[CapeCodMermaid]

I had a surveyor come in to my building at 7:45 am today on a report I sent in last month. It was a rather involved medication error. Luckily the patient ended up being fine but I'm sure we'll get a GTag. What do you say when she asks why the nurse didn't look at the name on the top of the paper and transcribed someone else's meds? I didn't and don't have an answer,,,yah...it's basic,but lots of nurses are missing the basics these days. I am totally fried and guess I just needed to vent. I'm sure there really is no good answer. We are all human and all make mistakes. The state is so punitive it's small wonder most mistakes go unreported.

[marina17]

Originally Posted by CapeCodMermaid

I had a surveyor come in to my building at 7:45 am today on a report I sent in last month. It was a rather involved medication error. Luckily the patient ended up being fine but I'm sure we'll get a GTag. What do you say when she asks why the nurse didn't look at the name on the top of the paper and transcribed someone else's meds? I didn't and don't have an answer,,,yah...it's basic,but lots of nurses are missing the basics these days. I am totally fried and guess I just needed to vent. I'm sure there really is no good answer. We are all human and all make mistakes. The state is so punitive it's small wonder most mistakes go unreported.

I would councel the nurse and ask her why..write down what she/he is
saying about it..then maybe highlight the names on the MARS..ask all the nurses for input..in regards to improve future medication passes..showing a plan of correction with proven results.Question..were the names similar? Hope this helps a little

[noc4senuf]

CCM, how was this a reportable case? I had a nurse two weeks ago that gave a resident over 70 units of NPH and Regular insulin when he should have given her the Forteo. He had been carrying both syringes with him at the time. The resident was ok and the MD and NP happened to be rounding that day and did see her. The nurse was written up and counseled, he also will never carry two syringes again. But, it was not reported as it was an error and not intentional.

[CapeCodMermaid]

If someone falls and fractures a bone, that is unintentional but still reportable. It has to do with the error not the outcome. Medication errors are huge. It wasn't a benign drug like colace...it was Coumadin, Insulin, antihypertensives, etc etc. I felt it was significant enough of an error to report it. The state apparently felt the same way because they came into the building to investigate.

[achot chavi]

You were right to report- it shows that you have nothing to hide . Recently in Israel we researched the med errors and found that while most go unreported because of fear of backlash- most nurses are even willing to LIE to avoid the criticism that goes with reporting a med error!! The advice was not to overdo the criticism- its enough to point out the 5 checks -right patient, right drug, right route, right time, right dose. And write up the error in the nurses file. WE ALL MAKE MISTAKES!!! Start with the president of almost every country and on down. When the inspectors come its enough to say that obviously the nurse was careless this one time and has been given the appropriate instructions, I would also keep an eye on her for a bit (not in an obvious way)and write a follow up note for her file (hopefully) that there was a marked improvement and compliance to the regulations of medication administration. Between you me and the doorpost- it is physically impossible to NEVER make a med error. Life goes on (hopefully)