have you ever "written up" yourself in an incident report? - page 4

especially when you could have swept it under the carpet.......a short while back, l went into the pt room to give an IM inj. Almost always, l draw up meds in the med area, for some reason, that... Read More

  1. by   blue280
    I have written myself up twice and both times a system change was put into place because of it. I still feel nervous when I write myself up but these are supposed to be used as tracking devices so others do not make the same mistakes. Unfortunately, I now get to write another when I go to work tomorrow. This time it was not chrecking for informed consent for blood transfusion on a pt before hanging the blood. sigh I hope i learn from this mistake!
  2. by   healingtouchRN
    yup, knowing that incidence report or PI's as we call them, are a sorce of tracking human error & preventing them in the future. I am all for someone learning from my mistakes!!! I know there is a God because I have had some tuff things happen & no adverse outcomes came about!
  3. by   Sardonica
    Yes....I write myself up if I did it-----it was my error and I feel I should own it and be accountable.....luckily it was a minor thingie,
    but we had a fresh grad there & I thought it was ethically the right thing to do plus it was an opportunity to be a good role for the newbie.
    I figure----since I write up everyone else, I should definitely include me when it comes to incidents---integrity has to be a basic foundation of this business!
    Plus, I learned from it!
  4. by   KailuaNurse
    Yup!!! It was a couple days after orientation. Just a little med error (pt recieved dose couple hours early). Called the doc, let the charge nurse know. Luckly it was alright. Made a new grad a little shaky though.
  5. by   janesny
    Yes I have, I don't remember what for now, but I always figured that it would sound better comming from me than from someone else.
  6. by   JasonGreen
    Originally posted by l.rae
    especially when you could have swept it under the carpet.......a short while back, l went into the pt room to give an IM inj. Almost always, l draw up meds in the med area, for some reason, that evening l did it in the pt room....l change needles after l draw up the med, so when l re-capped the firs needle, l laid it on the counter, turns out the cap was loose. Next thing l know, a visitor was stuck with this needle... thankfully it was not contaminated biohazard-wise....pt did not want to see a doc, wasn't upset, and no one else knew....but l wrote it up, didn't feel l had a choice. If anything had come of it later it would have been much worse and the injured could have made false claimes. So l got a "verbal". My NM was great about it but stopped short of commending me for my honesty, which l found dissapointing.

    Anyone care to share? .........LR
    that is very commendable!
  7. by   live4today
    hello l.rae

    yes, i have written myself up several times in my sixteen year nursing career. it's a learning tool for myself and others, so why not?

    Perhaps with all the errors we write up about the things that happen in nursing due to shortstaff and too many patients per nurse, etc, the hospital just might realize something needs to be done to fix the situation like better staffing and less patients per nurse and really really really making the best of those acuities i hate to do every morning.
  8. by   janesny
    My largest med error was working in PICU. I Do not recall the exact med, but I pulled it from stock instead of waiting for pharmacy. I checked the dose with two other nurses being that it was an unusual med to give, maybe it was atropine or a code drug. Anyway, when the med came up from pharmacy the concentration was different than I had given. My heart dropped about ten thousand feet straight down. I cried, I called the resident, the cardiologist, and G-D also. The child was fine. His heart rate stayed stable. No negative side effects at all. The other part I remember is that because of the class of the medication there may have been disciplinary actions. It took me a long time and a lot of tears to write up that one. I feel and still do that if a med needs to be checked with another nurse, both should suffer consequences if its wrong. Not just the one actually giving the dose. Just my opinion, no flames please.
  9. by   goingCOASTAL
    Absolutely! I know there are a few nurses out there that like to pretend they've never made an error . . . but, I like to think they are just being less than honest.

    Temptation will tell you to do otherwise ("I'll get in trouble!" "No one even knows unless I rat!"), but your conscious should kick in, as well as your logic center! The fact is that your mistake COULD get discovered via patient outcomes, computerized medication or supply tracking systems -- and you could get in WORSE trouble trying to cover up than being honest.

    In healthcare, honesty is ALWAYS the best medicine, even if it's a "bitter pill" to swallow.
  10. by   ahill1000
    I work nights and one night I made a med error. I hung an IVPB of a med I was not familiar with. Even so, prior to hanging it, I looked it up in our micromedex so I would become familiar with it. Turns out, it was the same med, just in IV form, as another medication she was taking po. The order was written to give the IVPB only if unable to take po. The nurse that put in the order had placed it as a scheduled med so it turned up on my MAR to be given. I did not catch it because in the IV book, nowhere did it have the same name as the po med. Although it was similar. I should have caught that though. I caught my mistake on chart checks when I saw the actual order and the way it was written. The patient's doctor came in about an hour later, early am, and I immediately told him of my mistake and what I had done to fix the problem. I changed the med to prn instead of scheduled and passed it on to the day nurse. Also I held the po dose of the medication that was due for 5 that morning. The patient already had a drug level for that drug to be drawn at 5 also. He was very polite and admitted that we are only human and all make mistakes and what I did to rectify the situation was appropriate. I also wrote myself up. As others have said, by doing this can help us to look at the process in which orders are put in and prevent other med errors such as this. Needless to say, the patient suffered no ill effects and believe it or not, her drug level was actually below the therapeutic level.
  11. by   GRETTY

    Yes I believe in honesty also so I have also taken the route of self discipline and written myself up. I did this not only to be honest but to make sure that I never repeated the same error again. It Works! It makes you not only a better nurse , but a better person.
  12. by   Debbie, RN
    Yes, I like to think of "getting written up" as a learning tool instead of something to be used as punitive. I have indeed written myself up for errors - hoping that including myself, my co-workers could learn from my mistake. Unfortunately, it was not used in that way. Management thought we were writing up too many, so the variance reports stopped. Now mistakes just happen and unless its a grave one, it just gets slid under the carpet so to speak. So sad.....
  13. by   VA_CCRC
    At my place of employment we refer to 'incident' reports as Quality Reports. I think this conveys a less disciplinary-type image. I do not hesitate to 'write' myself up. I feel that USUALLY a report needs to be completed due to a SYSTEMS fault and that completing this document calls attention to things that need to be tweaked out to prevent further errors. Completing QR are important in instances of near misses as well. If I find an error from someone else I usually talk to that person and try to leave it up to them to complete the QR themselves. Still so many of us automatically associate reports with negativity.

    Let's use these tools to make our working environment safer for nurses and patients!! Take the time to complete these reports.

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