The easy way

I caught a med error today when discharging a patient, and, though it technically doesn’t fall under my responsibility, I know I could have caught it sooner.

The woman had been started on amiodarone 200 mg bid. Last Friday, August 1st, the doctor had written an order to decrease it to 300 mg daily in 2 weeks. Sometime early Sunday morning, the night nurse saw the order and thought it was a missed order. So she faxed it again to pharmacy and had the med profile changed.

The order was written very sloppily; so much so that “amiodarone 300 mg daily” was the only part that was easily made out – and the lettering was nearly twice as large as the rest. I only caught the error because I noticed the discrepancy in the current med profile and the prescriptions left by the cardiologist’s nurse when making out the discharge medications sheet.

No adverse events followed the mistake. Sunday the woman missed 100 mg of her prescribed dose. Today she received 300 mg in the morning, and she could still have gotten caught up if so ordered. When notified, the cardiologist’s nurse rewrote the prescription to continue the 300mg dose as woman’s rhythm had remained in sinus during the change – and she didn’t want to be flip-flopping the dosages.

That night nurse is the one that will be responsible for the change. I still felt guilty when making copies of the signed chart checks, order, and MAR. That order was only a few pages back. I try to be diligent in looking through the most recent orders each morning, but this morning I didn’t.

I need to get out of this false sense of security I have when it comes to my daily med sheets. Lesson learned…