Incident Reporting - page 2

Hi all, I'm looking for valued input - as always :nurse: I've been a nurse for nearly 4 years now, however, I still have the need to post rants, vents and "what-have-I-done-now" situations. Here's the latest... I've... Read More

  1. 8
    i listed what i thought was critical points of your post in bold and black and responded with my response in bold and blue :

    looking for valued input - here is what i have to offer -


    receive the handwritten report left by the evening nurse - ?
    the evening shift leaves right at midnight
    we receive their handwritten reports
    not much in the way of overlap.
    report looks brief and basic


    horrible that you received no verbal report no walking rounds and i assume no phone numbers to contact off going staff

    initial rounds - new pt. his iv pump is "beeping"
    retrospect....beeping in the background when i arrived on the floor before shift change.
    i noticed a primary of ns and an ivpb of mag sulfate - the bag was full.
    mag sulfate? i didn't get in report that the pt had a mag sulfate bolus
    found that the medication had been administered at 1042...14 hours after administration time
    1500, the pt was transferred to my floor.

    i call the physician he questioned why the delay. i had no answer
    -
    a.)the med was never administered, or b.) there might have been backflow ... either way i do not know
    i didn't get any information about the mag bolus in report.
    i do assume that the medication didn't infuse properly


    good initial assessment on your part with noted documentation of when a critical incident began and correct intervention

    it appears...given the information....this is a medication error
    i decide - to call the house supervisor ....would be documenting on it.
    suggested that i file an incident report
    thinking about quality assurance stuff ...take it down so there is no confusion
    incident report was conveyed to the oncoming charge nurse

    all complete and totally appropriate /reasonable actions on your part



    started yelling about the incident report being filed
    she said it wasn't worthy of an incident report and that it was a communication issue.

    unacceptable response from day charge who rendered an opinion but not a corrective plan of action to error
    to correct a potential sentinel event

    room is full of all the evening shift nurses- it is strangely quiet / not making eye contact
    nearly all of the nurses....making comments to the nurse that had admitted the pt
    comments like, "yeah, i know what you mean, that shouldn't happen to you" or "yeah, some people..."
    with one other nurse present she confronts me, demanding to know why i wrote an incident report
    i tried to explain to her - and when i indicated it wasn't in her report, she exclaimed, "i just forgot!
    "

    clear example lateral violence and unacceptable leadership of charge nurse



    but - if i'd had that piece of information, i might have handled things differently.
    she stormed out and left she was acting as charge nurse.
    she left no safety huddle sheet, other paperwork not filled out
    she should not have left the floor when she did. we are required to have two rns on the floor at all times - last night when she left - it was just me and an lpn on the floor at shift change.


    behavior that defines professional abandonment and gross dereliction of duty

    she says i probably shouldn't have filed an incident report
    because it was either saline solution or the mag sulfate in the bag.
    she said i could have just infused the mag.
    she also encouraged me to try to see this from the other nurse's point of view
    that i should talk to her when this blows over (which i will).

    all are entitled to opinions however what did supervisor direct you to do and what is policy of which it appears you followed

    i've been cautioned about making enemies where i work.
    rumors about others' cars getting keyed and vandalized
    i'm concerned
    i'm also concerned about retaliation
    rumor has it that nurses on this floor will look for things
    pick other nurses apart - especially when one feels threatened or attacked
    .

    now we are talking about another situation that is a critical incident and entirely that requires action on your part for your safety

    i'm a little afraid to even go to work.
    i'm not sure what i will face, what kinds of attitudes and treatment.
    i don't exactly feel supported my manager, either.
    but, the best i can do is press on and hope for the best.


    any thoughts-

    this place does not deserve you and the patients deserve better

    you did nothing wrong -nothing at all friend
    1. consider your protection - regarding your safety personally and professionally -
    2. this hospital is the definition of a hostile work place -
    3. no professional should ever go through what you have gone through.
    4. never mind scratches on your car but do seriously be concerned about and worried aboutabout being brought up on false charges as retaliation.

    after much thought i suggest the following -
    document everything you stated regarding what actions have occurred.
    immediately
    - with no hesitation -give a written resignation but no work notice


    send a copy of your detailed resignation to the don and hospital administration

    file for unemployment citing hostile work enviroment

    file a complaint and ask for an investigation with the bonregarding the nurse who abandoned patients without adequate / and left the floor against policy staffing ratios.

    notify the state doh and jacho about the policy and method of reporting on patients at shift change

    consider obtaining legal counsel for direction and advisement



    conclusion and reasons for my rationale -


    one may think this is over the top or dramatic however
    not when one considers the following both separate and in total :

    serious and potentially lethal error of an iv medication

    patient safety compromised by lack of adequate off going report

    the very idea that a nurse has fear of retaliation due to historical rumors

    the lack of support by a so called manager who clearly does not professionally


    nurse manager is inept demonstrated by refusing to intervene with offending staff and more so refuses to insist on safe patient care and a safe working unit


    duality of direction by manager/charge nurse and shift supervisor

    willingness of nurses not to follow procedure /policy in reporting med error


    willingness of nursing staff not to follow standards of care by the nursing profession

    lateral violence by being yelled in front of others and tolerated by n manager


    lateral violence by entire shift of nurses encouraged by a charge nurse

    patient abandonment and serious violation of staffing policy

    lack of report as a retaliatory action following incident



    considering all the suggestions are not dramatic but ethical appropriate and sincerely suggested for survival.

    when nurses do no longer tolerate abuse and show that there is accountability for such actions directed toward us and our patients that such abuse will stop. when put in such situations of dangerous compromise it is appropriate to have consequence and actions that proportionate to such risk.
    negotiation and denial of the veracity of such situations not only tolerates but promotes that which is clearly never acceptable as a person or as a professional.


    i sincerely wish you well and safety on every level - i hate that you have gone through this.


    marc

    Last edit by SilentfadesRPA on Apr 20, '11 : Reason: spelling and doc management
    RiverNurse, canoehead, Cinquefoil, and 5 others like this.

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  2. 0
    You were completely in the right. We have these issues on our unit as well, and I've made it clear that I'm not there to make friends, but to ensure safe patient care and med administration. I'm a newer nurse (just about 2 years) and even newer to the charge position (4 months) and I constantly butt heads with the day charge (who has been there 35 years) when filing incident reports for things that were done incorrectly in the previous 12 hours.... but it is what it is.

    Not to mention, you said that it was suggested that you complete an incident report - so why isn't everyone on the same page? Because they don't want a blemish on their record? I see incident reports as a tool for improvement, not ratting out. I wish others would get over their pride (because we've all made mistakes!) and work harder on improving their observations/skills/care for the patient.

    Thanks for posting this - and letting me say my piece!
  3. 1
    YIKES! I am so sorry to hear this. I hate that nurses do this to each other. Its awful.


    I am so sick of the nurse on nurse violence. No wonder nurses arent seen as professionals.
    I have such doubts about continuing on in nursing.
    AmericanRN likes this.
  4. 0
    Quote from psu_213
    Mag (in a non-code situation) is usually 1, sometimes 2, gram(s) per hour. One place I worked, the Mag would have been written for by the MD at 1042 and still wouldn't be up on the floor by 1500 (a pharm. issue). I don't think its possible to prove who did or did not infuse the mag.

    Either way, an incident report is a must. An incident report is meant to report on an incedent (and hopefully a solution is found to prevent it from happeneing again...getting rid of the silly handwritten report thing would be a start). The report is not to "tattle" on a staff member. Shame that your coworkers do not realize that.
    ...I was reading it as hung at 1042......and thinking it should have been done by the time of transfer.
    The only thing i would have done differently in this scenario was ask that the nurse be called at home. And even that doesn't preclude the writing of an incident report.
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    I would have done the exact same things you did (except the incident report piece and I will get to that). You were diligent and put the patient first. You didn't make a big deal about it you simply sought answers to ensure you provided appropriate care to rectify the med error (and yes it is a med error since it was not given in a timely fashion, I mean last I checked right time is one of the 5 rights).

    Regarding the other nurse, she is embarrassed that happened and is striking out because that is how she is coping with the error. That said it doesn't excuse her behavior which appears to have been extremely unprofessional.

    Sounds like the ball got dropped on two different units/floors by multiple nurses.

    I am not sure of your policy but where I work if a med error occurs with no harm that is an internal QA process met by the filling out of a med error form. If harm occurs then we fill out an incident report. That said at the end of the day I bet that nurse who got all upity would have done the same thing if roles were reversed. We all want to do a good job but with too much work and not enough time we all are looking out for our licenses and a supportive environment is hard to maintain with that kind of pretext.

    Thank you for sharing your story and I hope that this blows over and the "lateral violence", as one poster stated, ends soon for that is never productive nor pleasant.
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    IV fluids seem to frequently back up into piggy backs, so I probably wouldn't have gotten as excited about this as you did. I would have looked at the piggy back settings and seen how much had last infused and and what rate. That, along with the documentation that mag was given, would have made me feel pretty comfortable.

    An evening redraw would also have been reasonable to me, especially for a fragile patient. Our protocol allows us to do this without calling up the MD. I wouldn't have called up the nurse, either, because I only do that if there is no way to sort things out on my own. And an incident report? Nah....they don't offend me when other people fill them out, but I don't the time or inclination unless something VERY serious and irreparable (without great effort) has occurred.
  7. 0
    I'm totally with SilencefadesRPA.

    I also wanted to point out that you consulted your supervisor, and did what you were advised to do. Refer them all, including your boss, to the supervisor on duty.

    If you are afraid of car damage or other retaliation....you deserve a much better grade of coworkers. An unsupportive boss, a coworker that has a snit fit about legitimate patient care concerns, that's just icing on the cake. Start looking and move on, you've given them enough of your life.
  8. 2
    Quote from Orange Tree
    IV fluids seem to frequently back up into piggy backs, so I probably wouldn't have gotten as excited about this as you did. I would have looked at the piggy back settings and seen how much had last infused and and what rate. That, along with the documentation that mag was given, would have made me feel pretty comfortable.

    An evening redraw would also have been reasonable to me, especially for a fragile patient. Our protocol allows us to do this without calling up the MD. I wouldn't have called up the nurse, either, because I only do that if there is no way to sort things out on my own. And an incident report? Nah....they don't offend me when other people fill them out, but I don't the time or inclination unless something VERY serious and irreparable (without great effort) has occurred.
    I get that there can be some backflow into the piggyback bag, but I have never seen enough backflow to completely fill the bag unless someone deliberately backprimes it.

    With Mg IV being a high alert med, I think the OP is absolutely within reason to file an incident report. What if the pt's AM mg was critically low, or the pt developed an arrhythmia?
    canesdukegirl and morte like this.
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    Quote from ChristineN
    I get that there can be some backflow into the piggyback bag, but I have never seen enough backflow to completely fill the bag unless someone deliberately backprimes it.

    With Mg IV being a high alert med, I think the OP is absolutely within reason to file an incident report. What if the pt's AM mg was critically low, or the pt developed an arrhythmia?
    I actually see it happen quite a bit, but I'm not sure why it happens...does anybody know? I may come in at shift change and see an almost empty bag infusing, then see the same bag full when I go to hang the next dose.
  10. 0
    ::: nods :::

    That is true - about checking to see how much had infused. However, the IV pump was beeping and flashing "error" on it, so it was impossible at the time to determine how much had actually infused.

    Also, given that it had been hanging 14 hours out, I felt uncomfortable infusing it without a lab draw.

    However, point well taken.

    RiverNurse


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