Whose medication error is it?

Nurses Safety

Published

Working at a personal care home, sending a resident to the ER for chest pains...

In the process of sending out a resident, the paperwork was copied and the usual routine was followed. 4 days later the resident returns from her hospital stay and upon readmission, her medication orders sounded the same as her room mates...so calling the floor nurse to review the paperwork that was sent with her, indeed it was her room mates MAR. The name on the MAR sent with her clearly showed the "improper name" and not the patients. Upon return, the doctor was phoned and discussed that the patient was dosed during her entire stay at the hospital with the wrong medications because of the paperwork sent. When dealing with medications, should you not do your FIVE Rs and verify that the med list sent is indeed that patients??! None the less, no harm was done and luckily they had a very similar list of medications!

Anyways, who truly should be responsible? The personal care nurse that included the wrong paperwork? The ER for not reconciling the medications properly. They both played a part in the error, of course. The personal care nurse did not dose the medications, yet she sent the wrong MAR. The ER doctor would have had to be the one to write the admission orders, including the Meds. How many hands does this pass through and noone caught the wrong patient MAR was sent!? Who should be repramanded for this mistake?

Would it be a transcription error? A dosing error? If the personal care nurse sent the wrong MAR, what exactly would be the med error on her/him? What are your thoughts?

By the grace of God, thankful this turned out to be an ok situation! It could of been disasterous depending on medications or allergies!!! Maybe even fatal!?!!!

Specializes in Critical Care.

Both! The name had to be on the copy that was sent!

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Specializes in LTC.

The person who did the admission should take the primary blame along with the MD. The hospital was the last link in the chain between those medications and the patient. They should of verified that it was the RIGHT patients' MAR. They should of paid attention to the DOB, NAME, AGE, and etc. This happens alot believe or not. The nurse that gave the wrong MAR should not receive that harsh of punishment. Maybe just a verbal warning, IMO. The hospital should take the main blame.

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Instead of BLAMING, how about we just all learn from the incident and do better next time?

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Specializes in Home Health.
You all should know that whoever sent the wrong mar would be the one reprimanded...

If a clerical employee pulled the MAR, the nurse transferring the patient should have made sure the documents were for the right patient.

If I found out I had done something like that, I think I would drop dead on the spot!

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Specializes in Tele/Neuro/RN Super/LTC.

Many of you feel it should be the one sending the MAR?

In reverse thinking, how many times have you worked on your floor/facility and received a document that didn't belong to any of your residents/patients?! What have you done?! Called and sent it in the proper direction!? Or how many times on the floor did you notice someone elses information was in the wrong chart?!! Were those people suspended for 3 days for errors THAT COULD OF CAUSED but DIDNT?!

Yes, the nurse who sent the MAR was totally devistated at the "WHAT IF" possibilities and the horrible outcomes. But before any of us dose medications (ESPECIALLY)!!!! do we not make sure we have the RIGHT PATIENT, dose, route....etc?! Before surgery do you not VERIFY you have the right papers/patient? Before ANYTHING in the medical ...isnt verification one of the most important plays?!!!

Truly, the nurse from the sending facility, should maybe have some punishment.

But look at the Kaycee Anthony case....NOTHING could prove guilty beyond a reasonable doubt so she walked away from murder!!!!

This nurse DID NOT DOSE the medications and they are the ones getting the harsh time?! Because they are focused on the WHAT IFs that could have happened, she could have had a severe reaction, she could have died! Yes!!!! Your right!

Don't you think that before that ER doctor who was prescribing the meds should have looked at the bottom of the MAR that was sent to assure it was the RIGHT PATIENT ....FIRST?!

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Specializes in Tele/Neuro/RN Super/LTC.
You all should know that whoever sent the wrong mar would be the one reprimanded...

Should the ED Doc not have checked the bottom of the MAR to see who's name was on it, before writing for the meds?....You dont blame him?

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Specializes in Chemo.
Many of you feel it should be the one sending the MAR?

In reverse thinking, how many times have you worked on your floor/facility and received a document that didn't belong to any of your residents/patients?! What have you done?! Called and sent it in the proper direction!? Or how many times on the floor did you notice someone elses information was in the wrong chart?!! Were those people suspended for 3 days for errors THAT COULD OF CAUSED but DIDNT?!

Yes, the nurse who sent the MAR was totally devistated at the "WHAT IF" possibilities and the horrible outcomes. But before any of us dose medications (ESPECIALLY)!!!! do we not make sure we have the RIGHT PATIENT, dose, route....etc?! Before surgery do you not VERIFY you have the right papers/patient? Before ANYTHING in the medical ...isnt verification one of the most important plays?!!!

Truly, the nurse from the sending facility, should maybe have some punishment.

But look at the Kaycee Anthony case....NOTHING could prove guilty beyond a reasonable doubt so she walked away from murder!!!!

This nurse DID NOT DOSE the medications and they are the ones getting the harsh time?! Because they are focused on the WHAT IFs that could have happened, she could have had a severe reaction, she could have died! Yes!!!! Your right!

Don't you think that before that ER doctor who was prescribing the meds should have looked at the bottom of the MAR that was sent to assure it was the RIGHT PATIENT ....FIRST?!

Then again we do not know full story, nor do we know if there has been other instants. Hindsight is 20/20. There are many people who are culpable in this change of events, but it starts with the first link.

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Specializes in MR/DD.

This is definitely a situation that can be learned from.

I have been in situations where I had to call 911 for patients and send a copy of the current physicians orders/MAR. Usually things are pretty intense and events occur very quickly, it would be very easy to make the same mistake, and makes me wonder how often it actually does occur.

Thankfully, the patient who was given the wrong meds was not harmed.

However, what about the other patient?... would this be a violation of privacy? Should the other patient be notified that part of his/her medical record was viewed by people not providing care to him/her?

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Specializes in MR/DD.

Another thought... lets say that 2 patients came in at the same time from the same facility. The MAR's got mixed up and the same thing happened. In this case it would clearly be the fault of the person who transcribed the information because they did not take the time to make sure the MAR was for the correct patient. For this reason I feel that the person who transcribed the medications/orders is to blame. Any records after that point would have had the name of the patient admitted, on them.

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Specializes in Emergency, Telemetry, Transplant.

At the hospital in which I work, the last person to blame would be the ED doc. The ED doc writes the "admit to" order...eg "Admit to Dr. John Smith, dx: pneumonia." At no point is it their job to reconcile the pt's at home/LTC meds. The admission doctor (or the team of residents, the NP working with that doctor, etc.) will write the actual medication admission orders. I realize that this works differently at different institutions.

When I look at this situation, if I had to 'place' blame (and I hope this situation becomes less 'who is to blame?' and more of 'what can be done to prevent this from happening again?') I would place the blame on these people:

1. The nurse who sent the pt out with the wrong MAR.

2. The nurses who at the hospital that did not realize that this was the wrong MAR for the wrong pt.

3. The doctor/NP/PA/etc. who 'signed off' on the incorrect meds/dosages.

I really don't think anyone deserved to be reprimanded for this situation, but each person invovled should be made aware of the mistake(s) they made and be given a plan for preventing these mistakes in the future.

As a sidenote: do you think we could lay off the multiple punctuation marks (such as the string of 5 exclamation marks with a question mark thrown in)? For example, it makes the message of the OP more difficulty to read and makes the post seem driven by crazed emotion and not by logical thought. Anyway, just a personal request.

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this sort of thing happens because nurses and drs are run ragged. The healthcare profession is so busy i am surprised more things like this don't happen.

We are pushed beyond our limits trying to get everything done and not incur overtime.

The breakdown in the system was not enough time. That is usually the source of errors. People are rushing and stressed to get done so management doesn't get on their backs. Being pulled in too many directions at the same time is another source of the breakdown in the system. I think this is all common sense but the higher ups who have never worked as a nurse or an md will never get it.

this is true and sad

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In my personal opinion it was the responsibility of those who prescribed the meds for the patient's stay in the hospital. Even if the clerical error was made, the ED docs get paid a lot of money to do their job, including the responsibility for receiving the MAR with the wrong name on it. But this sounds like it was a breakdown in the system. First the clerical error of the wrong MAR being sent, the ED staff not reading the name and other identifiers on the MAR that was sent, the wrong meds being prescribed for inpatient, etc. In my hospital it would be a nurse who does the med reconciliation after they go through the ED and are admitted to the floor, but even then, we call the doc if they didnt already check off on it, and verbally go thru each medication prescribed, and the corresponding DX for each and every med. It seems to be that this incident should be used as a learning opportunity for both the residence the patient was sent from, all the way to include the docs and nurses that were involved in the patient's care at the hospital.:nurse: Thankfully the original poster stated that nothing bad came from this, and if they can learn where the breakdown occurred the whole way around, then they stand a chance of fixing it so it doesn't happen again.:nurse:

I AGREE WELL PUT:yeah:

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