October 20, 2009

Handling med errors

The nurse that I'm relieving asks me if I gave this patient his medication the day before.  I tell her I did. 

Well, she tells me she wrote the order incorrectly on the MAR.   He should have received a higher dose.

Oh, I said. 

I was the one who double-checked it, so I went to look at the original order.  Yes, the MAR was written wrong...but in checking, I missed the error and OK-ed the entry.

I went back and told her that.  Meanwhile, she's editing the MAR to reflect the correct order...which anyone in a Nursing Fundamentals will tell you is a big NO-NO. 

So I went to my charge nurse and asked for an incident report, and then took the matter to the supervisor.  I did sign off on an incorrect order and take full responsibility for that, so I had myself written up.  But I wanted it on record that not only did she transcribe it wrong, she edited the MAR after the medication was given.  I'll fully own up to any mistake I make, but I'll be damned if I'm made to look the fool by an edited MAR.  Fortunately for me, said nurse had told the charge nurse she wrote the change in on the MAR, so it's not a "my word against hers" thing; also, the night nurse who first discovered the error also knows what the MAR originally read.  Last, the supervisor told me that said nurse has been making a lot of med errors lately.

I don't know what came of all this yet, as I've had a few days off.

The supervisor told me that should I encounter an incorrectly written order during a double-check, I should rewrite it and then file an incident report about it.  To be honest, if I had come across the incorrect order while double-checking, I probably would just correct then sign off on it, then leave a note for her instead of writing her up.  I think to tell her about what she did wrong would be just as effective as filing a report...at least, if it was the first time I came across it.  If I had corrected 5 prior orders from her already and this was #6, I may get the form first.  But I'll be damned if I let her get away with changing the MAR so it looks like I'm the only one in the soup on this when she started it.

It was also a reminder to me to be more vigilant about transcribing and checking orders.  As I said before, I'm culpable in this too, and if I had noticed the error when signing off on the order all this could have been avoided.

Fortunately and most importantly:  no harm/no foul to the patient from this.

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