Published Oct 13, 2002
Please help me:
Last night at 9pm , I had a patient who was insisting she had not gotten her Zocor. I checked the MAR, it was signed off. I told her this. The family said they were there at 5p and she had not gotten it, or her glucophage. I checked the bedside chart for the B/P just to see how it was. There was nothing there since 1230 (it was 160/70 something) So I took it right away-190/92. So I checked the Mar again, saw she could have a clonidine. I gave her that. I checked the Pyxis while I was there, and there was no record of her having gotten either med. I checked our other machine-same thing-no meds signed out.
About the same time , my LPN came to me saying another patient was saying she did not get her Vit K shot from this same nurse.Not signed off in the Pyxis either. I called her(the day nurse) and asked if she had given the meds, and she said *I signed it off* I said, "ok, but did you give it- the patient is insisting she didn't get it-no big deal I could give it" she said again, " I signed it off" Then I asked her about the Vit K- she said she had given it, written it down for 1530.
I went back and checked the MAR-nothing there- checked the rest of the MAR, found another Vit K signed at the exact same time, double checked the 2 orders, double checked the MAR, double checked the Pyxis. It seemed that order had been missed altogther.
So here's where I'm in trouble I think: I went ahead and gave the zocor based on: 1. the patient is completely alert and oriented 2.The family cooberation 3. No record in the Pyxis 4. The elevated B/P and marginally: 5. She had messed up on the Vit K shot and other things were missed and messed up.
So now I find out the Pyxis isn't legal documentation. (I never got orientation per say ( I'm a traveler), I signed a confidentiality agreement, maybe I should have read it better?)AND I had forgotten -sort of- her signing the MAR is legal documentation. I half-circled her sig and initialed mine with the time. I told the house sup, he said to fill out a med variance, and kind of agreed with me about it. I hadn't thought much about the whole thing until I told the charge about it and she brought up the legal thing about the nurses signature.
So now what? I am going to lose my license? Can I still practice in the 2 other states I hold licenses? (quite selfish of me I know)Chances are if I don't make an issue of it, no one else will probably know. The charge said to keep the variance and talk to the unit manager on Monday if I wanted to. The patients B/P was ok, never got below 150/60. IS there anything to make an issue of? Thank you for any help and guidance.
I have never been in this situation before, and I'm not making excuses, I will take what I learn to heart. I wasn't feeling well, and maybe that clouded my judgement-- or Iam i making a mountain out of a mole hill? A hill out of a mole hill?
Hmmmm....no you are not being stupid. I have been in similar situations. We use a Pyxis, also, and you are correct about it not being legally evidence of having given a med. I have seen some nurses see the Pyxis drawwer open and a med they need is in the drawer and they pull it saying, "well I will document & charge it from the Pyxis later. Right now I'll just go ahead & grab it out." And the nurse who had written it on the MAR as given IS legal "proof" of administration.
I DO see your prob w the pt tho, as she/he is A & O and said "Hey, I know I did not get it!"
I guess the only solution (as I have done it) would be to thoroughly document all the interventions, phone calls, patient statements, etc., monitor BP,and other VS, and call the MD for one-time orders for meds if the patient's condition warranted intervention.
To soothe the patient, I have sometimes had to try to cover the previous nurse's "mistake" with "Well, at the time the nurse gave you other meds also...perhaps you didn't realize you had this." Or the old: "Our hospital uses a different manufacturer/pharmaceutical company and the meds appearance may have been unfamiliar to you." (Which is true in many cases.) And reassure the patient that his/her VS and conditionwas being carefully monitored, called to the doctor, and being cared for in an appropriate manner. Usually that calms them fine. (Especially when you say the doctor has been called. But DON'T lie about that...they WILL say something to the doc later! :chuckle )
I would not give meds that another nurse had documented on the MAR as having been given, no matter how sure I was that a mistake had been made...her signature will hold up in court and your "double dose" will be the legal problem.
But for now, I agree that if you don't make big waves about it, the chances are HUGE it will go away on it's own. The pt wasn't hurt. Maybe "watch" that nurse's care on future patients...especially on controlled drugs....hmmmm... And it is good the admin knows what happened.
As for your license...nahhhh....as I said the pt is OK, and even if somebody made a stink about this, you sound like you tried to do everything right. Just let it be a lesson for the future. Nurses do not lose their licenses this easily.
Thanks, I guess I feel a little better about my license (more selfishness I know) The time has past- Do I go back to work today and try and document? I never did call the doctor- really was straight out with other problems-no excuse-. And did keep checking the B/P. I sooooo want to quit right now. I will never sign up again for a place where you routinely get 11-13 pts on a med/tele floor. I'm used to 6 maybe 7. I guess I can go talk to to the unit manager tomorrow, and do an addendum to the the notes. thanks again
dumdee - frankie here. I would not worry about this. Your actions were prudent. I agree with regnursein99. The one thing I would always do id call the MD and get an order for what you do. One of the great things you did was to discuss this with a supervisor. You may get a "talking to" about blah blah blah blah, but you proceeded in a safe manner. You will not lose a license in a state over a med error, unless this is you routine. It does not sound like you are careless. Get that MD order always - It really make the murky waters clear. Another thing - I have worked with nurses who are hostile towards agency staff. So, calling the previous shift nurse may not be the wise thing to do. This is something you will have to develop a "gut " instinct determinator of hostility towards agency staff. You are NOT NOT NOT stupid. I say you nursing judgement was above the average bear! frankie
FYI: Zocor is a tx. for high cholesterol, not bp.
I'm sure I would had done the same things......and we also use the pyxis which i hate!! I also hate it when you question a nurse and they say "I signed it didn't I?" I know of alot of nurses who sign things and don't do them. I'm not sure what recourse you have. It scares the hell out of me that so many nurses are lazy........about meds, drsgn changes and such........I've even seen some sign off RT tx. during the night because the pt was asleep.........hell don't sign if off.....chart the patient was asleep and resp were even and unlabored.......or something........
I understand your worries and concerns! Sorry you got caught up in this snafu. Because I can see that you tried to correct the problem and do the right thing, I hate to worry you. But, maybe this will help you in similar situations in the future.
A nurse can ONLY make judgments about things that fall within her scope of practice. That means that you can ONLY do things that do NOT require any other collaboration with any other heathcare provider. You can only practice and make decisions about things that you can do INDEPENDENTLY.
When not sure if a med has been given, the actions that you can take would be to do an assessment including objective (what the patient and family says) and subjective data (physical and verifiable -- repeatable, things like the BP). That's as far as you can go legally, because as a nursing judgment you are allowed to withhold a medication, but a nursing judgment does NOT allow you to give ANOTHER dose.
After your assessment of the situation, when there is conflicting data, you are required by law to VERIFY AND VALIDATE YOUR DATA. You did that with the other nurse, but she indicated that the med had been given, which supported her documentation.
Your action to validate the data did not verify the data! The data still conflicts, because of your physical assessment and the patient's report. At that point, you were UNABLE TO VERIFY THE DATA. So, you are then obligated legally to resolve the matter by reporting it to the doctor and filling out an incident report for the facility/hospital.
Suppose that the other nurse had really given the glucophage and BP med, and you gave another dose. This would be a med error and could result in a negative patient outcome.
To keep you and your patient safe, remember that ALL conflicting data MUST be verified and validated. ANY nursing action you take, can only be done if the data can be validated COMPLETELY to support your actions. If you are unable to completely and compelingly verify, then you must notify the physician.
Under the ANA's Professional Standards of Practice, you did not successfully "validate" your data. So, you have no legal grounds for giving another dose of the medications. Then, you took a nursing action that required "collaboration" or another healthcare provider (the doctor), by giving a second dose of a med that had been documented as given, and so went outside your scope of practice. And you could be held legally responsible.
I realize that you did not believe the nurse when she said that she had given the meds, and you believed your patient instead. But, in that situation, you put you and your patient at risk by deciding on your own who to believe. A "belief" is not enough justification for risking a med error.
I hope that helps, but I'm afraid I probably just made you feel worse. I've tried to give you the supporting nursing "critical thinking" and supporting basis for this so it didn't sound like I was just fussing at you. I sure do understand the dilemma. Maybe what I've said, though, can help you avoid a problem in the future. Good luck to you. I sure do sympathize with the position you were put in by the other nurse! That nurse needs her license looked at!
Oops! I'm sorry, I meant accupril, the zocor was another screw up she made that was able to be straightened out. So much for typing at the end of a horrible shift. The problems she caused last night seemed endless, my LPN and I spent probably 2 and a half hours straightening out what she and her RN did. I didn't tell you all about all the IV lines thrown out b/c they had no caps, 4 IVs they put in and 4 that blew on me,yes the same 4-coincidence???? And yes I have spoken to and then later reported the RN for the "mischief" she causes. Now this LPN.... Yes, I'm being quite sarcastic.
The accupril was a 5mg dose, and her history of B/P's was that lowest she had been was around 150/60's.
I generally know to call the doctor, if all else fails, hell, I've told many newbies that, but for some stupid reason, all sanity left me last night. Its now that I made this stupid judgement, what do I do? At least I know I'll never do it again, maybe something else but not this. :-)
I can tell you 2 times in the past when I called the doctor after being told by my superiors I didn't need to and ended up having the patients sent to surgery stable. Or when I have called about questionable meds, doses, times, etc. This place I'm at seems quite antiquated, and now I see what people have been talking about for years. I been very lucky in the past, to work where standards were higher. I know I'm a good nurse. Maybe I need a break, maybe I'll get one :-( Thanks again, for your advice, reminders and encouragement. I let you know what happens.
I do not quite understand what you meant by half-circling the other RN's time and initails on the MAR. You cannot chart or unchart for another RN. That is where I can see you getting into trouble. We are moving away from laying blame on med errors and are supposed to view a med error as an "opportunity" to study and improve the process. However, you cannot change someone else's documentation. If the other nurse sees that you half-circled her med documentation, she could create problems.
As others have said, if this ever occurs again, you should call the physician, explain what the other nurse said, what the pt and visitors said and the "non-legal" pyxis info. Give a quick report on the pt's current status and the concerns the pt has verbalized and then let the physician make the call. Document everything and fill out an occurence report. Then, the other nurse will have to explain how she gave a med without it being charged out to the pt. If the med isn't charged out to the pt then that med wasn't charged out to anyone. Of course she may have a hard time explaining how the count was not off when the next nurse took out the same med for another pt....But, if she is pulling meds without charging for them and forgetting to go back later, the suits won't like that. Some meds are very expensive and those lost charges add up quickly. So, she is either losing a lot of charges for the unit or she is falsifying MAR's by documenting something she did not do.
I think just giving the clonidine would have been sufficient. But as long as you checked the patient, you should be OK. I just tell them that the other nurse signed it off as given so I can't give it again, but there are other medications for your blood pressure to be given as needed. Don't worry about your licenses. I have been in similar situations and still have all 7 of mine with no sanctions on any of them. And definitely find out the nurse/patient ratio on your next assignment. I worked a Med/Surg/Tele unit and we were 6:1 max on nights. Document well and keep copies for yourself. I believe you will be OK, though.
It is doubtful that anyone who works with her regularly is unfamiliar with her "work habits." For that reason, it is unlikely that anyone will want the situation looked at very closely, because you are a potential "witness" to negligence.
The problem I see, as indynurse said, could be this nurse. In an attempt to cover-up her own negligence, she could make an issue out of your giving the meds "again." But, if she's smart, she'll lay low, too, because the suits will eventually ask why she wasn't charging out her meds, as indynurse said.
So, all in all, I think you're sitting in a good place. Anyone who is likely to make a fuss would only bring problems down on themselves to do so.
I'd let sleeping dogs lie, as they say. Document something for your own records, and then file it away somewhere to jog your memory if a problem comes up later because of it. Your memory is fresh now, but in a month you won't remember all the detail.
It's tough to follow a bad nurse. The only way I've found to deal with it is to adhere as strictly as I can to standards. Since you're a traveler, hold to those things, collect your pay, and hope your next assignment isn't like this one. You have my respect for trying to fix all the things that nurse screwed up.
yes, I was wondering if you meant Zestril...(an ACE inhibitor )
cause I was wondering about the Zocor too...but I see you have enlightened us.
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