Aug 28, 2006

Med Error....Or not


I'm very sorry I haven't been frequent with my entries lately. I've just had little interesting to say.

My latest development is that I sorta kinda made a med error yesterday.

I worked yesterday and today and had the same patients both days. Today I was confronted by a not-so-friendly resident about an order he wrote on Saturday. (I was off Saturday) He had increased the patient's dose of Insulin (Lantus) from 10 units a day to 20 units a day. Well on Sat. that order was signed off by the nurse and sent to Pharmacy. When I had the patient yesterday, the med order on the computer said 10 units. Pharmacy screwed up and hadn't changed it.

I gave the patient 10 units because that's what the MAR (med record) said. This morning....I was looking in the past doctor's orders (Those are still written and not on computer yet)...I was looking to clarify another matter and came across Saturday's increase order.
I caught it...called the pharmacy to inform them to fix it and gave the patient 20 units. After that...Cocky not-so-friendly resident gets huffy with me about the 10 units yesterday. I told him I caught it after the fact and that it was corrected this morning.

He actually WROTE an order to file an incident report. That's like basically the doc saying "Nanny Nanny boo boo....I'm telling on you"

Well I was happy to file the report. I explained to my charge the situation, he showed me how, and I described in it....in depth...what happened.

Now yes...I could have checked the PREVIOUS DAY"S orders but no nurse with 5 or 6 patients has time to do that. If I had dug into the comments of the MAR on the computer I could've found the increase but that was not where it was supposed to have been. It was not listed correctly on the MAR by the pharmacy. The nurse on Saturday should have caught that when she or he should have given the patient an additional 10 units that day as well.

The whole damn hospital shuts down and nobody wants to work on the weekends. The Lab, the pharmacy, the doctors, even the damn nursing staff get lazy and use the fact that "It's a Sunday" as an excuse.

I really hate working weekends.

*****************
Listening to: "Save me" by Aimee Mann

11 Comments:

At 21:23, Anonymous moondog said...

well, all i have to say is that people shouldn't get into a 24/7 profession if they don't want to work weekends and evenings. people don't stop getting sick just cause it's after hours....

 
At 23:17, Blogger Kim said...

You didn't make and error, you caughtan error.

Errors happen where there is a weakness in the system or if policies aren't followed.

You weren't the weak link here, and I'd point out to the attending that the resident basically called attention to the mistake by even mentioning an incident report which you NEVER, EVER put on a medical record...

What a maroon he was. sorry to hear they are still putting out the "cocky" version of residents

 
At 11:52, Anonymous S. R. said...

Didn't the 2-4 nurses since the original order do charrt checks? you just got unlucky. Parmacy did drop the ball.

I'm surprised the original nurse didn't just cross out the "10" and write in "20" in red ink. Simple, but effective. it alerts the future nurses that something is up there.

 
At 17:10, Blogger Jo said...

SR,
Those nurses....Apparently not.
Unfortunately there is no writing anything in red anymore since we are computerized. The order is signed off with the carbon copy sent to Pharmacy. Nurse's can't alter the MAR in any way, shape, or form. The Pharmacy inputs everything. All we can do is re-schedule or chart not given.

 
At 19:54, Blogger Intelinurse2B said...

Good catch! God forbid the resident say thank you.

 
At 22:52, Anonymous Nuckles said...

America is built on a 5 day a week world. You know it's annoying in hte military as well. We may have people working 7 days a week 24 hours a day but goodness forbid you want to get any admin work done other than 8-4 monday through friday!

 
At 15:02, Blogger Judy said...

The pharmacy has to make all the changes to our MAR's as well. My unit still gets a printed copy, and you can write on it, but that doesn't change anything for the next day, so there's not much point.

Really sucks when the pharmacy screws up and it's a couple of days getting caught -- good thing you picked up that error.

 
At 23:44, Blogger shrimplate said...

Hey, you did good.

An ORDER to file an incident report?! Hehehe.

 
At 15:38, Blogger Miette said...

You didn't make an error at all. The resident should have thanked you for catching it.

 
At 13:32, Blogger Doctor J said...

Sounds like a system error in pharmacy caught by you due to good, old-fashioned nursing.

The cocky resident is a moron. You were part of the solution, not part of the problem. Also, a written order for an incident report is just asking for litigation if something goes wrong...

 
At 14:31, Blogger WICatholic said...

Even on MARs that are on paper, it is not technically legal to cross of and write a new dose over the old... lawyers would have a field day "When did this change, when did you start giving 20 units????" etc. Always write out the NEW ORDER on new line, and discontinue the old order...

As for computers, if the pharmacy is responsible for writing in the med changes, they are the responsible ones, yet I have never seen them take any responsibility for their errors. At the places I work with computerized med records, it is the nurses who imput the changes into the puter...

You did not truly make any error... even the one for the day before, since you gave what was on the MAR. HE did when he wrote any kind of thing that implied med error permanently into the record. A simple notation to note order of (date) and rewrite the order would have done the same thing without causing potential legal grief.

I hope that you did go into detail...it sounds like you did. Good job, good catch.

 

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