When something goes wrong with a patient or a med

When the medication is not on the MAR

When a med floats outside the MAR, don’t backfill the mystery. Assess, notify, and document what you actually know.

8 min read built on 2 full opinions updated 2026-09-18

Written by a med-surg RN, ten years, day shift. Why there is no name on it · How this guide is made

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You find out a patient got, or may have gotten, a medication that is not on the MAR. Maybe it was pulled. Maybe it was opened. Maybe it is sitting at the bedside. Maybe the patient says they took it. Maybe it came up in handoff. But you cannot find an active order.

Key points

  • Stop on that medication until you can verify the order, dose, route, time, and last administration.
  • Don’t sign for a dose you didn’t give or witness. Don’t chart in someone else’s MAR space.
  • Assess the patient first: vitals, symptoms, sedation, pain, blood glucose, BP, allergies, or whatever fits the medication.
  • Notify the charge nurse, provider, and pharmacy with facts: what was found, what is missing, and how the patient looks right now.
  • Document what you know, how you know it, what you did, who you notified, and what orders or instructions you got.

What to write

as written

Norco pulled but not charted. Day shift must have given.

as it holds up

0718 During handoff review, eMAR showed no hydrocodone/APAP administration since 1900 yesterday. ADC dispense report showed hydrocodone/APAP 5/325 mg x1 removed at 0639 by RN [NAME]. I did not administer this dose and did not witness administration. Patient assessed: pain 4/10, RR 16, SpO2 96% RA, awake and oriented, no sedation noted. Charge RN [NAME], pharmacist [NAME], and provider [NAME] notified. No additional opioid administered pending clarification.

as written

Patient took own meds. MD aware.

as it holds up

1030 Patient found with personal medication bottle labeled lisinopril 20 mg at bedside. Patient reported taking 1 tablet at approximately 1000. No active inpatient order for lisinopril located in eMAR at time of review. BP 118/72, HR 76, denies dizziness. Medication secured per facility process. Charge RN [NAME], pharmacist [NAME], and provider [NAME] notified at 1038. New order received to hold further antihypertensives today and monitor BP q4h.

as written

Signed 0900 meds late for [NAME].

as it holds up

1505 eMAR showed metoprolol tartrate 25 mg due at 0900 with no administration or not-given documentation. I did not administer or witness the 0900 dose. Current BP 104/60, HR 58. Provider [NAME] notified at 1510 for direction regarding missed/late dose. Order received to hold missed 0900 dose and resume next scheduled dose if HR above [PARAMETER].

as written

Medication not on MAR. Pharmacy problem.

as it holds up

0842 Ceftriaxone 1 g IVPB noted in patient bin; medication label dated today 0805. No active ceftriaxone order and no ceftriaxone MAR row found in eMAR at time of review. Medication not administered by this RN. Pharmacist [NAME] notified at 0845 and stated order verification pending review. Provider [NAME] notified at 0850. Awaiting active order before administration.

as written

I think patient got extra insulin. Will watch.

as it holds up

1216 Lunch tray arrived. eMAR showed insulin lispro 6 units scheduled with meal. ADC transaction history showed insulin lispro removed at 1152 by RN [NAME], but no MAR administration documented. I did not administer or witness insulin administration. Blood glucose at 1218 was 142 mg/dL. Patient alert, skin warm/dry, denies shakiness or sweating. Charge RN [NAME] and provider [NAME] notified. Per provider order, hold current lispro dose and recheck blood glucose at 1300.

as written

Med error, no harm.

as it holds up

1735 Medication/order discrepancy identified: patient may have received gabapentin 300 mg at approximately 1700 based on medication cup found empty at bedside and patient report. No active gabapentin order located in eMAR at time of review. Patient awake, oriented, RR 18, gait not assessed, denies dizziness. Charge RN [NAME], pharmacist [NAME], and provider [NAME] notified. Fall precautions reviewed with patient. Monitoring continued per provider instruction.

Template

Chart note

[DATE] [TIME] Medication/order discrepancy identified during [HANDOFF/MED PASS/CHART REVIEW]. [MEDICATION] [DOSE] [ROUTE] was [FOUND AT BEDSIDE/REPORTED BY PATIENT/SHOWN AS REMOVED FROM ADC/OTHER], but no active order or MAR entry was located in [EHR/MAR] at the time of review. I did not administer this medication and did not witness administration. Last documented administration in MAR: [DATE/TIME OR NONE FOUND]. Patient assessment: [VITALS], [PAIN/SEDATION/MENTAL STATUS/OTHER RELEVANT FINDINGS]. Charge RN [NAME] notified at [TIME]. Pharmacist [NAME] notified at [TIME]. Provider [NAME] notified at [TIME] with above information. Orders received: [ORDERS OR NO NEW ORDERS]. Actions taken: [MED HELD/DOSE NOT GIVEN/PERSONAL MED SECURED/MONITORING/OTHER]. Patient response at [TIME]: [RESPONSE].

Provider message

[DATE] [TIME] Provider notification sent to [PROVIDER NAME] via [CALL/SECURE CHAT/PAGER]. Patient [NAME/ROOM] may have received [MEDICATION] [DOSE] [ROUTE] at approximately [TIME] based on [PATIENT REPORT/ADC DISPENSE HISTORY/MEDICATION FOUND/STAFF REPORT/OTHER]. No active order or MAR line was located in [EHR/MAR] at time of review. Current assessment: [VITALS], [SYMPTOMS], [RELEVANT LABS], [ALLERGIES OR NONE KNOWN]. Last documented dose: [DATE/TIME OR NONE FOUND]. Requesting direction for monitoring and whether to give, hold, discontinue, or resume [MEDICATION/RELATED MEDICATION].

If an order is clarified and you administer the dose

[DATE] [TIME] Order for [MEDICATION] [DOSE] [ROUTE] [FREQUENCY] verified in [EHR/MAR] after clarification with [PROVIDER NAME] and [PHARMACIST NAME]. Medication administered by this RN at [ACTUAL ADMINISTRATION TIME] and documented on MAR at actual administration time. Patient assessment before administration: [RELEVANT ASSESSMENT]. Patient response after administration: [RESPONSE].

Internal safety report

[DATE] [TIME] Reporter identified a medication documentation/order discrepancy involving [PATIENT IDENTIFIER] and [MEDICATION] [DOSE] [ROUTE]. Discrepancy: [NO ACTIVE ORDER/NOT ON MAR/ADC REMOVAL WITHOUT MAR DOCUMENTATION/PATIENT SELF-ADMINISTRATION/OTHER]. Source of information: [EHR/ADC/PATIENT/STAFF/MEDICATION FOUND]. Known timeline: [TIMELINE]. Immediate patient assessment: [ASSESSMENT]. Immediate actions taken: [ACTIONS]. Notifications completed: charge RN [NAME] at [TIME], provider [NAME] at [TIME], pharmacy [NAME] at [TIME]. Orders or instructions received: [ORDERS/INSTRUCTIONS]. Follow-up needed: [FOLLOW-UP].

Words to avoid

Word or phrase Why it causes trouble Use instead
probably givenTurns a guess into a chart factunable to verify administration
must have been given by daysAssigns an action you did not witnesseMAR shows no administration documented; ADC shows removal by [NAME]
med errorA conclusion before review is completemedication/order documentation discrepancy identified
MD awareToo vague to help the next clinicianDr. [NAME] notified at [TIME] of [FACTS]; order received: [ORDER]
no harmToo broad and too earlyno symptoms observed or reported at [TIME]
covered for nurseSuggests signing for someone elseI did not administer or witness the dose
charted late for previous shiftMakes timing and responsibility unclearactual administration time unknown; prior dose not documented
pharmacy issueBlames a department without factsno active MAR entry/order located at time of review; pharmacy notified

Tidying up the MAR after the fact

The usual trap is trying to tidy up the MAR after the fact. You see that a medication was pulled from the ADC. Or someone says another nurse gave it. Then you chart it as given, not given, or late, even though you don’t actually know what happened.

That makes a bad record. The MAR has a simple job: show who gave what, by what route, at what time, and under what order. If the medication is not on the MAR, or there is no active order, don’t force it into a MAR box. Write a clear note. Keep facts separate from guesses.

The next nurse needs the practical answer: did the patient maybe get exposed to this med, is another dose safe, and who already knows about it.

Bottom line

Chart facts, not guesses: what you found, how you found it, how the patient looked, who you notified, and what happened next.

Official guidance

  • If the eMAR, barcode scanner, medication label, or ADC information does not match, stop. Check it before you give the dose or document it. (NCBI Bookshelf, Nursing Skills 2e)
  • Medication documentation should be done on time and should match what actually happened, including the patient’s response when that response matters clinically. (OpenStax, LibreTexts/11:_Principles_of_Medication_Administration/11.03:_Documentation_of_Medication_Administration))

In court, 1989–2009

What happened in 2 court cases
  • Davis v. Louisiana State Board of Practical Nurse Examiners, Louisiana Court of Appeal, 2009. The allegations included medication without a physician order and MAR/controlled-substance documentation problems. The court affirmed the Board’s license revocation and related sanctions. One line from the decision: “Ms. Davis administered 3 tablets of Tylenol P.M. to a resident without a physician's order.”
  • Ethridge v. Arizona State Board of Nursing, Court of Appeals of Arizona, 1989. The court reviewed nursing-board discipline involving medication-order and charting issues, then affirmed in part and vacated in part. One line from the decision: “Eaves administered Percocet-Demi to a patient without first obtaining physician orders”

Court decisions

Published decisions, linked to CourtListener.

All decisions behind this guide

From nurses online

Quoted as written. Opinion, not a source.

Other guides

Advice, not law.