med error--real world answer?

[sweetieann]

So I caught someone's med error. I work night shift and have to check over the new orders. It was for pepcid, pt to get before each meal and at night, and the nurse who took the order off (we still use paper documentation) omitted the HS dose and therefore the next shift's nurse didn't give it, because it wasn't on the MAR to give as such. I felt like it had to e reported, because then whoever has to check the orders (me, in this case) would ultimately be held responsible for not reporting, and most importantly I had to end up fixing the order which of course couldn't be done without noticing the error. It wasn't a "big" error--no harm to pt, pepcid isn't that big of a drug, etc....but why should I put myself at risk for catching it and not reporting it.

What would you have done? I just feel bad, I hate getting fellow nurses in trouble. Also, I'm afraid the nurse will find out who filled out the report (although I think they're anonymous....and the second shift's nurse could have caught it at the end of her shift and filled it out for all anyone knows) will find out I filled it out and she has been there forever and I'm pretty new and it seems the culture is "don't tell on your fellow nurses" where I work.

[MichelleB34]

You were certainly within your rights to feel out a report if that's what you felt was the right thing to do. At our facility our meds are profiled by the pharmacy. ie During pharmacy hours we can't take anything out of the pyxsis until pharmacy profiles the med (puts it into the computer). With the exception of a few select emergency drugs. We have computer generated MARS. When you come on to your shift you have to check your MAR against the kardex. If there is any difference or a new order is hand written you have to check the original order. Also at the end of our shift we have to run a report to check for any omissions. So technically the day nurse should also have an error for transcribing the order wrong. The evening nurse would have an error for omission and possibly for error in checking practice (at our facility) provided the order was transcribed correctly on the kardex. That being said I probably would have not made out an error report. It sounds like you work nights? If I had caught the missed dose early in the shift I might have chosen to give it. Otherwise I probably would have just fixed it and let the nurses know because it was only pepcid. But if it was an antibiotic or bp med that would be a different story.

[meluhn]

no, i appreciate you honesty. i contemplated this--however, the nurse who didn't end up giving the HS dose (because it wasn't marked) is also working today and would have seen that this dose was added on by me and clearly wondered "wait--why I a giving an HS dose today and I didn't yesterday." The pt is on no other HS meds, so when the nurse goes to give her a dose tonight of a med, she's realize the error that had been made by the transcribing nurse. And this nurse coming on is VERY anal, so I didn't want thrown under the bus. Also, by my just having corrected what was written on the MAR, it could have made it seem like the nurse who didn't end up giving the HS dose (b/c none was marked) was in the wrong and forgot to give the pt their hs dose--and that's not fair, since the nurse was just following what was transcribed. Hope that makes sense. Thanks for your response!

Technically, the nurse that missed the hs dose should have checked the orders in the chart. Being that she made an error too, she might be less likely to make waves about it. I agree with the previous poster who said she would just correct it and move on. I dont think you would get in trouble for not reporting such a minor error. jmo