do you think I should be written up?

[daisymae65035]

I want an opinion if you will....I am an LPN in a nursing home working the evening shift. A nurse on the day shift took an order from a dr. to start a resident on an antibiotic a month prior. She passed onto to me in report the order was taken and the med was ordered from the pharmacy. I have a med tech that passes meds on my shift so never saw the EMAR. I charted in the progress notes that resident continued on antibotic therapy and was afebrile. A month later I find out after the resident has a uti that has festered for a month, that the day nurse never entered the order in the computer or ordered the med from the pharmacy, but, because I charted that entry, I am written up for "falisifying information" because I charted something that wasnt true. I am told it was my fault for not checking on the other nurses order. What do you think? I dont think I am at fault. do you?

[RNsRWe, ASN, RN]

The short answer: yes.

You are at fault because you assumed a med had been given, and therefore charted based on that assumption. Nursing 101 would tell you that you can't chart something you didn't do, or didn't see with your own eyes had been done. And obviously, since you didn't check on the med itself being given, you didn't check on the order being entered/received, you were certainly at fault.

Sometimes assumptions bite you in the butt, as this one did, and I'm sorry you have to deal with it. But please don't believe that you did nothing wrong, or that you bear no responsibility. It does lie with you.

[nerdtonurse?, BSN, RN]

Okay, this happened, you can't undo it. So, fix the system that allowed it to happen. For critical meds -- abx, anti-rejection meds, serious heart meds (I'm not talking about 6.25 mg of lopressor daily, I mean amiodarone), potassium replacement on Lasix folks -- institute a double sign off on the order. One person puts in the order, a second verifies it, both sign off on it.

This one would have been hard to catch since it was never written in the first place, but that's the first thing I do when someone says -- "Bed 34 just got put on x, y or z" -- I go check the order. I've had people get Reglan ordered instead of Lopressor -- big difference! Yes there's a lot of patients, yes time is tight, but they always have time to write you up.

[Wishinonastar, BSN]

Unfortunately I think you showed the same assumption type charting that I see in home health. Unless you KNOW the patient is still on a med why would you chart it? It is unclear to me when you charted this though, unless I misread- it looks like you were saying you charted it that first day before the med was even obtained. Sorry to say that I cannot argue for you. It was an error, but a sloppy one.

[Happi2BRN]

Ultimately, patient care falls on the nurse. If meds are being passed by someone else but you have to chart on them, you must be sure that the med tech passed them. I always review the chart from the previous shift and make sure that everything that was ordered was done. If you chart it, make sure it was done, just like if you did it and didn't chart it, it is considered not done.

[bella44]

Well, anything you chart is considered part of that pt's care & also a legal document.

Seems to me your nursing staff just has a lack of communication.

Our nite shift used to double-check any new Dr. orders for that day and ensure they were entered on the EMAR.

I don't think you should be the only one written-up.

[mazy]

The original nurse made the mistake of not following up on the med correctly. Mistakes happen, sometimes in spite of our best intentions, things fall through the cracks, get forgotten, don't get transcribed correctly, don't get sent from the pharmacy, or the correct med doesn't get sent, etc. etc.

That is why nurses should always double check to make sure new orders went through and that they went through correctly, and that the med you are giving is the med that was ordered. It's just good teamwork and common sense, and most importantly, good patient care.

So the original nurse made a mistake, but one that could happen to anyone. That doesn't make it any better but as a team you need to be backing each other to make sure stuff like this doesn't happen.

You made the mistake of not checking. For an entire month, which to me is bizarre and unconscionable. No one else checked either apparently, and I'm wondering what their documentation looked like.

Then you made the critical mistake of charting false information on a patient. Were you actually monitoring this patient? If a UTI was festering for a month, what did his urine look like? Smell like? Was he confused? Was he in pain? What were his other vital signs? etc. etc.

Sounds like the facility is also not following up on patient care issues very well, but you can't allow yourself to sink to the level of the weakest link. You have to always strive to do whatever it takes to make sure your patient is OK.

Yeah. You made a bad mistake, and you do deserve to be written up.

But there is something wrong with that facility that something like this could have happened to begin with. Scary.

[zorabanks]

If you where doing the progress note, then yes, you should have looked at the MAR or at least the order. Otherwise how would you know what the pt is taking? Yes, you should be written up along with anyone else who charted that the med was given WHEN IT WAS NOT. The AM nurse should also be written up because it sounds like she droped the ball. Sorry this happened to you, but let it be a lesson learned, I have had plenty of those in nursing!!!! LOL. Glad that you are just being writen up and not fired. Always CYA...although there is a med tech, you have a license and still responsible.Good Luck!

[9livesRN, BSN, RN]

Dont ask about my opinion, because I dont know you, LOL, but in the real world YES, you should be written up not only because you did not verified the MAR, but also because you should be responsible for completing you chart checks, and in all honesty, they turn around and bite you right in the butt if you dont pay attention to them!

Something happened along the line where this order was not carried on. If you view yourself as the nurse receiving the order from the doctor on the day shift, and calling the pharmacy and confirming everything, you probably would want the nurse coming after you to make sure things were there wouldn't you?

Would you be mad if you got written up for something that was suposed to be carried on and the shift after you didn't?

Nursing homes are tough, the more help you have (med techs, 3 shifts, etc) the more checking you have to do!

[GitanoRN, BSN, MSN, RN]

I'm deeply sorry that this happen to you. However, what Troubles me is that for an entire month, this patient continued to deteriorate and no one from any of the shift, took the time to revise the EMAR. Moreover, try not to forget the Golden rules regarding meds. it's one responsibility to follow through always. Therefore, you should count your blessings that you weren't let go, keep in mind, that it's your license on the line every time you sign for meds. or doctors orders. Lastly, I'm sorry this had to occur in order to give a wake-up call to the entire staff regarding the EMAR. Wishing you the best always...Aloha~

[Laboratorian]

I'm not a nurse but can I ask a question?

Does this "med tech" who passes meds have to sign off on what meds were passed?

This sounds strange???

[wooh, BSN, RN]

Should "you" be written up? No. The SITUATION should be written up though, and a solution found to prevent this from happening again. Most anything in healthcare that can be screwed up by just one person making a mistake needs some checks and balances.

[nurseharried]

Did You ask the tech did she take the antibiotic and how she tolerated it? Thats kind of a iffy situation. Always Always go back and cover your behind because you cannot trust someone else to do something and expect it to be done....it just don't happen...