Do you document errors?

  1. Let's say during your shift you find that the wrong IV bag was hanged 3/4 hours into your shift. It is potassium the IV fluid ordered was NS. You are at fault for missing it during your inital assessment and the previous nurse was at fault for hanging it. Yes, you can do an incident report but can you do someone else to cover your butt. Can you document in the chart what happened since potassium in this client can have negative consequences. The incident report is just for the hospital and really isn't much to this hospital.
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  2. 10 Comments

  3. by   KIAN
    Document what was running in the IV, how fast, when, how much did the patient receive and that you removed it and started an infusion of NS. Document pt. assessment and that the Dr. was notified, when, what he ordered.
    Keep it accurate and simple. Do not chart why you think it happened or that you didn't notice it the first time around, or what you should have done.
    You made a mistake. Be a professional and own it, learn from it, and go on.
  4. by   meownsmile
    I agree keep it to what you found, your actions taken and dr notified. Let someone else decifer who's fault what was.
  5. by   SmilingBluEyes
    Errors, and their specifics are documented in variance reports where I work. These are separate from the chart and go to risk management and our manager for review and action.

    All that I chart on the patient note is the fluid initially infused, the change and any effects or lack thereof of the patient. I do not use the word "mistake" anywhere on the patient chart at all. Also, like said above, I document the notification of the doctor and actions/orders taken.

    Errors should be documented in occurence/incident/variance reports in-house for risk management. Be careful what you chart in the patients' charts. The assignment of blame, if there is any, also is not to be documented in patient charts. This again, is for you to do on the inhouse report for risk management. Just state the facts as you know them and any and all personnel involved/aware of this situation. Not for you to assign "blame" so much as to document objectively and comprehensively what happened and when, and who was notified.

    Let Risk Management take it from there.
    Last edit by SmilingBluEyes on Dec 7, '06
  6. by   TrudyRN
    1600 NS with K+ 40 mEq per R forearm IV site at 75cc/hr; per order, IVF changed to NS at 75cc/hr.; pt A&Ox4, MAE, NAD, VS whatever they were; Dr. Smith notified; K+ level drawn and sent to lab; B. Jones, RN

    1730 K+ 3.8 pt. status quo; VS if you repeated them, which wouldn't hurt; Dr. Smith notified of all foregoing information; no new orders; B. Jones, RN
    Last edit by TrudyRN on Dec 7, '06
  7. by   savedbutterfly
    Quote from TrudyRN
    1600 NS with K+ 40 mEq per R forearm IV site at 75cc/hr; per order, IVF changed to NS at 75cc/hr.; pt A&Ox4, MAE, NAD, VS whatever they were; Dr. Smith notified; K+ level drawn and sent to lab; B. Jones, RN

    1730 K+ 3.8 pt. status quo; VS if you repeated them, which wouldn't hurt; Dr. Smith notified of all foregoing information; no new orders; B. Jones, RN
    This sounds goo, you let them know that you changed it, everything is document well, but you refraine from placing blame Especially in the chart.
  8. by   augigi
    Absolutely! The whole purpose of incident reports is to identify contributing causes to errors and learn how to avoid them next time! Honesty and a no-fault policy is essential. It's an opportunity to examine your practice, work out WHY the error happened, and decide how you can avoid it in the future. Look at it not as a mistake but as a learning opportunity.
  9. by   nur2007sing
    Thank you guys! I never had this happen before and I wasn't sure what I did was right. I did not place blame or name individuals in the chart, did an incident report, called md- which ordered labs, I just did'nt know if there was more i should do.
  10. by   sming
    yes, write up the incident report in a non punaitive way. What are the contributing causes, in most cases nothing is going to happen. If you get shy about doing this, somthing tragic could happen out of fear or apprehension. I had a patient that had a bleeding problem quite awhile back in my career, he was the exact person you did not want to screw up with his coagulation. I hung heparin he was on it but at a low dose, when I put into the maching iv pump the rate it was wrong, I was rushed, the whole bag 25000 units went in, thank god he did not bleed. I went to the doctor told him what had happened, we took blood work, and gave the patient corrective measures, and told the patient togeather what had happened. Mistakes are going to happen, more people die each year because of this, and studies are being done all the time to try and prevent them from happening. Being up front and immediate is the most important thing to do, I did not want this man to bleed from my mistake and if I kept my mouth shut, he may have bled, and then how would I have felt. By the way the patient was not upset with the event, he was relieved that our actions showed him how much we cared.
  11. by   littlebear
    I have also been in the situation of making a drug error. It is an awful experience to go through, but i immediately informed SHO, together made a plan of treatment required, informed the patient, completed incident form and handed it personally to my manager. I kept everything to the facts. My manager was great she supported me through out and thanked me for having been honest. I actually had a collegue express surprise that i was reporting it which i found hard to believe. As it happens the patient suffered no ill effect from my error and again was greatful to know that it was being dealt with. Sometimes it is just a case of being more careful and taking more time even when in a rush. It can be a hard lesson, but make a mistake once and you will do everything not to be in that position again.
  12. by   RN BSN 2009
    Keep a reminder note of what had happend during that incident exactly, for your own reference. Never know when years later you are called to court

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