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.... Read More

  1. Visit  morte profile page
    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.
  2. Visit  Anglkses profile page
    0
    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.
  3. Visit  Orange Tree profile page
    0
    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.
  4. Visit  canoehead profile page
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    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.
  5. Visit  ChristineN profile page
    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.
  6. Visit  Orange Tree profile page
    0
    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.
  7. Visit  RiverNurse profile page
    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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