Who takes the med error hit?

[BuckyBadgerRN]

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?

[BuckyBadgerRN, 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.

Yes, this exactly---clearly much better said here, LOL

[caliotter3]

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.

If only this were true everywhere.

[BuckyBadgerRN, ASN, RN]

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.--Except that the envelope that came with the patient wasn't delved into until several hours later. He got meds based on the orders that were faxed before his arrival. Charge nurse that accepted him never checked the envelope, the one that took over in the morning did.

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?

It depends on your definition of "reasonable time" I think

[jojo489]

If the faxed med list was called to and approved by the MD, then there is no med error. Once the updated list was found, MD should've been called and discussed differences and changes made at his/her discretion.

What we did in my old facility was as follows. On the rare occasion we got a med list before a patient, we would enter the orders into the queue without approving them. Once we got the hard copy that arrived with the patient, we'd compare, then call the MD and get the list approved and add in that so and so took x narcotic in the hospital for this, but t isn't on the d/c list, should we add it? Only after we got the list approved by the MD did we save to the MAR and start administering the meds. Worked out pretty well as far as I remember.

[kaydensmom01]

I don't understand how this is a med error unless the nurse that entered the orders based on the first discharge instructions and gave the medications did not contact the physician before she saved the orders and administered the meds.

Anywhere that I have worked you have to have orders from the physician assuming care for the patient- you can't just order meds and administer them based on papers that the hospital sent, you must have an active order for them meaning that after the patient arrives you must call the MD to verify the med list. So if the case is the nurse put in the orders based on the paperwork, didn't call the MD, administered the meds- then she is the one that is at fault. If your facility is in the habit of not calling the MD to verify orders when the patient arrives before giving medications then I would think the nurse entering the orders and saving them is at fault because they were not verified by MD. If the med list was verified by MD, meds were given, then the 2nd list was found, the MD changed the orders then this is not an error because the order was active at the time the meds were given.

[toomuchbaloney]

I don't view this as a medication error but rather as a procedural error.

The med list that was provided prior to the patient arrival should have been reconciled with the list that came with the patient.

The orders that had been received for the care in the facility were correctly followed, but there was no reconciliation which is intended to insure that nothing is missed that should have been either continued or discontinued from the inpatient POC.

In my opinion

[BuckyBadgerRN, ASN, RN]

Um, I'm sorry----where did I use the phrase "threats of discipline"? Or even the WORD discipline? I was curious as to on which staff members shoulders the problem would be attributed to, you've really read into my OP far too much.

@ 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]

You've read between the lines far deeper than I have, Alta. I'm new to the facility (it was my second shift on orientation) and am learning their "systems", hence my question.

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.

[loriangel14, RN]

You used the words " take the hit". That implies someone getting in trouble.

[medicalforonevoice]

Normally when med list, etc., is faxed over ahead of time, the packet with the discharge summary and other particulars comes with the patient. Hmmmm, hard to say. I guess it would be up to the Nurse who checked the patient in. You know what they say, triple check! Check the policy for your facility.

[BuckyBadgerRN, ASN, RN]

I wouldn't imply that's it's going to be a disciplinary action.

You used the words " take the hit". That implies someone getting in trouble.

[jadelpn, LPN, EMT-B]

I am not sure why there would be disciplinary action, however, a med list from the hospital may be different than what the hospitalist/primary care would like to see the patient continue to take. The MD that takes over care in the nursing home can decide to order/not order anything they would like.

If said nurse calls and gets telephone orders from MD for the meds as described, the MD could have said "wait, Lovenox? Let's bridge to warfarin." And gone on to give INR orders, ect. (Is the resident in for an INR? Perhaps the lovenox is continuing until the INR is therapeutic?) Or "lets give Tylenol for pain, ________for breakthrough".

All of these orders can be clarified very easily. Doesn't matter who co-signed the orders, as at the time they were orders. The charge nurse was attempting to help with an admission as to why a hospital med list was used as opposed to waiting to see the discharge meds. But here's the important thing--medication lists--hospital, discharge or otherwise are NOT medication orders.

The practitioner can and does have the say in what is ordered or not ordered for an admission.

So you can get clarifications, and does the MD have to come see the patient at some point within the admission? Chances are you would get different orders then as well.

You also should have some sense of typical meds. For instance, if the patient is on Coumadin, there's no need for lovenox. If the patient is getting a large amount of Tylenol, then Percocet could dangerously add to the daily max of 3-4 grams--what is contraindicated and such--of course the MD should know this, however, if they are half listening while the nurse is rattling off meds, it may or may not be caught.

Perhaps the BEST policy change is for a facility to fax over the patient's discharge medication list only. On it should have all of the medications that the patient was taking routinely prior to/during hospitalization. And a medication reconciliation form is also a good tool to use on admission.