Wrong patient. Wrong narcotic.

Chavez,

You really haven't given anyone enough information for us to help you with your post. Not following the 6 rights is a big deal, but people do make mistakes. We have to find out the whole story, for instance- Did you go behind her and check the patient? With duragesic, every nurse should check every patch for placement every shift, so if the prior nurse checked the wrong patient and ordered another patch, the next nurse should have caught it if he/she were conscientious.

How did this nurse "order" another patch under that patient's name when they never had an order to begin with? Also, with narcs you can't "order" patches willy nilly; they must show the Rx that they were used correctly or they will want to see incidents reports, a comment, a call, a new order from the MD, where did the patch go, etc...

Schedule II meds Must be ordered monthly in all 50 states.; there is no 90 day supply. It also depends on the narc's delivery system and facility (pyxis, narc box/drawer, etc...)

Also, when you get in the middle of an investigation you will find that it's not always as straight forward and fair as it should be. Many things at work there...

Our supervisor went behind the nurse still looking at the wrong patient and agreed it was missing. The PCP was called to ask if we could apply a new patch. Shift change happens and no patch was reported missing. The doctor called back informing the night nurse saying to apply a new patch. The day nurse was called and she admitted she forgot to say it was missing. The night nurse applied a new patch without looking for a old one. The next day an aide realized there was two patches on her one on each deltoid. That's when they realized the day nurse was looking at the wrong patient. The night nurse is being written up for not changing the order in the MAR for the patch and applying a new one. The day nurse isn't getting written up at all. Fair?

Doesn't the system you document the meds in have a protocol for where the patch was placed on the patient initially and each time it's changed (to avoid placing multiple patches and also to not keep putting the patch in the same place)? If you did, then the nurse who put the patch on and then discovering more then 1 patch would have looked at where the patch was placed at last application before putting on another patch.

In order to prevent this, we round on the patches at shift change, sign in MAR with a double signature (outgoing and incoming nurse) that acknowledges the patch is where it is supposed to be.

Sounds like a lot of extra work, but not a bad idea at all!

In order to prevent this, we round on the patches at shift change, sign in MAR with a double signature (outgoing and incoming nurse) that acknowledges the patch is where it is supposed to be.

In order to prevent this, we round on the patches at shift change, sign in MAR with a double signature (outgoing and incoming nurse) that acknowledges the patch is where it is supposed to be.

We do the same thing. On coming and off going nurse eyeball the patch and document they've seen it.

Good point. We round, but only daily, not QS. Before our unit managers leave, we print a patch report from the EHR and go around and check them. takes 10 minutes and also gives us an opportunity to check on those patients.

i check the mar and the wrist band if theres no wrist band i ask another staff to verify identity. too much risk not to be diligent. you have to wonder how many med errors the place must have. the name is on the box the patch comes out of....