Incident Reporting

[RiverNurse]

Hi all,

I'm looking for valued input - as always

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 been working the night shift at a new job - I've been there for two months now. So far, so good. So, I arrive at midnight for my shift and receive the handwritten report left by the evening nurse - at this facility, the evening shift leaves right at midnight and we receive their handwritten reports when we arrive. There's not much in the way of overlap. Anyway... I find that there had been a pt transferred to the floor during the evening shift... still, so far, so good... The report looks brief and basic, but covers the main points for the pt.

I do my initial rounds - first one on the new pt. His IV pump is "beeping" and, in retrospect, I remember hearing a faint beeping in the background when I arrived on the floor before shift change. When I walked into the pt's room to examine the pump, tubing, IV site - I noticed a primary of NS and an IVPB of Mag Sulfate - the bag was full.

::: shuffling through my papers::: Mag Sulfate? I didn't get in report that the pt had a Mag Sulfate bolus... So, I did a little digging. I found the pt's most recent Mag level. I looked for the medication hx and found that the medication had been administered at 1042. It was now 0100 the following morning, 14 hours after administration time, and, at the time the Mag was hung, the pt was on a different floor. At about 1500, the pt was transferred to my floor.

What to do? Do I just continue to let this delinquent bag of Mag infuse even though it's been hanging for more than half a day or do I call the physician for another lab draw and further orders? I chose "option 2". I called the physician to see if he wanted another lab draw and if he wanted more Mag to be infused. No to the lab draw and yes for another Mag bolus. He questioned why the delay. I had no answer - but he understood that I walked into this situation.

Next thing, because the the bag is still full, I have to assume that a.) the med was never administered, or b.) there might have been backflow from the primary set. Either way, I do not know for sure as I didn't get any information about the Mag bolus in report. Because the bag is full, I do assume that the medication didn't infuse properly. It appears to me at this point, given the information I have, that this is a medication error of some sort. I decide - yes - to cover my assets - to call the house supervisor as the physician knew about the situation and would be documenting on it. It was suggested that I file an incident report (which I was going to do anyway).

I'm sitting here thinking about quality assurance stuff - like - when an electrolyte is complete, take it down so there is no confusion, etc, etc. In safety huddle that morning, the incident report was conveyed to the oncoming charge nurse - who immediately 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.

That night, when I arrive, the conference room is full of all the evening shift nurses. When I walk in, it is strangely quiet and not many are making eye contact. I put my things away and sit at the table. By that time, nearly all of the nurses have left the room, making comments to the nurse that had admitted the pt the day before - comments like, "Yeah, I know what you mean, that shouldn't happen to you" or "Yeah, some people..."

It's pretty obvious what's going on... Then, 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!" I get it... boy to do I get it... forgetting that is. BUT - if I'd had that piece of information, I might have handled things differently. She stormed out and left. In addition to that, she was acting as charge nurse. She left no safety huddle sheet, other paperwork not filled out and 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.

So - I talk to my manager about this whole thing. 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 - I get that... and that I should talk to her when this blows over (which I will).

In the meantime, I've been cautioned about making enemies where I work. There have been rumors about others' cars getting keyed and vandalized - but I have no proof. I'm concerned - and glad I drive an old battered up car. I'm also concerned about retaliation - although there is a "policy" in place "prohibiting" that. Rumor has it that nurses on this floor will look for things and pick other nurses apart - especially when one feels threatened or attacked.

Now 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/comments? Just looking for moral support, I guess... that, and it feels good to process this among fellow nurses.

Take care,

RN

Next action item,

[tahoe77]

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.

[morte, LPN, LVN]

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.

[Anglkses]

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.

[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.

[canoehead, BSN, RN]

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.

[ChristineN, BSN, RN]

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?

[Orange Tree]

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.

[RiverNurse]

::: 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