Transcription Error- was I also in the wrong?

[Bestmaf1]

In my facility a transcription error was made so that a resident was getting twice the dose of an antibiotic than what he should have. I did my five checks with the medication and the MAR and did not catch the error. I ended up administering the second dose of antibiotic that day. My facility considered it my med error even though I did not transcribe the order. Everyone who gave the med regardless of if it was the first dose or second dose received the med error. I feel that since I did my five checks I shouldn't be held responsible for the error.

[michaelhansonRN]

This is a peculiar yet not uncommon issue. I myself found myself in this same situation years ago. I was outraged when I had received a written warning (as did every nurse on every shift for over two weeks) in a nursing facility that I worked in as an LPN. I cannot recall the medication, but the physician had rounded the night of changeover. He had changed the dose on some medication that was not carried over appropriately. Over two weeks later, this order was caught by the ADON who reported it to the DON, resulting in everyone who cared for that particular patient receiving a write up.

A few years back, I was working as a Rehab Unit Manager and a situation arose once again where the order was not carried over during changeover, resulting in several days of medication errors. There was no harm to the patient and it was simply a change in dosage. I researched until I figured out where the original error was and I administered an "Opportunity to improve" or an episode of education to this nurse.

I believe that when an order is signed off by a nurse as complete, that it is unrealistic to think that each order will be compared to each written order every shift in any setting; let alone a nursing facility where the nurse is caring for 30+ patients at one time. The way this situation is handled would depend on the facility's administration and if any ill-harm came to the patient. In the court of law, I would hope that the court (and/or jury) would recognize that the transcribing nurse should be at fault, but unfortunately, it could very well hold each nurse liable for each dose administered inappropriately. This is a very gray area I'm afraid; but i would venture to say that each nurse will always be held accountable, although the error lies in the system or with the transcribing nurse.

[evolvingrn, BSN, RN]

I don't see how you could realistically check the original order for every med you give..... When I worked in a facility like this each transcribed order had to be double checked and initialed by 2 rns. They owned the error if one occurred

[needlesmcgeeRN, ASN, RN]

This makes no difference - you are CERTIFIED to pass meds. What did that certification involve? I worked as a direct support staff for individuals with developmental disabilities and we were certified/delegated to pass medications, which meant we had an initial training, and then annual training, and the rights of medication administration were always discussed and also orders were discussed. If you are passing medications, you are most definitely responsible for ANY med error you make.

One important thing to note however, is that I am cbrf certified to pass meds. I am not a nurse, nor have I had training beyond the basic med passing classes. Anything I have learned about orders and such have been self-taught. I give 40 kids meds every day and have never been told to check the orders before giving the med if the order is written in the MAR. I suppose if I was a nurse I might be more inclined to do so.

[iluvivt, BSN, RN]

A court of law will hold the person who administered the dose accountable should any harm come to a patient and there is a lawsuit. There are no ifs, ands or buts about it.Yes, they will hold anyone who contributed to the error accountable as well.Many pharmacist have been sued and punished for dispensing incorrect doses. I just read an article about a hospital pharmacist who mixed a fatal dose of chemotherapy and the sad sequence of events.