Missing MAR

The mystery of the

Missing MAR

A Medication Mystery

The morning med pass has begun.You’re five patients deep and one MAR short.Somewhere in this charting chaos, a serious error is waiting to happen.Your job: Find it before it finds you.

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You’ll step into the role of a nurse in a real-world scenario where every decision counts.Your goal: apply the 6 Rights of Medication Administration while keeping your patient safe and your license intact. You’ll need to:

• Verify orders and allergies
• Calculate safe doses
• Catch errors before they happen
• Decide whether to give it, hold it, or clarify it

Every choice matters. Some lead to safe practice.Others… not so much. 😬

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Cast & SettingPatient: Harold Jennings, 72 years old History: CHF, HTN, Type II Diabetes, mild CKD Allergies: Penicillin (rash, SOB) Setting: Med-Surg floor, 0700 morning med pass Shift Mood: Chaos level = Moderate 🫠

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“Report is Over. It’s Go Time.”“You grab your scanner, log in to the MAR system... and realize — it’s gone. The entire MAR for Mr. Jennings has disappeared.”

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Morning med pass. Mr. Harold Jennings is waiting for his meds. You realize the MAR is missing.

What’s your first step?

You receive a faxed copy of the MAR from Pharmacy. (with questionable data)

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Partner says, “Maybe? It was on the counter…” Time wasted. It's not there!

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You find most orders but missing doses. Time wasted. Without doses, you STILL can't pass meds!

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You receive a faxed MAR from pharmacy with the following:Furosemide 40 mg PO dailyLisinopril 20 mg PO dailyPotassium 20 mEq PO dailyLantus 12 units SubQ QHSAmoxicillin 500 mg PO q12hYou recall: Mr. Jennings has penicillin allergy and K+ 3.1 on morning labs.

What is your next step?

GOOD CALL! You demonstrated "Right Drug" with "Right Patient" and clarified the order or held the meds for a reassessment! Your patient's heart and health THANK YOU!

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Patient breaks out in rash and BP drops — “CODE CONFUSION.”

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You ignored the allergy and gave Amoxicillin. Mr. Jennings develops a rash and shortness of breath.

Which RIGHT did you violate?

YES! By administering the medications you violated: Right Med - The medications are inappropriate for his allergy and potassium levels Right Patient - Mr. Jennings was NOT the right patient for those meds

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NO! GO BACK and review your 6 RIGHTS of Medication Administration!

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Mr Jennings reports leg cramps!

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You ignored the Potassium level and now your patient is suffering.

Which RIGHT did you violate?

YES! By administering the medications you violated: Right Med - The medications are inappropriate for his allergy and potassium levels Right Patient - Mr. Jennings was NOT the right patient for those meds

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NO! GO BACK and review your 6 RIGHTS of Medication Administration!

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Patient breaks out in rash and BP drops — “CODE CONFUSION.”

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You reprint the MAR from Mr. Jennings' chart and begin passing morning meds. You scan his wrist band, and then the first med, only to find:

MEDICATION ORDER OUTDATED! ERROR #173.67

ERROR

You've just almost administered an expired order. What's your best option?

CURRENT ORDERS MISSING ITEMS. PLEASE REVIEW ORDERS FOR CLARIFICATION ERROR #345.98

ERROR

You know that without correct doses - you don't have ALL OF YOUR 6 RIGHTS!

What's your best option?

Your partner can't help you find the MAR! Your window to pass Mr. Jennings' meds is closing quickly.

What do you do???

You review the vital signs put in by the CNA. BP 92/58 with a HR 56 Orders for Furosemide 40 mg and Lisinopril 20 mg are due.You’re already behind schedule.

What should you do?

GOOD CALL! You demonstrated "Right Time" with "Right Assessment" and clarified the order or held the meds for a reassessment! Your patient's heart and health THANK YOU!

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OH NO! Mr Jennings just became hypotensive and dizzy! Now he has fallen!

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Mr. Jennings has FAINTED!

What RIGHTS of administration did you violate?

CORRECT! By holding the medications you upheld: Right time - His assessment said it was too soon Right Med - The medications' actions only worsen his already low BP Right Patient - Mr. Jennings was NOT the right patient for those meds at that time

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INCORRECT! By administering the medications you violated: Right time - His assessment said it was too soon Right Med - The medications' actions only worsen his already low BP Right Patient - Mr. Jennings was NOT the right patient for those meds at that time

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You see a new order come in from Mr. Jennings prescriber. The new order reads: “Potassium Chloride 10 mEq PO BID.” The MAR already states: “KCl 20 mEq PO daily.” And the pharmacy sends up TWO bottles: Bottle A: KCl 10 mEq tabsBottle B: KCl 20 mEq tabs

What should you do?

CORRECT! By holding the medications you upheld: Right Dose and Right Documentation You saved Mr Jennings from a potentially life threatening med error- and used your clinical judgement!

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INCORRECT! By administering the medication(s) you violated: Right Dose - GI Upset, double dose, hyperkalemia Alert Right Documentation - You missed/ignored updated provider instructions by not clarifying

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I think you misunderstand your role! Nurses cannot order medications or invent doses! What are you? A mad scientist?

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Against all odds, you FINALLY complete your med pass, but your partner says they already documented your 0800 meds for you.

What do you do now?

GREAT JOB! Documenting your own medication pass is crucial to the "RIGHT DOCUMENTATION"! Let the coworker try to explain the double documentation - you protected your patient AND your license!

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FAIL! You have now triggered an internal Audit and possibly a visit from your friendly Director of Nursing, and possibly your Accrediting Body! You ignored "Right Documentation" and now your job is on the line.

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MAJOR FAIL! Not only did you fail to verify the "Right Documentation" - you FALSIFIED it! The Board of Nursing is on the phone- and it's for YOU!

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Before you signing off for the day, your Charge Nurse hands you some doses to double check.

Order: Cefazolin 25 mg/kg IV q8h.Weight: 10 kg.Available: 100 mg/mL.How many mL per dose?

MEDICATION ERROR! Wrong dose! Try your calculations again!

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Aweome! Now double check this dose:

Order: Ibuprofen 30 mg/kg/day ÷ 3 doses.Weight: 18 kg.Available: 100 mg/5 mL.How many mL per dose?

Great! One more, and you can give report to the oncoming nurse:

Order: Levothyroxine 75 mcg PO every morningAvailable: Levothyroxine 0.05 mg tabletsHow many tablets should you administer to provide the ordered dose?

Congratulations, Nurse!You made it through a wild shift, navigated missing MARs, sketchy orders, and questionable pharmacy faxes—and you still managed to keep your patient safe.Even after a rocky start, you:💊 Verified your orders before giving.🧮 Double-checked your math.🩺 Used your judgment instead of rushing.📝 Documented like a pro.You’ve just demonstrated the 6 Rights of Medication Administration in action:➡️ Right Patient➡️ Right Drug➡️ Right Dose➡️ Right Route➡️ Right Time➡️ Right Documentation🕰️ The next shift is ready for report, your charting is clean, and your conscience is clear.You can clock out tonight knowing you protected your patient, your license, and your reputation.🌙 Now go grab that well-deserved coffee, snack, or nap—you’ve earned it.

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