They can happen, but the odds are so very small if you follow protocol.
I walked into the station one day, and I was told that I was missing a page of med orders from my new admit last night. I looked at the chart. Ummmm, no. These are all the orders I had. Why do you say I’m missing orders? Apparently pharmacy placed additional meds on the patient’s electronic profile. The night nurse couldn’t find an order to verify them.
I picked up the phone and called pharmacy, wondering why the night nurse hadn’t done this already. I explained the situation and asked if pharmacy could please fax me a copy of whatever orders they used to place the extra meds. Silence. They had none. I asked them to take them off immediately. Please.
Mistake #1. What probably happened was that they received several faxed pages of different patients and somehow entered two different patient’s meds under one name. However, there are checks in place. This could have been caught had the nurse followed protocol.
When new meds are added to the electronic profile, there is an additional measure where the nurse has to acknowledge them – manually click a box that means the order is correct. We scan meds at the bedside, and you cannot scan a new med to administer without first acknowledging it. (After you acknowledge it the med is then able to be scanned and given for the rest of the patient’s visit unless discontinued.)
So I asked the night nurse how he acknowledged the medication if he had no order for it. Shrug. He was scanning meds in her room when one little annoying box popped up. Instead of verifying it with the chart, he said he asked the patient if she took it. He said she said yes, so he acknowledged the med and gave it to her. Mistake #2.
Mistake #3 was throwing the chart at me and telling me that I was missing orders. Dumb ass.
* Patient was fine, doctor notified, manager notified, variances filed, etc.
** Interestingly enough, I asked the patient during my first rounds if she was familiar with those meds or had ever taken them (without going into any details). She recognized one as a heart med but said she didn’t take any of them. Hmmmm….