Med Errors and reality

My hospital has gone to electronic Mars. A laptop on a cart we give meds as entered by pharmacy and checked by us, scan each med and the pt arm band, like produce at the check out counter. I have found it has corrected me from more errors than I ever cared to admit. God what I would give for a little more time for pt caring. Interesting poll.

We are going to that system in several months. Glad to hear a good report on it. Recently we had a patient that had local skin reaction to sulfadene salve. It was clearing written on MAR that he was alergic to sulfa but no one not even the pharmacy made the connection. Perhaps the computerized system would have picked up on it.

I'd like the opportunity to try this system!

We have also been using phones we carry with us, the pts call us directly for their needs, now they are asking us to try the over head piece to free both hands to work while we talk. I have found this very disconcerting when I want to talk to another nurse, as I can not tell when they are free for me to talk to or not. My deep concern is that the pts will feel the same way, and how much more difficult this may make for us to keep pt confidentiality, with all this multitasking while we are suppose to be free to do more pt care at the same time. So far I have refused this new and improved work saver??? It would free my hands for meds and other stuff during all the times I am put on hold.Any comments regarding this.

One of my concerns is the ability to concentrate on the main task at hand....are thye asking for to much "multitasking?"
I had been asked to get a headset that i could use while I pulled arterial lines and was holding pressure...I didn't agree....was afraid I'd loose control of the situation and not pay close enough attention. in the end, my superiors agreed...thank goodness!

Oh, yes I agree whole heartedly, If my brain could stretch to cover so many varied topics and do good at each at the same time, I would have loved to learn to play a pipe organ instead of a saxaphone which plays one good note at a time. LOL

If we shoved a broom up our behinds, they'd make us sweep up after ourselves!!! (so don't tell THEM)

Enough is Enough!!!! I wanna be a nurse - a great nurse!!!

When I'm with one patient, I STAY there, making him/her feel like the most important person in the universe. (which they ARE) Multi-tasking, to me, depersonalizes them and minimizes them as people. It is distracting and contributes to poor assessments, and unnecessary errors.

(did I get off track again? sorry!)

Computers are only as good as the people programming and using them.

We've had Pyxis Machines for years and it doesn't correct mistakes by physicians writing illegible orders, or pharmacy/unit secretaries taking them off incorrectly or nurses that are being rushed and make mistakes.

Bout the only thing they're good for is saving time vs running to pharmacy for common meds, and for making sure the patient gets billed for every freakin Tylenol.

Andrew Lopez, RN
http://www.nursinghumor.com

And the Pyxis (or Med-Dispense in my facility) is only as good as the pharmicist programming it. Ours was a nightmare until all the nurses boycotted it. Admin fixed that after about 3 days of us ganging up on the pharmacist who was whinning about the nurses bothering him. Inputting data and filling the darn thing makes it a whole lot user friendly!!!

The trueism is, there will always be med errors and it requires the diligence of everyone from the doctor to the patient and all parties in between to keep them to a minimum. Doesn't matter if you have a computer or are doing it all by hand, if one person drops the ball an error will be made. Sad but true.

I had an error the other day. It wasn't a med error but a "transcription/communication" error. We have 1 lady Phillipino MD who has the worst writing every (she's family practice and came to my OB unit as a consult) Her hudsband is a surgeon and says he can't read her writing either. So she write her orders and I ask her what they say (so I thought) and I take notes as she's reading them to me. Well the next day she says where is this BMP? I show her the lab results from the BMP I'd ordered the day before she says no I ordered a BMP (at least that's what I heard and am still hearing with her accent) Well if finally comes out she wanted a BNP not a BMP but the N looked like a M and it sounded like it too when she said it several times and I was saying that is a BMP. It was kind of funny she's saying no not BMP...a BMP (BNP) and me saying that is a BMP. She could stand a computer to type on if she knew how to spell or say what she wanted. Usually everyone gathers around her orders and votes on what it says.

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.

The scary part of it is that the majority of medication errors probably go unnoticed, by both the nurses administering the medication or the patient receiving it.

As fast as we have to move these days, it is difficult to catch everything when so much of it doesn't have to deal with us personally.

The physician orders the wrong medicine (but at the right dose), the pharmacy sends up the wrong medication (labelled as the right drug ordered), etc.

Makes it downright scary to be a patient these days.

Andrew Lopez, RN
http://www.nursinghumor.com

I have been using the laptop scan the med and pt system for about 6 months now. We still have the pyxis but the stinger cart scanner checks each barcoded med pre pt being given. I still remain totally amazed at how many times I find myself going back to the pyxis to correct myself. I truely believe I am and always have been a careful nurse. This system has proven itself to me for greater pt safety.

Hi, everyone!! I am new to this forum. But I must comment on this issue. The hospital I work in just were inserviced on new pumps, Outlook from BBraun. Well, it has the bar coding and automated programming. I cannot say how much I love these new pumps. We are all so busy and these pumps really help me. I work in a critical care setting and are often hanging numerous IV bags in a day. Have any of you all worked with this system?

National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP):"Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. A significant portion of those deaths is due to medication errors. That's more than die from motor vehicle accidents, breast cancer, or AIDS- three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems."
http://www.nccmerp.org/consumerInfo.html


Not exactly comforting statistics.

Andrew Lopez, RN
http://www.4nursing.com

Has anyone ever seen a study on med errors and who is making them? If you look close you will see that most med arrors are done by the ever so educated RN.Look at the stats.

maybe those RN's are giving the majority of the meds?

[ QUOTE ]
jzahn said:
Has anyone ever seen a study on med errors and who is making them? If you look close you will see that most med arrors are done by the ever so educated RN.Look at the stats.

[/ QUOTE ]

Care to share the source of the statistics you're referring to? Otherwise it sounds like you've got an ax to grind rather than making an objective point. While you're at it, you didn't happen to mention your own licensure or education.

LPNs/LVNs, RNs, NPs, Pharmacists, MDs, etc all make errors. Sorry, don't think licensure or education has a damn thing to do with it.

Andrew Lopez, RN, ADN
http://www.4nursing.com

I bet more RN's on my unit do make the most errors but then it comes down to numbers if everyone makes 1 error say: We have on a day shift
1 Pharmicist
1 LPN
7 docs (if they are all there or 3 that make rounds for their group)
5 RN's

As a unit
4 LPN's
38 RN's (2 with BSN one being me)
7 docs
3 pharmicists
3 secretaries
so the precentage is there like Andrew said everyone can make a mistake.

We use the Pixis machine. Well I have seen it stocked incorrectly. Even in the narcotics bins. I have seen where the Doctor read a home med list wrong, and wrote an order to continue that med. We scan our orders into the computer for pharmacy. Take the Dr. s poor hand writing and the poor quality scanner, there have been errors. SO Why is most errors created by NURSES.

1st Here at my hospital they do not say who is to blame instead we say, "How can we do better." Pointing fingers and making judgment calls without scientific backing or study creates more problems, including social problems on the unit.

I agree with Andrew, jzhan has a problem with the letters R.N.

In the public's eye, the last person to "handle" their medications is the nurse at the bedside, so they're expected to "catch" errors (and get blamed when an error is discovered). When they say we are the patient's "last line of defense" they are not joking.

As Mark (1mg.epi) said, from the time the doctor writes the order, to the time pharmacy dispenses and sends the med to the floor, there are a million and one things that can go wrong, many that we as nurses have no control over.

Andrew Lopez, RN
http://www.4nursing.com

we use a pysix also (just got all new ones they spent big bucks on..work just like the old ones)We still have patient drawers for routine meds. But we do the scan to pharmacy also and get preprinted MAR's from pharmacy but there's still the transcription problems. All the same problems everyone else has. We do the no blame reporting too and are told we don't report enough. For our l&d post part. patients we have preprinted orders so not too much usually too different on them it's the GYN's that are different for us.

<font color="purple">I disagree with you. The orders are put in the computer by the doctor, so that does away with the sloppy writing. When the order is input by the doctor it then goes to the pharmacy were were the pharmacy verifys the order wether it is correct and reasonable and that it is formulary. After that the order is sent to the BCMA program and then when the medication arrives on the floor it is administered. It isn't perfect, but it is one of the best things going. It was developed by the Veterans Administration.Text</font>

A computer is still only as good as the person typing the order. If there are several consulting docs do they see all the meds that all the other docs have ordered? We have summary sheet on the chart (on M/S units) that list everything as it's ordered and yellowed out as d/c...more writing for the nurses to help the docs.

[ QUOTE ]
explorer said:
<font color="purple">I disagree with you. The orders are put in the computer by the doctor, so that does away with the sloppy writing. When the order is input by the doctor it then goes to the pharmacy were were the pharmacy verifys the order wether it is correct and reasonable and that it is formulary. After that the order is sent to the BCMA program and then when the medication arrives on the floor it is administered. It isn't perfect, but it is one of the best things going. It was developed by the Veterans Administration.Text</font>

[/ QUOTE ]


Tell that to the patient that gets digoxin toxic because the pharmacy sent 2.5 mg instead of 0.25 and labelled it wrong.

As long as the nurse gave it (labelled as 0.25 or not), they can establish liability on the part of the hospital and you've got a viable lawsuit.

Andrew Lopez, RN
http://www.nursefriendly.com

It all comes down to the person that hand that med to the patient. We can try to shift responsibility to the pharmacy or to the transcriber. The person that hands that drug to the patient is responsible. If the doctor orders patients home meds and I notice the dosage is ordered different I bring it the the dr.'s attention. Because, it is me giving the med. It is MY Responsibility. We do not have the computer system that allowes the doctor to order medications. Even with that I am the person that gives the meds and it is MY Responsibility.

you are right about handing the medication to that patient but you still have meds that are labeled wrong. I'd like to know what every medication looks like but I don't so when I get a med that's not familiar to me the label says ABC but what's inside is XYZ and to me looks like little white pill.
When I worked home health it was real confusing for little old people let alone me they were used to the green pill then their pharmacy changed generics and now it was a blue pill.
Several years ago my son was on a routine med and it was white then I got yellow ones...guess what not generic but wrong med but it was labeled correctly. I also one time got 3 times the number of pills ordered guess the TID really threw them.
It'll be a cold day someplace when the docs at my hospital enter their own orders only a couple can look up their own patient lists let alone lab results then to get them to type I just can't see it in my lifetime.

Hi cassioo your post before you last on said, [ QUOTE ]
A computer is still only as good as the person typing the order

[/ QUOTE ] I once was a computer programmer. we said garbage in, garbage out.

Is it true that the average doctor kills 3 patients before he/she graduates? or is that just legend?

From things I have heard from nurses that work at teaching hospitals this is probably not true. The Nurses save the patient before the student doctor kills them.

We have DO residents...got an order from one yesterday to change dressing NOW which really ticked me off. It was a c-section from abruption at 23 weeks I was giving blood for Hgb of 4 dressing was FINE. We also don't change c-section dressings day after surgery we take it off when they get in the shower but she wasn't getting up to shower. I was already in the mood yesterday so I asked him why change the dressing? he says it's just a petri dish and it needs replaced told him no it didn't it'll get removed later etc etc when her doc came in he asked who wrote that? (we have our routine you know) and just laughed...then I hear today that the little twit "told me off" so he told my co-workers but they just laughed at him too poor thing as I don't get told off. Same yahoo today orders extra labs & test on a 2 day section because she's sore...DUH major abd surgery=sore no S&S of anything else so extra $$$ on labs that weren't needed. No problem if there's a reason but WHY. I know because he could oh well let him do what makes him feel good I guess.

I am just waiting for them to issue each of us our own personal "johnny mop" so we can add toilet cleaning to our other duties. Come to think of it, I already do a lot of that already. I guess I could use that "johnny mop." I remember one Christmas my poor patient had a Golytely prep and refused my offer of a bedside commode; she made it to the bathroom, but managed to "paint" the floor, walls, etc.
I called Housekeeping who told me "You clean it up and we'll put the finishing touches on it." However, all was not lost--I had one bright and shining moment when a doctor accidentally brushed up against my rear end through the curtain while we were both tending to patients in a semi-private room. I said "Excuse me." He replied, "My pleasure."

in our L&D after 3pm we do clean our own rooms housekeeping leaves. If there is a discharge anyplace in the hosp the nursing staff strips the room and if the 2 3-11 shift housekeepers get to it they clean it if not it's left for day shift housekeeping...I think hire a few more evening and a night shift housekeeper.

Yes, I think that it would be a good idea to hire more evening and night shift housekeeping.

Last night I carried a pager, a locater button and a bulky cell phone. I am not the floor manager, nor was I charging--and I was not working on a particularly large floor. I felt like one of the Three Stooges trying to find out which one was ringing. More than one patient has told me to go tend to the other matter, thinking it was more important than what I was doing at the time. I am beginning to suspect that the inmates have taken over the asylum since some of these decisions must have been made by someone completely out of touch.

You have to wonder just how much floor time, the decision makers have.

Is it that hard to tell, that the people making up the "rules" are not catering to the nurses convenience?

They implement policies that are "cost effective" will "improve morale" and "recruitment/retention." However in my experience, they're much more effective when nurses have some input.

Sometimes I get the feeling it's the "bean counters" making decisions based on strictly financial/public relations issues rather than what will allow the nurse to provide quality care.

I usually have a cell phone and I hate it.

Andrew Lopez, RN
http://www.4nursing.com

You have to wonder just how much floor time, the decision makers have.

We have Joint coming next week oh my gosh we're so busy cleaning things up, making sure the right trash bags are in the right places, getting rid of old forms, getting all the policies retyped, not letting staff have a drink in the nurses station, reading little booklets that were printed with questions "they" might ask that I didn't even know we had patients...I just hope when they come to our unit I'm the one scheduled to do OR and recovery and they stay out.. but I know one day I'm in charge and already been instructed no trading that day. Hoops hoops hoops got to jump through a bunch of them.

We have the Pyxis and the eMar. The Pyxis is great. The e-Mar is going in the right direction, but there are problems with the programming. For example, we fax the written order to Pharmacy, they put it in the e-Mar, it only stays on the screen a short time (about 1/2 hr). If you were not aware the order was written (unit clerk or doctor didn't tell you, or you didn't get the message), the only way to catch it is do your chart check before your shift ends or sooner.
Otherwise, you are SOL. There are other problems also. I feel that the programmers were not nurses, or were nurses who hadn't actively practiced in a long time or ever. Incidentally, every night I ask God for doctor computer order entry.

We have doctor order entry here in Kansas City MO. The name of the program is CPRS Computerized Patient Record System.

Oh Geez, don't get me started on inspections. I've worked agency through dozens of them in facilities I go to.

Floor conditions at that time have no connection or resemblance to reality. They might as well be back in nursing school where "anything is possible" and you "have everything you need."

Andrew Lopez, RN
http://www.4nursing.com

I don't know if I posted here or where but we did pass that Joint inspection. The did have a few "recommendations" Get privacy curtains with bigger mesh on top for better air circulation.....guess the screens in my windows at home have too small mesh and air can't come in little holes. Lock the anestheia cart that is kept in the sub-sterile area behind the L&D nurses station to the wall...that way nobody can go in there and steal the anestheia cart...I probably wouldn't notice a strange person going into the OR, getting that big craftsman toolbox and pushing it down the L&D hall, down postpartum hall then out the front lobby. Same with the crash cart chain it to the wall...that way when you have a code find the key or remember the combination, unlock it, then unplug it the go to the code...I wouldn't be able to remember the combination or the keys would be with another nurse in another room or locked in the pyxis. You think a "smart" crook that wanted anestheia or crash cart stuff would open it and take out drugs needed....don't know what they'd want with a spinal kit. In all of the records they reviewed they did find 1 trailing zero (on an anesthesia record). They also didn't like the concious sedation policy for some reason. Just basically nit picky stuff

I had just started working in in this LTC facility and this pt was there that had been given an antibiotic that he was allergic to and it sent him off to the hospital. when he came back he was there for a couple of weeks and I get a call from his daughter who has him at home with her for a visit and she is giving me all these symptoms so I pulled his chart to see what new meds he was on and sure enough he was given the same antibiotic at the same nursing home I just told her to get him to the hospital fast. Scary isn't it.

People need to be more careful with meds. The buck certainly got passed on this one!!

HI. There is a Forum for LTC nurses. Might want to post these horror stories there. Good thing the pt. didnt have anaphylactic shock. If I ever had to go to a nursing home just to be on the safe side I wouldnt take any medication.

Post is " Med Errors and Reality" and the patient did go into anaphalactic shock the first time. I am a Nurse, I have worked LTC, Acute care, agency (per diem and travel), LTAC. I know some view LTC as a lesser position when in reality it is a more rounded position. Not a lot of technical skills required but, over all nursing assessment and people skills are utilized more.

The system has its pros and cons. The system works well preventing medication errors especially preventing patients from receiving medications they are allergic to. I know at our hospital before you give certain medications it will display critical information (PT/INR, K+, Platelet Count, etc...). I will be one of the first to admit that I from time-to-time have problem scanning the bar code on some medications. One of the biggest drawbacks with the system is the cart used by my hospital. It is big, heavy, difficult to maneuver. The laptop provides no wrist support so carpal tunnel can be a big problem. If they could find a better way to deliver the medications this would be a step in the right direction.

I think those electtronic MARS are great..but dont forget they can make mistakes too..Always keep the 5 rights in mind!

Just the other day I had a pharmacist come up to me to point out that another pharmacist had entered the IVPB antibiotic wrong. The nurse doing the 24 hour check did not notice either and unless I was going back a couple of days of orders I would not notice it either...not that I had time to sit and review two days of orders. Our system is using an electronic MAR which can be updated by the pharmacy and the nurses may not see the order because the pharmacist has talked to the doctor it just appears on the computerized MAR (of which most of the RN's print out in the morning) very bad communication and lots of room for error. So nurses are not the only ones to blame.

lam wrote:I had just started working in in this LTC facility and this pt was there that had been given an antibiotic that he was allergic to and it sent him off to the hospital. when he came back he was there for a couple of weeks and I get a call from his daughter who has him at home with her for a visit and she is giving me all these symptoms so I pulled his chart to see what new meds he was on and sure enough he was given the same antibiotic at the same nursing home I just told her to get him to the hospital fast. Scary isn't it.

One of the good things about electronic EMARS is once the allergy is listed into the hospital computer system it will be there for all hospital admissions. This really is a plus since unconscious patients can not tell you if the medication that you are about to give them will cause an anaphylactic reaction or not.

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.

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 ;)

1mg.epi wrote: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:

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......