Med Errors and reality

[cassioo]

I had to write up a med error today. I delivered a patient yesterday so knew what the order was ...for BID then today the pharmacy printed MAR said BID PRN which isn't what the order was. The pt was offered the med last night and refused so she really didn't miss a dose and it isn't a major medication and is one that is often PRN but had I not been the one to see the order in the first place it would have stayed PRN instead of BID and after talking with her today encouraged her to take it BID as ordered because it would help here with the problem she had. Just good thing it wasn't some B/P med or the like.

[kimmiejs]

We use electronic EMARS at my hospital. Once an order has been entered into the computer it is up to the nurse caring for the patient to verify the medication order by comparing what the pharmacy placed in the computer with the original order. This is a measure put in place to help prevent medication errors. On a rare occasion I will catch one where the pharmacy has entered the medication into the system incorrectly. It is all about checks and balances, even in nursing

[BigRedNurse]

I almost had a med error of all errors. < 2 wks out of nursing school. I was a know it all new grad with a bad attitude. (smart ass).

I started a hep lock and drew up some ns from a bottle in the I.V. tray. I started to attach the syringe to the hep lock. Just happened I noticed off to the side the bottle I drew up the NS. It was not NS But KCL. Back then the bottles looked alike and we kept stock bottles of KCL in the ER. I dropped the syringe and almost vomited. I was shaking and told the patient, "oops, got to get another syringe." I have not had a med error since then, that I know of.

Which is EXACTLY why I triple check the order with the actual med.......:eek:

[BigRedNurse]

I'll try to kill two birdies with one stone; maybe this will help explain the difference between CNA and RN responsiblity; Scenario; report from 3-11 RN states direct admit from Dr's office. Pt had been administered Phenergan in office, was found unresponsive in exam room, transferred by ambulance to hospital. Pt groggy but improving on 11-7 assessment. Later in shift, pt complains of nausea; RN checks PRN orders and sees (can you guess?) PHENERGAN IV for nausea. I call physician @ 0300 to clarify order; Dr thanks me and suggests, maybe, Zofran? I alert our pharmacist, who is usually VERY dilligent, he can't believe that he actually OK'd the order and has to see it for himself. Can you say red-faced? Of course, I had to write up the previous RN for OK'ing the order; nothing personal, of course but part of my required job. All's well that ends well (and, by the way, I was still a pretty NEW RN at the time) and had 8 other patients that shift on a gen. med floor........)The CNA reference is for Mad in Texas ( I LOVE good CNA's). This is one reason why I so believe in good reports and clarifying confusing orders......