.

I'm a RN student with questions.

I had a med error today. That scares the CRAP outta me. I am very smart, and I am (and was!) very very careful and there is absolutely no excuse for medication errors.

Here's what happened:

I was assigned the role of LPN today. Each patient has about 20 pages of doctor's orders, with adding and D/C'ing meds in some sort of sanskirt they call "handwriting." Somehow, I'm supposed to check through this entire thing against the MAR and come out with the right orders in time to give meds at 0730. My first thought when opening those charts was "this is one big med error right here..." UGH.

Long story short. The patient's been getting Regan q4hr, and it was D/C'd four days ago. I gave it yesterday and I gave it today. I checked the MD's order yesterday, and I checked it today. I personally overlooked it because it was buried under ten pages of other orders and I had about 50 other meds to check. The night nurse signed off on it all four days, and the day nurse gave it too. Pharmacy even overlooked it. Ok, no harm done, but what if it was an antibiotic she was allergic to!? Holy crap guys!

Reasons for error:

1) Because the stupid MD's order was crammed at the bottom of page and very hard to read. It looked like the tail end of a dressing change order because of where it was.

2) Because I checked the MD's Orders against the MAR instead of the MAR against the MD's orders. I knew as soon as I did it I may not catch a D/C'd order and sure enough.:uhoh21: That is what the nurses and my instructor told me to do (cause I was taking way too long), and I trusted the night nurses to have checked properly.

SO:

This would have been caught if I had started at the very beginning of the chart, which is over a month long, and built the MAR from scratch. I simply CANNOT do that on every patient every day I show up to clinical! However, there is no other way that I can think of that is not foolproof. Even that is so complicated that I'm bound to overlook something -- I gave approximately 30 meds today and I only had three patients.

So what do you guys' suggest? Because if it's this complicated, I will not give meds because I will make errors and I guess that puts me out of nursing school...and well, I gotta get through nursing school.

Thanks