RN medicated my patient without documenting!

[poppy07]

I need some help regarding a situation in which another RN medicated my patient without documenting. This patient was seeking medication when I came to see them, and it had been well enough time before they were allowed medication (according to the computer documentation), so I administered the med. The other RN came by later on to inform me that they were going to chart on this medication that they gave earlier and noticed that I gave the med just a little while ago (and had never told me they gave it.) Now, this makes it seem as if I gave the medication too early after the other RN had done so because this person is able to adjust the time in the computer when they document. Best advice?

[All_Smiles_RN]

Just a side note to comment on something you said earlier... Please don't pull out a med and save it for later. This practice creates room for errors.

[gentle]

Hi Poppy,

I'm sorry you ended up in this mess. It does happen. It just happened to me today and I was the one who didn't chart it. I was busy trying to go on a road trip with another patient off to CT. The nurse who was covering for me saw a now order and gave the medication correctly. I was the one who took the verbal order from the Doc because, I know him and having dealt with him I took the order and kept moving to get the ?PE guy checked out. BAD IDEA all the way around on my part.

Anyway, I wrote up the incident report. I notified the Doctor what happened because it was my fault that the double medication occurred. I didn't chart it.

Your preceptor should have taken responsibility for his or her mistake. I think that was pretty lousy.

I do look at our pyxis system to check when my meds were last given. But this is just me. This is not a standard of care. Charting all medications immediately following giving them is a standard of care, period.

Your preceptor should have filled out the incident report. In fact if you have never done this before, that should have been a teaching moment with the stress that "sometimes things don't go perfectly; here's how we document incidents."

Perhaps the most tactful way to handle this situation is to ask him or her, how this type of situation is handled. "That way you will know how to honestly and concisely document errors if something should occur in the future. After all, we are all human."

BTW, I also notified my clinical lead nurse of the incident. I'm human, I try not to mess up but sometimes it happens. I like to keep my clinical leads and supervisor aware if something significant happens on my shift whether it's bad run-in with a doc or patient problem.

It's unfortunate that you didn't have one of the allnurses nurse as your preceptor. People here seem to own their mistakes etc.

Gotta go, hubby and the kids want the computer.

Best wishes with everything Poppy.

[bill4745, RN]

The error here is totally with your preceptor, not you. You should have been told immediately after the med was given or it should have been documented.

[leslymill]

It is policy to document before admin. med.

Are you sure? I thought this was a BON nono. Is the policy written?

I used to chart as I pulled them out so I could get my five rights done by check list. Then there is this BON recommendation NOT to chart till after the patient has taken them.....

So I think, when or if I return to nursing, I write or check as I pull and initial given when I return from giving them.

[BBFRN, BSN, PhD]

I agree with Lesly. It shouldn't be policy to document before the med is given. Whoever told you this was wrong. In light of what happened to you, if it was your preceptor that told you to do this, I'd be asking for another one. I doubt there is a written policy that says to do this.

[poppy07]

there is a medication scanning system in place, in which you scan the med, make sure it is right dose route etc., scan the patient, and save it. It helps because at times, concentrations change in meds, like antibiotics, and the computer will catch the difference in concentration before hanging the piggyback.

[EmmaG, RN]

... should read a bit further LOL

[EmmaG, RN]

there is a medication scanning system in place, in which you scan the med, make sure it is right dose route etc., scan the patient, and save it. It helps because at times, concentrations change in meds, like antibiotics, and the computer will catch the difference in concentration before hanging the piggyback.

Are you saying your preceptor did not scan the med and patient before administration?

BTW, don't get too comfortable with those scanners. Always check the medication / bag (not just the barcoded label) and continue to practice "the 5 rights".

[poppy07]

The other RN did not chart the med for at least an hour or so after giving it. So...it was not scanned prior to administering. I'm just wondering what is the best way to go about this now? No ill effects on the pt, but does it need to be documented? Do I need to document, or the other RN? I'm hesitant to discuss this further b/c I don't want to raise problems in the unit.

[oramar]

You don't have a scanner? This indicates a weakness in the system because a scanner system allows for documentation at time of administration. This is not YOUR error. It is a combination of the other nurses negligence and a weakness in the system. I honestly think a review board would find in your favor.

[poppy07]

there are scanners in each pt's room. the other RN did not chart the med when administering. I have no idea why.

[pagandeva2000, LPN]

It was always mentioned in school that it is extremely important to chart medications the moment that they are administered to avoid problems like this. How would you know that meds were given if the previous nurse did not chart them? And, if you are using computerized charting, no matter what that other nurse has done, someone can look into the database and pull out the fact that you charted before she did. Hope that the med was not a dangerous one.