Worried...caught med error but only CNA

  1. I would like some nurse's opinions on this. About 2 weeks ago I was cleaning a pump after a pt. was d/c. I tore off the label that was on the saline bag w/antibiotic from pharmacy. I didn't get a chance to clean it at the time as a call light was going off. I went back to the pump and noticed that the antibiotic was not activated. I don't remember exactly who it belonged to, but I have a very good idea who. When I noticed it I went to the charge nurse who wanted to know who it came from. I explained to her I didn't know exactly as I had put the sticker in the shredder(which is kept locked). She told me to ask another nurse. When I went to that nurse with the antibiotic in my hand she told me to forget about it and throw it away. I feel that I made the wrong decision doing this. The pt. diagnosis was pnuemonia/bronchitis and had chronic lung problems. The antibiotic was unysyn. A week later it was brought up (not by me) and I was told to fill out a med error form. I am not a nurse(only CNA). Did I over step my bounderies by filling out this med error? I was pretty upset the day it happened. Not only did the pt. get charged for an antibiotic that was not recieved, but this pt. also has chronic lung problems. Should I just have forgotten about this? I know the nurse who hung the 'antibiotic' and don't wish to get anyone in trouble. I'm not trying to play nurse but I feel that I was completely disregarded by these nurses. Did I do the right thing? I feel that an error is an error and everyone makes mistakes. I'm torn. Any thoughts on this?
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  2. 22 Comments

  3. by   Luv2BAnurse
    You did what you thought you needed to, and that's ok. If you were asked to fill out a med error report, then do it.

    There could be several reasons why a bag of unasyn could be left hanging. The IV site could have infiltrated, the MD could have changed the med to a po medication, if a bag of fluid was hanging with the antibiotic...it could possibly have backed up to the piggy back, making it look like antibiotic that was never administered. (usually the nurse would go ahead and take down the antibiotic if it were discontinued, however). Or, the nurse could have forgotten to start it.

    You just continue to do what you feel is necessary, and don't let the "maybes" make you second guess.
  4. by   AlexCCRN
    Yes, the incident should have been reported as soon as you understood something was amiss. It's our moral obligation. In the future, I strongly recommend NOT tampering with or handling medications as a CNA. Even if your intentions are good, you're going to find yourself in sticky situations.
  5. by   P_RN
    May I ask who had you fill out the report? It might not have been an error so much as a change in orders. I have had minibags fill up with backflow in spite of the anti reflux valves.

    You correctly went up the chain of command.

    Is it part of your job description to discard the bags and shread the labels? To me it seems you did the correct things.

    You sound like a very observant person. Thank you for caring.
  6. by   Bipley
    Are you referring to a Baxter Bag? As in you remove the "cork" and mix the powder with the IV solution?

    Regardless, if you are unsure about something you absolutely did the right thing by doing what you did. Better safe than sorry. If there was no error, the nurse can explain this and it will likely be in her documentation why this was the case. Maybe the doc changed the orders, could be lots of things.
  7. by   bethin
    Quote from P_RN
    May I ask who had you fill out the report? It might not have been an error so much as a change in orders. I have had minibags fill up with backflow in spite of the anti reflux valves.

    You correctly went up the chain of command.

    Is it part of your job description to discard the bags and shread the labels? To me it seems you did the correct things.

    You sound like a very observant person. Thank you for caring.
    Yes, it's the CNA's responsibility to clean the pumps and remove the IV bags. A nurse told me I needed to fill out the report. The saline bag was empty but the glass bottle still had the med in it. I assumed (I have to stop doing that) that the antibiotic wasn't activated.
  8. by   bethin
    Quote from Bipley
    Are you referring to a Baxter Bag? As in you remove the "cork" and mix the powder with the IV solution?

    Regardless, if you are unsure about something you absolutely did the right thing by doing what you did. Better safe than sorry. If there was no error, the nurse can explain this and it will likely be in her documentation why this was the case. Maybe the doc changed the orders, could be lots of things.
    Yep, that would be it.
  9. by   P_RN
    Worried...caught med error but only CNA
    Oh and you are NOT ever an ONLY anything. You are somebody who cares.
  10. by   Marie_LPN, RN
    Did I over step my bounderies by filling out this med error?
    I don't think so. I mean, you've got a empty saline bag, with an antibiotic powder (assuming) still in the bottle. It's would be obvious someone didn't receive an antibiotic. The question to be determined (through the investigation) is why.
  11. by   bethin
    Quote from AlexCCRN
    Yes, the incident should have been reported as soon as you understood something was amiss. It's our moral obligation. In the future, I strongly recommend NOT tampering with or handling medications as a CNA. Even if your intentions are good, you're going to find yourself in sticky situations.
    Well, that sounds like a great idea. But according to the nurse manager CNA's are the ones responsible for cleaning and discarding IV fluids. I might bring up to her that nurse's could remove the bags and CNA's clean them then. Kind of off this topic, but this weekend when I went to clean a pump and PCA I noticed that the morphine had not been removed from the PCA. I dropped the IV tubing like a hot potato and got the charge nurse. She took care of it promptly.
  12. by   Marie_LPN, RN
    The nurses really ought to take that stuff out before the pump gets cleaned, instead of leaving it for you all to do. The morphine incident is a good reason why.
  13. by   bethin
    Quote from Marie_LPN
    I don't think so. I mean, you've got a empty saline bag, with an antibiotic powder (assuming) still in the bottle. It's would be obvious someone didn't receive an antibiotic. The question to be determined (through the investigation) is why.

    That's why I assumed it was an error. The fact that the saline bag was empty but the powder was in the bottle. Is there a reason you would hang such a small bag of saline, other than as a flush? The nurse who hung it is a very thorough, caring nurse so I think it was just an oversite on her part.
  14. by   bethin
    Quote from P_RN
    Oh and you are NOT ever an ONLY anything. You are somebody who cares.
    Thanks P_RN. I needed that.

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