Incident Reporting

  1. 0
    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,


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  2. 19 Comments...

  3. 8
    Oh wow. So instead of focusing on patient safety, this nurse decides to act like a child when you write an incident report. If this were NS or LR infusing, then I would probably have let it go. We all forget. But MAG?!? Oh, back up on that yellow brick road, Dorothy! Ain't NO WAY I am going to let that go! This nurse endangered her patient. Yeah, she forgot. She would remember when the pt starts having arrhythmias. When I administer Mag, I do so with the same vigilance as hanging blood.

    You did the right thing. Unfortunately, you work with what sounds like an episode of "Nursing Mafia". There have actually been reports of cars being keyed? What's next? Planting drugs in your locker?

    It concerns me that your NM did not take exception to this med error. You can't be sure if the Mag was infused or not. I can't believe that she told you that you should have just infused it. I also can't believe that the doc did not want labs drawn in order to establish current mag levels. I suppose his rationale was that the Mag was not infused...but what if it WAS and the NS just backed up into the bag hanging?

    You did the right thing. I would probably start looking for a new position within the system you are currently working. It sounds like you are working with some questionable people who think that popularity is more important than patient safety. On the one hand, I hate that these immature nurses seemingly push nurses like you (vigilant, focused and SAFE) out of the unit, but on the other hand, I would rather work in an environment that encourages teamwork and the adherence to procedure in regards to medication administration.
    canoehead, netglow, Momma&RN, and 5 others like this.
  4. 3
    WOW, just wow! You were right in what you did. My first thought was that maybe the mainline had backflowed into the piggyback, but since you didn't get it in report, who knows. I probably would have tried to call this nurse as soon as I found the hanging MgSo4. If I couldn't get a hold of her, then notify supervisor and doc and see what orders he had.

    Incident reports aren't supposed to assign blame. They are there to help ID process problems and prevent harm. You were right, the manager isn't. This is exactly the kind of reason an incident report SHOULD be filled out.
    canoehead, Chin up, and I<3H2O like this.
  5. 4
    I am so stinking SICK of childish behavior! Whatever happened to accountability and getting your butt called on something when you screw up? Augh, this makes me want to scream! Ok now I feel better. I had a bit of a rough day myself, so I needed to get that out. I don't think you were wrong at all in filling out the incident report. Hypothetically, if it'd been me, I would have tried to contact the nurse prior. But I have seen incident reports filled out for much "stupider" things than actual dangers such as failing to administer a med. This is one reason I kind of like bedside reporting--gives the oncoming nurse the chance to ask questions, look at IVF and IV sites, etc. And you'd better believe I'd raise bloody h*** if there's something in question and the off-going nurse is trying to play off a situation. Find a more supportive unit and a manager that has the you-know-whats to call people on their mistakes and shortcomings. No need to be punitive--anyone of us can and likely has done something similar, but I'll be danged if I'd stay on a unit that penalized ME for looking out for my patient's safety and let the nurse who made the mistake off the hook (and free to key cars! what a joke!).
    TickyRN, Chin up, CompleteUnknown, and 1 other like this.
  6. 2
    I agree...this is exactly the kind of thing for which an incident report should be filled out. It might help correct a system error.

    Everyone makes mistakes. Management should approach those who do, with a teamwork attitude of how do we make this better? rather than a rage that someone goofed. How does the latter help anything?

    I think you did the right thing. It's a shame there aren't supportive people where you work, to back you up. Maybe there are some? If there aren't, please consider if this environment is emotionally safe for you, even if it would be safe from retaliation possibilies.

    If I was manager, I'd be keeping my eyes wide open for any sign of threats and would confront as soon as I noticed them. I wouldn't let it keep on keeping on. I think your manager should do the same.
    I<3H2O and CompleteUnknown like this.
  7. 0
    Argggghhh don't you just HATE this sort of drama? And all for trying to do the right thing.

    As for your manager screaming about it being a communication issue, perhaps as a result of the incident, ooops sorry the communication issue, she can institute a proper handover rather than the written thing where there is no opportunity to communicate with the offgoing nurse!
  8. 1
    Thanks for sharing. If you feel you did the right thing, then you did. I would like for you to be my nurse, b/c you seem very thorough.

    If that happened to me, I would have called the nurse first.
    NurseLoveJoy88 likes this.
  9. 0
    It has been a lonnng time since I have worked acute care, so, how long would that mag bolus take to infuse? Since it was hung at 1042 and your floor didn't get the patient till ~1500, was the mag finished by then? Or would it have been still infusing? What was the rate on the IV pump? the bolus rate or the maintainence rate?
  10. 1
    Quote from morte
    It has been a lonnng time since I have worked acute care, so, how long would that mag bolus take to infuse? Since it was hung at 1042 and your floor didn't get the patient till ~1500, was the mag finished by then? Or would it have been still infusing? What was the rate on the IV pump? the bolus rate or the maintainence rate?
    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.
    canoehead likes this.
  11. 0
    WOW! Incident reports where I work generally are just written to show that orders/policy wasn't followed. There isn't any blame. It just is a way of documenting what areas could benefit from improvement.

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