Whose medication error is it?

[o0nurse0o]

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!?!!!

[OCNRN63, RN]

what if the patinet died or was harmed???????

What do you suggest? A flogging in the town square?

[OCNRN63, RN]

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?!

You aren't by any chance the nurse who sent the wrong MAR, are you? You seem to be intent on shifting the responsibility to someone else.

As "wooh" suggested, instead of looking for someone to blame, how about we look at the situation as a learning experience.

[lcarlson3355]

Every person who failed to do the 5 R's during the 3 checks that should have been done with each med dispensed.

I had a CMA inform me that I "caused" her to have a med error because I failed to tell her of a med change on the pt. I'm sitting there thinking "You obviously didn't do your r's or 3 checks of the r's". What she also didn't know is that she was chewing out the wrong nurse. I didn't process the pharm meds during delivery due to coming in late that night but I was so stunted that she's chewing me out over her error in not checking the pt's MARS. Who dispenses meds without the MARS? She openly admitted to just dispensing the meds on that pt (excuse being the pt had the same meds for years) meaning med dosage changes, meds added or removed would and probably are being over looked by her for not checking the MARS. Still shocked she didn't look at the MARS and she's a CMA. I know my pt's meds but I still have the MARS open and check them against the med and dosage.

[rn/writer, RN]

Every single link in this chain either made an error or passed it along (which is also an error). Any one of them could have caught the mistake, but none of them did. So they each bear some responsibility for the situation. You'd better bet that if there had been a bad outcome, a malpractice attorney would be including all and sundry in the legal complaint.

Harsh punishment may not be the most effective measure, but neither is it a good idea to brush the whole thing under the rug. In order to take this unfortunate situation and turn it into a learning experience, the first thing that every person involved needs to acknowledge is that each of them is responsible, and it's no good pointing a finger at someone else. That this mistake got through as many hands as it did and went on for as long as it lasted indicates that each person was relying on the others to have taken care of the safety aspects. That is a dangerous risk that could have had far more serious consequences. Killing someone or causing them harm is also a learning experience, but it's one most of us hope to avoid.

Each contributor needs to accept their part in the mess and not pass it off on someone else. Anyone who can't do that should be reprimanded further.

[noreenl]

As a clinical educator for school nursing I teach the 8 Rights of Medication Administration and they are as follows 1. Right Patient, 2. Right Medication,

3. Right Dose, 4. Right Route, 5. Right Time, 6. Right Documentation, 7. Right Reason- why am i giving this med to this patient, 8. Right Response - is this drug having the desired effect. By covering all these rights, and understanding them, the possibility of giving the wrong med is decreased significantly because you know the the who, what, where, when and WHY of each medication you are giving. Just my lesson plan and I'm sticking to it!