Not Nurse Ratched

Rehab RN just wrote a great post about near misses with med orders. I think they should be called “near hits,” because they were actually misses, but no one pays attention to this opinion. I wish more nurses would write up their med errors and near-errors because I don’t know about anyone else, but I definitely learn from other people’s mistakes, and my patients benefit.

For what it’s worth, which may not be much considering I just made a scary medication error (the med error I made occurred DESPITE all this triple-checking, which is actually what freaked me out the most), I spend a proportionately greater amount of time on medications than anything else at work. I’m always the last one done passing meds because I obsessively check lab values, rates, IV bag labels, and so on, and then I go through each med with my patients and ask if any are new and if they have any questions. If they look dubious, I explore it with them. “Are you unfamiliar with this drug?” They usually shrug with learned helplessness and say something like, “Well, if my doctor says I should have it, I’ll take it.” Not necessarily. I go get the paper chart and go spelunking to see whether it was ordered, and often I can tell by the surrounding orders why it was ordered. If not, I usually don’t give it until I have time to figure it out. It obviously depends on the drug. If the patient swears she has NEVER taken amiodarone or Rhythmol, is in normal sinus rhythm, and has no obvious indications for it, yeah, I’m going to hold it until I get confirmation. If it’s a fish oil capsule, it’s not going to hurt her.

Anyway, I find errors by doing this. Not daily or even weekly, but regularly enough and scarily enough that I don’t want to rush too much with my meds, because there are about a hundred places in the system that a medication order can get jacked up, starting from the admission medication reconciliation and ending at me emptying a pill out of a blister pack. Almost all of them occur, though, like this: the physician writes the order, and it is scanned to pharmacy. They enter it incorrectly (wrong patient, wrong drug, wrong dose…). The RN scans through the new orders and notes them off in a hurry, so bam, that med is then on the MAR. Or the reverse. An order to hold a med is scanned but never gets taken off the MAR, so it’s still there, looking all official. The RN on the next shift then administers the med, assuming the RN before her correctly noted it, and discovers after the fact that the order was wrong. And there you have it. A medication error. (And usually the nurse who gave the med receives all the blame, yeah?)

Anyway, before I hand over the meds, I ask the patient, “Are we agreed, then, on what is in this cup?” If not, we go through them all again. So I’m usually still scrambling at 10:00 to get the last of my 9:00 meds out, but I figure screw it, better accurate and late than wrong and on time. My hospital uses the COWs (computers on wheels) for medications, so I drag these things around with me. They’re pretty handy and have med reference manuals integrated with the MAR, so I can sit down on the spot with the patient and read up on meds neither one of us can figure out a reason for. Often I’ll list off-label uses (ever read up on all the weird stuff they’re using allopurinol for these days?) and the patient says, “Oh yes! I have that condition.” (Witness me, frantically scribbling this vital medical history not given to us previously.)

In the best of all possible worlds I would have time to do chart checks before passing meds, but that will probably never happen. I eyeball the charts, but nurses have about 7 minutes per patient to get report and look up orders before we have to get moving or everything will start off late, and gosh do we HATE that. Boring the patients with medication dialogues is a good second choice, IMHO.

Unfortunately I think that although the most experienced nurse out there can commit a medication error, experience does play a role. Some of that experience comes through making the errors; there is really no way around it. I’m just now starting to develop these antennae and safety nets! So please, nurses, let’s share our lessons, tips, and tricks with each other. It’s really helpful.