How bad is this med error?

  1. I got written up for leaving a saline flush in a patient's room. I had went in the room with it already having the plastic cannula on it, ready to use, but the previous shift didn't tell me that the patient was getting an IV at TKO, so turns out I didn't need it. I didn't throw it in the sharps container. I think I left it on the IV pump. So, the next night, I received a med error report in my mailbox, saying I left a "syringe with an unknown medication in it in a patient's room". The patient didn't even have IV push meds ordered, and the syringe already had "NORMAL SALINE" printed on it, so it couldn't have been an unknown med. So, on paper, it just looks bad, when in reality, it's something that every nurse has probably done on accident without discipline. I'm starting to think that if the next shift has time to write up reports like this on me, then they're probably over-staffed or is out to get me. Has anyone been written up for something like this? Or have you written someone up for this kind of thing? I realize what I did was wrong, but filling out a report with "unknown medication" on it seems petty to me. This could have easily been resolved with a quick, "Oh, by the way, here's something to remember..." Any thoughts? And how can I defend myself well on this? It just doesn't look good when the only thing I can think of to say in defense was that I was ditzy at that moment.
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  2. 16 Comments

  3. by   UM Review RN
    Wow.

    It took what? 3 seconds to toss the syringe into the Sharps container, and how long to write that incident up?! I sure wouldn't have had time to do that under most circumstances.

    Then again, we have had patients who will shoot just about anything into their lines hoping for a high and would've loved to find that NS to mix with their crushed pain pills and inject. (Yes, this has actually happened.)

    Guess you need to check your rooms as well as your charts before you leave after your shift.
  4. by   SmilingBluEyes
    It is not the end of the world.
  5. by   flashpoint
    Did you learn from the mistake? I would guess that you did. Did anything bad happen? It could have, but, no, it didn't. Will you make the mistake again? I bet not.

    It happens...it happens to the best, most careful, most expereinced nurse out there. You learned from it, nothing bad happened, and you won't do it again..don't sweat it!

    Last edit by flashpoint on Nov 9, '05
  6. by   ZASHAGALKA
    Wow, the thing about nursing is - if you want to be petty, it's a 2 way street. And when you have like 2376 things to do in any given shift, I can always find 1 out of 2376 that you didn't do just right.

    If I had been presented with this write up, I'd of asked my boss why she didn't ask the nurse that bothered to write it up what her problem is with you - and why he/she didn't direct her back to you to address it personally.

    And I'd go to to your boss now and state my case that this was an unfair write up and should be removed from my record.

    And I'd ask the nurse that wrote you up what her problem is. Yes, I'd be quite confrontational about it. If you don't want it to happen again, you have to make it clear that garbage like this will always be challenged.

    And frankly, if my boss didn't remove it from my record, I'd write up the other nurse for being unprofessional by writing you up over trivial matters and let your supervisor digest THAT.

    ~faith,
    Timothy.
    Last edit by ZASHAGALKA on Nov 9, '05
  7. by   misschelei
    You have got to be kidding! Nurses leave stuff in the rooms all the time. When you go on shift you discard it all and start with your own stuff. It's not that big of a deal. The nurse who wrote you up is taking anal to a neurotic level. If it bothered the nurse that much she could have just mentioned it to you. Clearly she has too much time on her hands.
  8. by   P_RN
    It may have saved you from ever making that mistake again.
    It's a shame that you feel that the other nurse was out to get you...I don't think she was, but even if it is so...you learned.

    I have made bigger, and I have made worse stupid mistakes and I will be the first to say it. But, if I felt that a write-up was wrong, I wouldn't sign the slip without entering my own comment.
    The facts are:
    You took a syringe and needle in the room.....correct?
    You didn't use it....correct?
    You left it...correct...?

    I'd probably have thrown it out and mentioned it to the nurse the next time I saw her.

    But in the back of mind will always be the nurse on my unit that was filling Demerol tubex cartridges with saline and squirting the Demerol into a saline bottle she kept in her pocket. She gave her patients SALINE. They caught her with 17 doses of Demerol in her pocket . That's also the reason I'd never use ANYTHING I hadn't opened myself.
  9. by   Darlene K.
    I would reply on the write up exactly what happen. Don't leave it to the imagination what the "unknown substance" might have been. Also, keep a copy for yourself.

    Good luck.
  10. by   lsyorke
    Quote from P_RN
    You took a syringe and needle in the room.....correct

    No needle, plastic cannula if I'm reading the OP correctly and the syringe was marked normal saline. Sure, it shouldn't have been left in the room, but writing this up is just stupid. If this is the worst mistake you even make, consider yourself a wonderful nurse!!
  11. by   HappyNurse2005
    Was it one of those prefilled saline flushes that clearly say "0.9% sodium chloride" on the side in big letters? We have those. People always leave them in rooms, and no one gets written up for it!
    Of course, they could have had the saline squirted out and filled up with morphine, too, so I can see the "unknown substance" angle.

    I think it's a bit petty. It happens all the time. Do you know who wrote it up?
  12. by   bth44
    Your flushes sound like ours. They do say "0.9% Sodium Chloride" on them. And I thought about the morphine or other drug in the syringe, but then I thought about how the patient didn't have IV push meds ordered. I do know who wrote me up. On the incident report, the person who's reporting has to sign it.
  13. by   SharonH, RN
    Quote from ZASHAGALKA
    Wow, the thing about nursing is - if you want to be petty, it's a 2 way street. And when you have like 2376 things to do in any given shift, I can always find 1 out of 2376 that you didn't do just right.

    If I had been presented with this write up, I'd of asked my boss why she didn't ask the nurse that bothered to write it up what her problem is with you - and why he/she didn't direct her back to you to address it personally.

    And I'd go to to your boss now and state my case that this was an unfair write up and should be removed from my record.

    And I'd ask the nurse that wrote you up what her problem is. Yes, I'd be quite confrontational about it. If you don't want it to happen again, you have to make it clear that garbage like this will always be challenged.

    And frankly, if my boss didn't remove it from my record, I'd write up the other nurse for being unprofessional by writing you up over trivial matters and let your supervisor digest THAT.

    ~faith,
    Timothy.

    Timothy, you and I may never agree on politics but on this matter we agree 100%. This is a bunch of baloney and the OP needs to stop it in its tracks or else they will follow her/him around forever writing her up for trivial stuff like this. People like the person who wrote the OP up always go for the easy ones and if they know that you will challenge them on the dumb stuff they will think twice before they do this again.
  14. by   Tweety
    Quote from SharonH, RN
    Timothy, you and I may never agree on politics but on this matter we agree 100%. This is a bunch of baloney and the OP needs to stop it in its tracks or else they will follow her/him around forever writing her up for trivial stuff like this. People like the person who wrote the OP up always go for the easy ones and if they know that you will challenge them on the dumb stuff they will think twice before they do this again.

    I agree with Timothy on this as well.

    Petty.

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