What is considered a Medication Error?

[nursemi]

My instructor yelled at me at a psychiatric unit stating that my medications were late, I stated to her that I had trouble looking for the appropriate size b/p cuff for my obese client. I had to go to two units to look for one. I was suppose to give the client his meds at 10am and it was 10:20am. She stated I show no concern for the client and I am jeopardizing her license.

I felt it was my duty to be accurate in taking his b/p by using the appropriate size cuff. Thank goodness I did, because it turned out I had to withold his b/p meds. She stated to me I can take a b/p without a b/p cuff. I did not know this or how to.

In turn she wrote me up?

Is this really considered a medication error? Was it appropriate for her to yell at me in front of my psych. patient?

What would you do?

[rn/writer, RN]

I agree that you were right in getting an accurate blood pressure first. It was not appropriate for her to yell at you. The correct size cuff is pertinent- too small or too large can produce inaccurate readings.

As for med error, I have to slightly disagree with siri. Yes, time is one of the five rights of medication administration, but there is also a window of time that meds can be given in. If 5 patients all have 10am meds, they cant all have them exactly at 10am. I think being within a half hour time frame is acceptable. The first hospital I worked at gave an hour time frame, half hour for antibiotics.

I'm actually curious on how she expected you to take a BP without a BP cuff.. any takers on explaining this?

Giving a med during the window of time allowed by your particular institution (and this does vary, both by facility and by med) should not be considered an error. The entire window qualifies as the right time.

As for taking a BP without a cuff, you can, as Siri mentioned, palpate peripheral pulses and come up with some minimum numbers, but there isn't any way that I know of to spot an elevated BP. So, palpating peripheral pulses is useful when assessing for shock and worthless when assessing for hypertension.

You CAN get a BP without a stethoscope by palpating the pulse just distal to the cuff. (Maybe that's what the instructor was really thinking of.) This comes in handy in the back of an ambulance when there is too much noise to hear well. That said, I know of NO way to take an accurate BP without a sphygmomanometer of some sort.

At any rate, I'd look up the P&P of the facility where you are doing your clinical to be absolutely certain of their parameters. I'd also consult with those in charge of your nursing program. The instructor may just have been blowing smoke, but if, indeed, she did write you up, find out if you are allowed to submit a letter of your own. If so, include (verbatim) the P&P of the facility where you are doing your clinical, and a simple, straightforward account of the incident. Then, let it go.

I wish you well.

[Gompers, BSN, RN]

In my hospital, there is a 1 hour window in which to give meds on the floor, 30 minute window in the ICU.

Of course the medication was ordered for 1000, but what if she had 6 other patients that all had 1000 meds? They cannot all possibly get them at 1000 on the button. How can you say it's a med error if it was given at 1020? That's being a little bit extreme, IMO.

I think the instructor was being a bit extreme as well, going off about doing BPs without a cuff. Most nurses don't know how to do that, much less nursing students! And it's NOT an accurate way to measure the BP of someone who is on BP meds, that's for darn sure.

I would say the only error here was in taking so much time to get the BP cuff. Maybe starting to look for it earlier, way before any meds were due? Or instead of running around looking for one, calling units instead so not as much time is wasted?

I cannot believe in this day and age of obesity that it was hard to find a larger BP cuff!

But no, officially, I don't see a med error here. The meds were given within a half hour of the scheduled time, and I'm assuming all the other rights of medication administration were honored. Plus, there was an issue with the patient's BP contraindicating one of the medications, and the student recognized that.

[Gompers, BSN, RN]

As for taking a BP without a cuff, you can, as Siri mentioned, palpate peripheral pulses and come up with some minimum numbers, but there isn't any way that I know of to spot an elevated BP. So, palpating peripheral pulses is useful when assessing for shock and worthless when assessing for hypertension.

So this is what they mean on ER when they're in the middle of a trauma and the nurse yells, "BP is 60 palp!" I always wondered why it would always be a multiple of 10 that they'd be reporting!

[UM Review RN, ASN, RN]

It wouldn't have been an error on our unit, either.

Meds can be given one hour before or one hour after, so we could've given the med anywhere from 0900 to 1100 and it would not have been considered an error.

Even though we're a cardiac unit, no unit is perfectly supplied at all times. We always have to hunt around for the right size cuff when we have an emaciated LOL or an obese patient. "Guesstimating" on a patient who is to receive a BP med is absolutely NEVER done; an accurate reading with the proper cuff must be obtained. So your choice to find the correct cuff, get an accurate reading, and withhold the med, would've gotten you a "good" writeup from your instructor here.

But that's not all! As a student, your instructor might've chosen this teachable moment to go a little further. Since she didn't, I will:

On our unit, we might also have rechecked the BP towards the end of the "window" (which for us would be around 1100) and see if the BP was trending up, down, or staying the same. In any case, the nurse would have followed up with a phone call to the doc, especially if the systolic BP was less than 90. The patient would've been assessed further for symptoms of hypotension (dizziness, weakness, palpitations, diaphoresis, along with pulse rate). Usually, if the SBP is too low, the doc will first order 250-500 ml of Normal Saline IV and recheck the BP in 15 minutes.

Also, some nurses would have called the doc just to inform him/her of the need to hold that medication. This would alert the doc of the possible need to reassess the medication for this patient.

JMO, but I think you did very well with your decisions.

[UM Review RN, ASN, RN]

In this instance, it is not the fact the medication was "within that window of opportunity". It is the fact the meds were to be given at 1000. A prudent individual should retrieve the B/P cuff before the time of the med administration. In this circumstance, the patient was to receive B/P meds and therefore, the nurse would need a cuff in order to measure the B/P and make a decision to give the med or not.

The nurse should prepare for alterations of events.

It is still a medication error.

Siri, I usually agree with you, but let's talk turkey here. You're completely right in a perfect world.

But in the Real World?

You know as well as I do--Murphy's Law--that had she found the perfect BP cuff an hour before the scheduled time needed and placed it in said patient's room, it would've "walked off" before she could use it.

[GooeyRN, ADN, BSN, CNA, LPN, RN]

I feel the instructor was wrong for yelling, period. ESPECIALLY if front of a patient, yet a PSYCH patient. Bad move on her part. Where I work we are allowed a one hour window either way. In school we were allowed 1/2 hour either way. Yes, you should have secured an appropriate cuff ahead of time. Now you know. But like someone else said, when you went to get it it would have already walked off. Maybe others needed it before 1000? What if you went to use it and it was then broken? These things all happen in real life. I don't think its an issue at all. DEFINATLY NOT a med error. You should not take a bp without a cuff except in an extreme rare occasion. ESPECIALLY not to be done when trying to decide whether or not to hold a BP med! You need to know the exact numbers in order to decide to hold it or not. I think this teacher has control issues and just likes being the boss. Some people, not just instructors, have to be in control and always be right or they freak out. Maybe she needs to be admitted to the psych unit!:roll:chuckle:clown: (j/k of course)

[all4schwa]

why wasn't the cuff handy...the other nurses should have been using it to monitor this pt's bp also...hmmm

[luvmy2angels]

In any place I have been we have always been taught that we have a one hour window (either before or after scheduled time) in which to administer the meds to the patient. Now if we go outside that one hour time frame it is considered a med error. As for the b/p without a cuff I think your instructor is crazy!?!?! I wonder if she can get an accurate temp. without using a thermometer???!!!??:roll

[CoffeeRTC, BSN, RN]

Um, after checking the facility P and P and if it was 30min to one hr, I would fight the write up.

In the real world..........

[TazziRN, RN]

No, it was not a med error as long as you're within the facility's window.

No, she should not have yelled at you. And how is a student supposed to know about palping for BP's?

Are you sure she wrote you up? If yes, I'd write a rebuttal.

[rngreenhorn]

This is a no-brainer. If the scenario really is as you have described, your instructor is a complete whack-job and should be fired post haste.

[gr8rnpjt, RN]

Let us remember that this was a Psych unit, so I would assume that this instructor is the Psych instructor. Based on that information I would assume that the instructors medical experience is not timely, in that she was probably a psych nurse for a long time. (nothing against psych nurses, but I would not float one to a tele or med surg unit) Another poster mentioned that the other nurses were to have been checking the bp's before giving this particular pt his bp meds, so where was the large cuff?

I would vehemently protest any formal write up of this scenario, it does not make sense. You were probably within the hospital P&P time frame, and you were doing the right thing. I would rebut this write up point by point and include the instructors professional opinion that the bp could have been measured without a BP cuff. That comment makes the instructor look really stupid.

OP, this was clearly a case where you were written up without proper cause.