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Neither borrower nor lender be

After working many years in a hospital, I took a job in a long-term-care facility. My supervisor and other nurses often "borrow" medications prescribed for one resident and give them to another. For example, if a resident dies or leaves the facility, my supervisor may cross off his name on his medication packet and write the name of another resident who gets the same drug. She says this eliminates waste and saves time.


My supervisor became irritated when I questioned her. She says they've worked this way "forever" and that I'm just used to doing things differently in the hospital. Are standards really so different outside the hospital?-C.C., ILL.


No. The practice you describe is unacceptable in any setting. Besides being fraudulent, it's unsafe for patients and far outside accepted standards of care established by the nursing and pharmacy professions and regulatory bodies such as The Joint Commission (TJC). The facility and clinicians participating in this substandard practice could lose their licenses and be subject to other penalties if an injured resident sues or if the fraud is discovered by agencies that oversee residential facilities.

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Refuse to participate in this illegal practice and submit an event report to give facility administrators a chance to correct the situation. You should also ask to see the facility's policy and procedure on medication administration as an approach to exposing the problem. Many resources are available to support your position, such as your state's Pharmacy Practice Act, the Institute for Safe Medication Practices (http://www.ismp.org), and TJC National Patient Safety Goals (http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals).


If medication administration policy doesn't change, we advise you to look for another job to protect your license. You may also have a professional obligation to report fraudulent and substandard practices to the appropriate licensing agency.



Don't fill in the blanks

At the hospital where I work, nurses document medication administration in two places: a paper-based medication administration record (MAR) that's eventually thrown away, and the electronic medication administration record (eMAR), which becomes a permanent part of the patient's medical record. In some cases, medications charted on paper don't make it into the eMAR. Management wants us to find these drugs and enter them into the eMAR-for other nurses, if necessary. I disagree with this policy. Am I right to be uncomfortable with this?-B.K., VA.


Yes, for several reasons. For one, it's poor policy because it opens the door to errors, patient injury, and inaccurate or fraudulent documentation. Expecting nurses to document medication administration in two places doubles the risk of errors. In addition, documenting for another nurse isn't acceptable except in certain specific circumstances, such as during a code when a scribe is designated. The facility should have a policy and procedure to address these exceptions.


In general, however, documenting for someone else exposes you to legal liability if a mistake is made. In the case of a potentially missed medication, the responsible nurse should make a late entry to document what actually happened according to facility policy.


Depending on how the eMAR is set up, documenting a late entry electronically can raise problems not encountered with paper-based MARs. For example, the system may close out before a nurse can make a late entry. If your facility has a policy permitting one nurse to document for another in limited circumstances, it should have a mechanism (for example, a drop-down box) that will clarify that one nurse is documenting on another nurse's behalf after consulting with her. Communicate all your concerns to management and offer to help improve and streamline the system according to best practices promoted by recognized authorities. For more on the benefits and pitfalls of electronic documentation systems, see "Playing it Safe with Bar Code Medication Administration" on page 32 of this issue.



Creating a just culture

I work in a large community hospital. Last week, we nurses received an alarming notice with our paychecks. It stated that "effective immediately, all licensed staff will be held accountable" for medication errors and various other mistakes, such as transcription errors or failing to report lab results on the day received. Disciplinary action ranges from a verbal warning for the first offense to a 3-day suspension with probable termination for the fourth offense. My manager says nurses will be "more careful" if their jobs are on the line.


I'm afraid this policy will backfire by discouraging nurses from reporting errors and close calls. Are harsh policies like this a new trend?-K.R., N.Y.


On the contrary. Experts in medication safety have long recognized that a punitive "name, shame, and blame" policy simply drives errors underground. Afraid of retribution, clinicians avoid reporting errors or near misses, allowing hazards and risky circumstances to flourish. The current trend is toward a "just culture" that's both fair to clinicians who make errors and effective in reducing risks.1,2


The medication administration process has many elements, and errors can be introduced at any point. A just culture encourages process changes that strengthen each link in the chain and remove incentives for risky shortcuts, work-arounds, and other unsafe behaviors.


To make meaningful process changes, management needs to track actual and potential errors and evaluate why they occurred. In the words of one expert, a just culture "rewards reporting and puts a high value on open communication[horizontal ellipsis]It is a culture hungry for knowledge."3


Advocates for a just culture have created a Just Culture Community to share information and ideas. Check it out at http://www.justculture.org, and work to change the culture in your facility.




1. Institute for Safe Medication Practices. Our long journey towards a safety-minded Just Culture. Part I: where we've been. ISMP Medication Safety Alert!! 2006;11(18):1-2. [Context Link]


2. Institute for Safe Medication Practices. Our long journey towards a safety-minded Just Culture. Part II: where we're going. ISMP Medication Safety Alert!! 2006;11(19):1-2. [Context Link]


3. Marx D, Comden SC, Sexhus Z. Our inaugural issue-in recognition of a growing community. The Just Culture Community News and Views. 2005;1:1. [Context Link]