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Medication Errors and Write-ups



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Nov 13, 2009 02:39 AM

Medication Errors and Write-ups


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.


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17 Comments
No. 1
from Goldenhare
Old Nov 13, 2009, 02:58 AM

Default Re: Medication Errors and Write-ups
Not standard where I was most recently. What would be the point of being punitive? If a mistake was made, it was reported to the supervisor and or attending if very serious. It would SOMETIMES be documented as an incident, but that report was used to improve the system, and try to pinpoint and problems. We were not written up.
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No. 2
from Virgo_RN
Old Nov 13, 2009, 03:25 AM

Default Re: Medication Errors and Write-ups
I've screwed up a few times, but have never (knock on wood) been "written up". I have been spoken to about my mistakes, and if necessary, incident reports filed. The incident reporting system is not meant to be punitive, but to help with systems improvement to prevent similar mistakes/problems in the future.
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No. 3
Old Nov 13, 2009, 05:11 AM

Default Re: Medication Errors and Write-ups
Currently work in a unit where med errors receive a formal written warning. I think it's ridiculous. Since when do we punish somebody for making a med error? Writing somebody up for making a med error is NOT going to make it not happen again.
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No. 4
Old Nov 13, 2009, 05:48 AM

Default Re: Medication Errors and Write-ups
Where I work incident reports are filed out if a serious med error occurs but they are more used for tracking purposes and punitive action is not taken(although I guess if it was really serious they may take action). I have reported minor errors to my charge and she has told me to not worry about doing an incident report, I think once I missed a Tylenol.
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No. 5
from htrn
Old Nov 13, 2009, 06:40 AM

Default Re: Medication Errors and Write-ups
Med errors are not supposed to be punative but it depends on where you work. I have worked at facilities that view all med errors as systems errors and the nurse is in no way punished for the error (unless it was blatent neglegence on her part.) I have work at other places that have done the 3 strikes and your out - even today they still have this policy. The problem is, all medications errors need to be investigated to improve the process to make the system better. Of course the hospitals that have the punitive policy have fewer med errors - because they are not reported unless they can't get around reporting it. I would be the non-punative hospitals have more "reported" med errors but not nearly as many "actual" med errors at other places.
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No. 6
Old Nov 13, 2009, 12:08 PM

Default Re: Medication Errors and Write-ups
Punitive is wrong.

A good way to handle an error is to ask the doc to give you an order to cover what you gave or didn't give. "Hold multivit today"
"Give multivit at 2100 with food" (some people get nausea if taking meds on upset stomach)

See? That will cover a lot of errors and is often used when the error caused no harm.
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No. 7
from Michigan
Old Nov 13, 2009, 12:26 PM

Default Re: Medication Errors and Write-ups
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.
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No. 8
from leslie :-D
Old Nov 13, 2009, 12:29 PM

Default Re: Medication Errors and Write-ups
i agree that sometimes incident reports are warranted...
but at what point should tptb, start becoming concerned and incorporating these errors into disciplinary action?

consistent med errors would set my radar off, for sure...

leslie
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No. 9
from Virgo_RN
Old Nov 13, 2009, 12:54 PM

Default Re: Medication Errors and Write-ups
To be honest, an incident report over a multivitamin does seem a bit extreme. On the other hand, if there is a pattern of missed medications, or a real problem with med errors at your facility, then the missed multivitamin fits into the overall picture, so I could see how it would be included.
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