Medication Errors and Write-ups

[skittlebear]

I have several friends at work who have had "write ups" for medication errors (1 was major...giving too much insulin and one of the others was forgetting to administer a Vitamin). At my facility, if you get 3 write ups you are fired!

I can understand the insulin error, but we are all human and make mistakes, especially when we are understaffed as we so often are. I would better understand an incident report being filled out for a medication error, especially if it wasn't a serious error...but to be written up over a multivitamin? I'm not going to mention the other errors but these nurses have come forward to our supervisors as they should do, called the doctor, and received a write-up the next day.

Is this standard? Just curious.

[Blackheartednurse]

i had a near miss during my days of nursing school ..the patient that i was taking care of (pospartum floor ) was a diabetic who had an order for two different types of insulin..being unexperienced student and all i mixed up doses between those two-and thank good my teacher double checked my med preparation and caught my mistake,i was really terrified and beat up my self for not double checking such high alert drug as insulin! i know that in perfect world another nurses should double check draw up insulins but sometimes the other nurse is busy or is not present there or might not even care and just quickly glance the insulin syringe and pretend to "look",basically you are responsible for you own four letters...

[wooh, BSN, RN]

To be honest, an incident report over a multivitamin does seem a bit extreme.

But that nurse might be diverting multivitamins! And multivitamins are a gateway drug to glycerin suppositories!

Making drug errors punitive only encourages covering up "the crime." Not to mention, it places the blame on one person, instead of the system which usually has plenty of blame to go around.

[Sewbusy~RN]

Don't get me started on this one! GRRRRRR! Guess what happens when you start writing up, disiplining, firing nurses over med errors? They stop reporting med errors. Obviously, if you have the same nurse repeating certain errors (like not giving a vitamin) you have to address the problem. However, a supportive environment with proper education is much more likely to get the results you want.

:yeahthat:

Seriously!

[skittlebear]

:heartbeat Thank you all for responding. I think it is a bit extreme to write a nurse up over a medication error, but since this is the only facility I have worked out I wanted to check. Every medication error made at our facility (whether it's the actual nurse who gave the medication that discovered it or another nurse that discovers it) has to fill out an incident report. Within the next few days, that nurse is written up for their medication error. If we have 3 write-ups we are dismissed! I agree with a few of the other posters who stated that medication errors should be documented to prevent the same thing from happening again! I don't believe that nurse should be punished though!!! Especially if the nurse realized her mistake, called her supervisor, called the doctor, and filled out an incident report. I think it's punishment enough that the nurse made the error and she/he feels guilty about it.

Heres another thing about my job that I don't agree with. Some nurses don't get written up at all! Here is an example. I'm not going to name the medication (I don't want people from my work finding me on here, lol). One nurse forgot to administer an important medication because she was busy and side-tracked. This nurse did not get punished at all. Another nurse gave the wrong medication to the wrong pateint, cried, and called her supervisor and the patients doctor...and she got written up the next day. This happens quite a bit! It seems as though some nurses are "favorites" of the supervisors and they don't get punished. I feel bad for the ones that do.

[skittlebear]

Don't get me started on this one! GRRRRRR! Guess what happens when you start writing up, disiplining, firing nurses over med errors? They stop reporting med errors. Obviously, if you have the same nurse repeating certain errors (like not giving a vitamin) you have to address the problem. However, a supportive environment with proper education is much more likely to get the results you want.

I cannot agree more!!! Thank you for posting.

[Vito Andolini]

I disagree regarding having Dr. write order to cover the error. If the med was given or missed prior to the order, then a med error occurred. An order after the fact does not change the timeline. However, I also disagree about med errors as a reason for firing- unless there is pattern or very far from normal. Med errors should be used to track why the error occurred and find / solve the problem to prevent another.

In a non-punitive environment, yes. When punitive conditions prevail, staff are forced to survive and protect themselves.

Also, does timeline matter? A vit can be taken any time. It's not critical. And lots of meds fall into that territory.

Also, how about when you have too many pts to pass meds for and there's no way you can give all your meds within the 2 hour framework most of us are familiar with? You'd be writing incident reports all day long.

And please note: I said HARMLESS errors. If the pt is harmed, it's another story. Salvaging the patient absolutely comes first.

And Skittlebear's post above sums it up so well - some get punished, some don't. Selective enforcement of the rules. It stinks and should stop but will always be with us. It's just human nature. Another reason to get Doc to cover you for harmless errors.

[happygrandma3]

it's not standard to write a person up for forgetting a med/giving it late/missing a vitamin- at least not where I work. However, insulin is another matter, since it's standard to have TWO nurses check insulin how did that one slip by? If the nurse did not check w/another nurse, then maybe some education is in order, in addition to being written up.

[HamsterRN, ADN, RN]

The Institute for Safe Medicate Practices (ISMP.org) would strongly disapprove of the way your facility handles med errors. Current best practice is that med error reporting should not be punitive, since that only discourages med errors from being reported, which then prevents us from solving the root problem (porr med labelling, distractions during med passing, not enough time to pass meds, etc)

[brownbook]

Our long journey towards a safety-minded Just Culture

Thanks HamsterRN. I put the Institute of Safe Medical Practice web site here. Please look over the site, download some articles, give them to your administrators. Tell them bluntly no nurse is going to admit to making an error if she will be fired for doing so!!!!! I am embarrassed any medical facility is still adhering to this wrong wrong wrong philosophy,

[caliotter3]

:heartbeat Thank you all for responding. I think it is a bit extreme to write a nurse up over a medication error, but since this is the only facility I have worked out I wanted to check. Every medication error made at our facility (whether it's the actual nurse who gave the medication that discovered it or another nurse that discovers it) has to fill out an incident report. Within the next few days, that nurse is written up for their medication error. If we have 3 write-ups we are dismissed! I agree with a few of the other posters who stated that medication errors should be documented to prevent the same thing from happening again! I don't believe that nurse should be punished though!!! Especially if the nurse realized her mistake, called her supervisor, called the doctor, and filled out an incident report. I think it's punishment enough that the nurse made the error and she/he feels guilty about it.

Heres another thing about my job that I don't agree with. Some nurses don't get written up at all! Here is an example. I'm not going to name the medication (I don't want people from my work finding me on here, lol). One nurse forgot to administer an important medication because she was busy and side-tracked. This nurse did not get punished at all. Another nurse gave the wrong medication to the wrong pateint, cried, and called her supervisor and the patients doctor...and she got written up the next day. This happens quite a bit! It seems as though some nurses are "favorites" of the supervisors and they don't get punished. I feel bad for the ones that do.

I also do not agree with writing up or even firing one nurse for making an error, yet letting someone else repeatedly get away with the same error or something even worse. Unfortunately this happens more often than we care to acknowledge.

[Medsport, LPN]

I have a dilemma for you guys. What if you discovered several med errors after the fact? Say you were doing the change-over and found that a narc that was given to a resident BID for over a year was changed to QD several weeks ago and you continued to give it on your shift when you should'nt have been? Say there were 6-7 times you gave it, but did'nt catch it. It was changed in the MAR so the nurse should have caught it, but got into the habit of giving the same meds to the patient every night (I know they should have known better) and will now be sure to read the MAR closely before giving meds. As far as I know nobody else has caught it and it still says BID on the medication bottle and on the NARC sheet. This nurse is not sure what to do as they don't want to get into a lot of trouble as there were several and not just one as stated above, but they do feel guilty and will be sure not to make the mistake again. btw, this facility is not managed very closely as most nursing homes or assisted living centers and this nurse recently got a write-up for something "stupid" that was non-nursing related and most likely somebody else's mistake, but this one is not. If it was just going to be a write-up or warning the nurse would most likely report it, but doesn't want to take the chance if this is something that may endanger their license, but does'nt want to keep worrying that something may happen down the road either.

[wooh, BSN, RN]

My attitude is that it's always better to report something myself than have someone else report it.