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Discussion

Verbal order

I received verbal order for Norco 5/325 mg from provider, when charting medication, I charted that I gave Norco 7.5/325 mg, when I realized the error verified that I gave the 5/325 by check the accdose machine I did pull the right verbally ordered medication, ask the provide he stated that he did want patient to receive 5/325, I entered the right dosage amount under the order in the note of medication. Am I in trouble

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    It was a documentation error, that did not reach the patient. Did you correct the chart to the actual dose given? Putting in a note that an error in transcribing occurred but that pt received correct dose should do it. In some cases they want an incident report for med error tracking, but that isn't really a black mark against you, it just means you are aware of situations and willing to take responsibility for yourself (not try to cover up).

    The only people who can say "if you are in trouble" are your own managers. Doesn't sound that serious from here though, (since you took the correct actions after).

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    I also would put that under the term "documentation error." I'm going to simplify what I see: A 5/325 was ordered, drawn from a machine, administered to the patient, and charted as a 7.5/325, which was caught and corrected to reflect reality. Are you in trouble? I doubt it. There should be "other records" that reflect what was actually drawn for that patient. Since you've apparently corrected the charting error and someone can see what the original chart error was, and the correction lines up with reality, you should be OK and you've learned a lesson in double-checking your charting to be sure what you wrote is accurate.

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    There are many facilities who are stepping away from the verbal orders for just this reason. This was a transcription error. The provider has a set amount of time to sign off on, so clarify your order, and re-write.

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