Who takes the med error hit?

[BuckyBadgerRN, ASN, RN]

Interesting situation, just curious as to public opinion on where fault lies. Going to keep it vague for obvious reasons.

I'm orienting to a new LTC/Rehab facility, so not directly involved. New admit coming to rehab unit following ortho surgery. In anticipation of admit, discharging hospital faxed over a med list, charge RN got them entered, ordered, etc.

Patient arrives to unit later that day, meds are administered as ordered for this gentleman.

New charge RN starts her shift and in "cleaning up the desk" sees large envelope of discharge papers for this new admit that came with the patient when he arrived. She is looking them over and starts to see that the original fax (that our MAR was derived from) and the ACTUAL d/c paperwork have MANY discrepencies. For starters, pt was given narcs that weren't on d/c med list and Lovenox as well.

Charge RN came to me wondering how this would be handled in a previous facility I worked in (I will eventually be a weekend charge once I've oriented) so I'm slightly in the loop, but I've never actually seen said rehab patient.

So obviously there are errors here--who takes the hit for the med errors? The charge nurse who didn't actually read the current orders? The LPN that co-signed off on them? The actual nurse who GAVE the meds based on the information provided to her in the EMAR?

Thoughts?

[heron, ASN, RN]

I'm not sure there is a med error, specifically. There are certainly discrepancies between the dc paperwork and the med list sent by the hospital ... but I think the answer hinges on whether the facility accepts hospital dc paperwork as legal orders applying to the receiving facility. We get orders from the provider on admission, using dc orders and med lists as guides only. You didn't mention whether there was any contact between the provider and the admitting nurse before orders were entered and meds ordered. If your facility accepts dc orders without review by the provider, then I would imagine that the admitting nurse would take a hit for not reviewing the paperwork and clarifying discrepancies before entering the orders.

[Here.I.Stand, BSN, RN]

Sounds like a systems issue, if you're receiving a med list and a list of ordered meds, which don't agree with each other. Incident report identifies issue and begins a systems change. "Hit" is taken by nobody.

[caliotter3]

If the envelope with the actual d/c orders was not seen or read by the person doing the admission, I would not charge any med errors at all, but I would question where they got the orders that were written and then acted upon. Once that is cleared up, if they want to go back to the envelope orders, write everything up as changes. Of course all of this needs to be done in conjunction with what the MD wants because the MD needs to be informed that his patient received narcs, etc.

[heron, ASN, RN]

I gathered from the OP that a med list was faxed prior to dc from the hospital, which were entered as orders. Subsequently, actual paperwork came with the patient which was different from the faxed med list.

[BrandonLPN, LPN]

Some unknown variables here. If the med list was received first (not at the same time as the "real" D/C orders), then I don't view it as a med error. The charge RN had a list of meds faxed from the hospital. She read this list to the MD. The MD verified the meds, and the nurse transcribed the meds as orders.

Later, an envelope of paperwork came in with the patient from the hospital that had D/C orders that didn't jibe up with the med list faxed earlier. So, I'm guessing the MD was called again, and the med orders were clarified to match the new paperwork.

Where is the med error? If the nursing home's MD okayed the original med list, then those were valid physician's orders. When additional paperwork came to light, those orders were changed.

Was there an unreasonable amount of time after the new envelope arrived before it was noticed? Was the charge RN supposed to wait for the "official D/C instructions" before contacting the facility's MD? Those are the only potential errors I see.

Everywhere I've worked, the discharge instructions from the hospital mean nothing until verified by our (the nursing home's) MD. The only orders that are "orders" are those given by our physician. Isn't this the norm in LTC?

[loriangel14, RN]

Where I work nobody takes a "hit" for a med error. An incident report is filled out and if it's systems error things are reviewed to see how it happened and how it can be prevented.

[dudette10, MSN, RN]

I wonder if the hospital RN faxed a med list printed from the hospital EMAR (it had narcs and lovenox on it) prior to med reconciliation for discharge. I bet the two lists were formatted very differently, weren't they? At my hospital, nurses are unable to print the discharge papers if the MD hasn't done the med rec.

I get that request from NH's all the time, but I always fax the actual discharge papers.

If ( and that's a big if) that is what happened, I see this as a systems issue and a nurse education issue. The hospital RN should know not to fax the EMAR print out instead of the discharge med list, and the NH Nurse should have recognized that the faxed list was of active hospital meds based on the formatting.

[MunoRN, RN]

If the medications that were given to the patient were the ones that the Physician ordered, then I don't see how it's a true med error.

It sounds like what happened was that the hospital sent over a list of the patient's inpatient med list, then sent over the discharge med list. Neither list is actually right or wrong in terms of what the patient should be on after discharge, which ever list the physician is using to refer to, it's still up to them to determine what medications to order. Since the doctors who manage a patient in the hospital is often different than those who will manage them as an outpatient, they will often leave it to the new physician managing them in a nursing home to continue any new medications started in the hospital, so they may leave the discharge med rec without any of these meds, but that doesn't mean the outpatient physician shouldn't be continuing them.

[Altra, BSN, RN]

I'm a bit disturbed that the discussion is centering on who is to take blame and possibly suffer disciplinary consequences, and not on fixing a pretty glaring systems issue.

[heron, ASN, RN]

@ Altra: Umm ... Most of these posts are describing, or at least trying to describe, where the system might have broken down. The consensus seems to be that no "med error" occurred, just a bad process.

I'm a bit concerned that you read it all as blame and threats of discipline.

[BuckyBadgerRN, ASN, RN]

I'm not sure there is a med error, specifically. There are certainly discrepancies between the dc paperwork and the med list sent by the hospital ... but I think the answer hinges on whether the facility accepts hospital dc paperwork as legal orders applying to the receiving facility. We get orders from the provider on admission, using dc orders and med lists as guides only. You didn't mention whether there was any contact between the provider and the admitting nurse before orders were entered and meds ordered. If your facility accepts dc orders without review by the provider, then I would imagine that the admitting nurse would take a hit for not reviewing the paperwork and clarifying discrepancies before entering the orders.

And that's a great question. As all of this was happening on the weekend and the d/c'ing MD was not the one would was assuming his care in skilled nursing, I'm thinking no, BUT I can't be 100% sure