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A student nurse was instructed to administer medication to her assigned patient. Since the patient was to receive a dose of indomethacin (lndocin) at 10 a.m. and another at 2 p.m., the pharmacist had put two prepackaged doses in the unit-dose medication cart. At 10 a.m., the student took the patient's medication administration record (MAR) from the MAR book, took one dose from the patient's drawer in the medication cart, administered the drug, and initialed the MAR. She kept it with her to chart the afternoon dose.
Meanwhile, the medication nurse arrived to give the patient his 10 a.m. dose. She checked the MAR book and found his MAR was missing. But instead of looking for it, she recalled the patient's order from the day before, pulled the remaining dose from his drawer in the cart, and administered it.
When the student nurse reported off the floor that afternoon, she returned the patient's MAR to the medication nurse, who then discovered the double dose.
This error happened because the medication nurse deviated from established charting practice. When she found the patient's MAR missing, she should have investigated further.
She also broke the cardinal rule for administering medication:
Check the medication against the orders on the MAR when pulling the medication from the cart. Check it again when you're preparing to administer it. And check it once again when you've completed administration. Then initial the chart immediately.
Failure to chart doses immediately after administering them is one of the most common causes of medication errors. The error usually happens when someone other than the medication nurse is responsible for administering medications on the unit (e.g., students, doctors).
But charting doses before or long after they're administered can cause errors, too. For instance, if a nurse prerecords her initials, then rushes off to answer a code, chances are the patient won't get that dose. Or if she administers a drug intending to chart it later, another person can easily assume the dose wasn't given, and the patient will get a double dose.
So make charting medications a ritual: Initial the patient's MAR when you administer the medication.