Nurse went "ballistic" over her medication error.......

  1. Hi all,

    Just want to talk about why it is some Nurses (not all for sure), go absolutely "ballistic" when another Nurse has to make out a medication error report when an error is found.

    Last weekend I found an error in a pre-op med that was to be given four times a day, for two days, prior to this resident's surgery on Monday morning. (The day shift Nurse did not give the med on her shift, for two days.)

    I contacted the Doctor, who stated, "not a big deal, just get two doses in before the resident leaves for the hospital on Monday morning. We did.

    But, I realized that this was an error that needed to be documented according to policy and procedure, so followed through on the right thing to do.

    When the Nurse involved saw the report she went absolutely ballistic!! Started making all kinds of claims, accusations, and went into a tangled scenario as to why "this just cannot be so."

    She's one of these Nurses and persons who can "do no wrong" and has been at the facility for 100 years now.

    But I have seen this same "reaction" by other Nurses during my lengthy tenure in this profession. What is that all about anyway???

    Any of you experience the same with your peers?

    Wondering, in Minnesota.
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  2. 29 Comments

  3. by   RNKitty
    I think most nurses see the incident report as punitive rather than constructive. I realize it is policy, but the nurses who take things to heart feel very criticized when they get "written up".
  4. by   P_RN
    Also, unfortunately, there is sometimes a "tit-for-tat" mentality. Just as soon as you write a report, you have to be on the lookout for them writing one on you . Therefore SOME just never write the first one at all. Then there are some who write up only their "enemies" and never their compadres.

    P
  5. by   RNPD
    If the error is one that can easily be seen by anyone reviewing the chart, I write an occurance report-no matter WHO made the mistake-even myself. I figure if I don't, it could be seen as an attempt to cover up the error, especially if I am the one to fix it. If it can be fixed w/o anythoing actually having happened, I fix it and ignore it. ( Although I have occasionally written up someone with a pattern of serious errors, even if nothing happened).

    I have never written someone up punitively or because I dislike them or had a disagreement with them.
  6. by   thisnurse
    some nurses see it as punitive because it is.
  7. by   WriteStuff
    thisnurse,
    How so? Occurrence forms do serve specific purposes. I agree that the "punitive" part enters in where people are entrenched in the power struggle game. It should never have to be that way - but we make it that way.


    There are plenty of instances where occurrence documentation is definitely not necessary, but reaching that conclusion calls for good judgment skills.
  8. by   nurs4kids
    I never write anyone up for a minor error. I notify the doc. If it's no big deal, I fix it and let it go. All my coworkers do the same. We're all human and each of us WILL make a mistake sooner or later. The only "specific purpose" I've seen from writing up someone is it benefits management by keeping nurses bitter at one another. I've never heard management say, "you know, they are having alot of med errors on this floor...I wonder if they need additional staffing???". Nah, they DO use it to punish. If you need to know what causes med errors, just ask nurses. Keeping track of who and how many does not prevent more from happening.
  9. by   cmggriff
    I usually only write up incident reports on the things I do wrong and those things that happened prehospital. I have to agree with nurse4kids, these things are used by management to their advantage, not the staff's. Gary
  10. by   Chuckie
    I
    Last edit by Chuckie on Jan 17, '03
  11. by   WriteStuff
    In all the years I've been at this, I've never known a Nurse to be "punished" for making a med error.
    However, I have seen management use it as a "tracking" tool for uncovering or fortifying evidence of a deeper and underlying problem that might exist. (an impaired Nurse, etc.)
    I just think that if a Nurse is competent, and secure in her own skills she/he is able to recognize that the human element is always going to play a role in what we do, and having to document med irregularities is just a part of it all..........and there is no need to go "ballistic" over anything, unless the error is truly so horrendous the patient is harmed in some way.
  12. by   canoehead
    We use incident reports to track problems and to hlp us find ways of reducing errors. Recently we adjusted staffing on 3p-7p because of increased errors during that time.

    We also deduct a percentage of the annual merit increase if someone has a pattern of errors- this is after counselling and reeducation have not worked.
  13. by   WriteStuff


    Good points canoehead.

    A good case can be made for documentation of med errors.

    The majority of Nurses understand the rationale for doing so, but I think the ones who get so damn defensive about it react that way for several reasons:

    1. There are the ones who "can do no wrong", and when their humaness jumps up and smacks them in the face, it's too much of a reality check.

    2. There are the ones whose expectations of themselves (perfectionist) is beyond reach, and the disappointment of discovering that "perfection" is an ideal to strive for, not a goal that can be reached, sends them into the stratosphere.

    3. There are the ones who "might" even want to be "hiding" something....(diversion??).....and have reasons to be defensive.

    4. There are the ones who are narcissistic and can't live with the fact that the "me, myself, and I" they worship is really only one french-fry short of a Happy Meal. like all the rest of us human beings.

    5. And last, but not least, is the power-house Nurse who is the last bastion of "I have all the answers" on this Unit or in this facility, don't ya know.......who can't stand their achilles heel being exposed.

    It's just interesting to observe human nature in action in our settings, that's all.

    I'm not judging anybody, .........I'm the first one to admit that when that form has my name on it.......it "feels" rotten for a few seconds, but when I see I indeed screwed up, I own it, and move on..........always thankful that no harm was done!
  14. by   prmenrs
    Where I work, anything that is seen as a deviation from the stated mission and goals of the institution warrants a "Quality Variance Report".

    That might mean going to the ER w/asthma 2ndary to pneumonia, and having to wait 2 hours for Resp Therapy to show up and give the pt. a treatment. It might mean having a planned discharge that has to wait 2-3hours for their scripts to be filled. Med errors, falls, an IV infiltration, an adverse drug reaction (which gets an ADO form from pharmacy as well). Having a piece of equipment fail or not being able to get equipment you need, having the lab take 2 hours to report a stat value. Not being able to get adequate staffing, a delay in surgery that is detrimental to pt. care--these are all examples of deviations from quality care.

    When people perceive reports of this nature as punitive, they avoid filling them out. That can, in some instances, leave the institution's [and the nurse's] proverbial a** hanging in the breeze. We got some people over this by saying it was a method of warning the liability/risk management folks of a potential/actual problem, and giving everybody a bit of warning. That way steps can be taken to deal w/the peoblem instead of being surprised when the lawyers come around.

    There a whole lot of research and literature regarding thinking of med errors as system errors, not people errors. Was the nurse too rushed to calculate properly, did the pharmacist not understand how the MD wanted the med given, was the docs handwriting too difficult to read, was the plan of care not communicated, etc.

    The last thing I want to mention is that for some cultures, any error is seen as a loss of personal esteem. We're all human, we all make mistakes, what can we do to prevent it in the future. The report should NEVER wind up in someones personnel folder!!!

    Management needs to be proactive in changing how staff view these things so that the focus is always on ways to "engineer prevention" of problems. On other words, take the personality out of the situation.

    The nurse you're describing may have some ego issues, but she also may know how she missed the med, and how to rectify the situation. Management should help her solve the problem of the med error, not try to do a personality makeover!!!

    Good Luck!

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Nurse went "ballistic" over her medication error.......