writing up another LPN for med error

[luvmy2angels]

First off, let me say that I hated to have to write up another co-worker for a med error but I feel it was my job and obligation. I mean, isn't our work to protect our patients??? I say this because when I handed the med error paper to my supervisor I could tell she was a little "peeved" that I had done it. The error was nothing serious, my resident was scheduled to start a multi-vitamin and the other nurse had signed off as giving it for 3 days in a row, however when I returned to work the box was unopened and the # of pills in the box was the # that was delivered. In my opinion, even though it was just a vitamin it was still prescribed my the doctor and should have been given, signing off for ANY med that isn't actually given is a med error, or am I completely off my rocker???

[jjjoy, LPN]

I am really offended by your miserably negative way of handling what you, her coworker (not her supervisor) deem as this nurse's poor handling of medication distribution to patients

Perhaps you mean that you think you would've felt offended if you were the reported nurse? After all, none of us really know exactly what happened. We are only responding to the situation as reported to us by the OP.

I also don't see any discrimination against LPNs. I think she mentioned that only to note that they were both LPNs and holding equal roles at the facility.

If someone is offended and angered by a situation like this, a colleague reports a med error of yours without first asking you about it, it also would be advisable to approach that person and calmly ask them why they didn't talk to you first and ask that they approach you directly with such issues in the future and not just go off ranting at them at how wrong what they did was.

[txspadequeenRN, BSN, RN]

do you not have stock mvi as well. because if i have a patient on a vit and get it out of regular stock then find out they have their own ...i'm not putting it back...

first off, let me say that i hated to have to write up another co-worker for a med error but i feel it was my job and obligation. i mean, isn't our work to protect our patients??? i say this because when i handed the med error paper to my supervisor i could tell she was a little "peeved" that i had done it. the error was nothing serious, my resident was scheduled to start a multi-vitamin and the other nurse had signed off as giving it for 3 days in a row, however when i returned to work the box was unopened and the # of pills in the box was the # that was delivered. in my opinion, even though it was just a vitamin it was still prescribed my the doctor and should have been given, signing off for any med that isn't actually given is a med error, or am i completely off my rocker???

[txspadequeenRN, BSN, RN]

i think she works in ltc if she double checked meds with another nurse she would be there until christmas.. she probably has 30-40 patients with 10-15 pills a piece. ltc is different than the hospital environment..

.just curious, do you not need two staff to check drugs prior to administration?? two trained staff have to check everything for our babies, from iv's to even vits, both have to check the meds, and the name bands etc! for iv's, we check the prescribed dosage from our drug formulary prior to making them up and giving them.

[loricatus]

Wouldn't you have wanted another nurse to come to you to question what seems a discrepancy before writing you up; or, have given you the chance to report an error yourself?

It was not if it was matter of life and death; and, rather than taking a judgemental stance, an inquisitive one would have been more appropriate. All you have done is set yourself up to be watched for the first seemingly looking error that can be reported, and, have contributed to a retaliatory working environment rather than a cooperative one. IMO this is where the toxic work environment gets it initial flame. Do you not know the old saying about "divide and conquer"?

[GooeyRN, ADN, BSN, CNA, LPN, RN]

I would have asked the other nurse about it first. How would I know if she didn't take a MVI from another drawer or documed or stock bottle or somewhere else? I don't write someone up unless I am POSITIVE there was an error. I actually only did 2 write ups in my time of nursing, and both I was involved in.

[TazziRN, RN]

I am really offended by your miserably negative way of handling what you, her coworker (not her supervisor) deem as this nurse's poor handling of medication distribution to patients. Here is my first criticism: you are one LPN writing up another LPN - why the distinction? You are a nurse; she is a nurse - if you worked with me (an RN), I would NEVER make that distinction - I don't discriminate against LPNs.

Second criticism: why didn't you sit down with this nurse and share your concerns? Instead you go off behind her back and spread more ill feelings (see your statement: "complaints filed by others..."). The whole thing with nursing is TEAM WORK.... we have had several nurses who needed a friendly hand to get into the swing of things... if you spend time supporting her instead of backstabbing her,you might find that she will trust you and ask for your help.

You even criticize your supervisor for her lack of experience. I really wouldn't want to work around someone who holds everyone else up for ridicule.

Should you have written up the error - did you speak with the nurse about the vitamin bottle and give her a chance to explain? Did you share your suspicions with her? Did you give her a chance?

If the OP offended you then it looks like it doesn't take much to offend you. The OP did not come on here proudly bragging about what she had done, she came on here to share and ask if she had done the right thing. You just whacked her across the head and (in your own words) criticized her!

I sort of agreed with the others about how she could have handled it differently, then I read her second post on the subject: it was a new med order so there was no excuse to have an unopened box, and she did go to someone else....her supervisor. Sounds like she got poor guidance, so she did what she thought was the next best thing.

And we don't know about the other LVN, maybe she's not approachable. Maybe saying something to her directly would have been the worst choice....we don't know that. The OP did not tell us what the other nurse's personality is like.

[pkapple]

an incident report or variance is to alert the facility of actual or potential occurrences that may or may not cause harm to a patient.

if meds were not given or given inncorrectly--write the report

if a nurse fraudulently documents in medical records--question her if you want, but you must notify the management, in Fl if you know of fraud and don't follow chain of command the state will fault you and the original nurse with both licenses in jepordy.

The biggest issue I see here is signing a med as given that was not. Med error--missed med or wrong time/route/pt etc.

[Larry in Florida]

I actually did take this to my supervisor first and she didn't know what to do about it, (she is relativley new). she said write it out and give it to dayshift to investigate, i didn't want to do that because it didn't happen on dayshift.

As far an another box being used up , it wasn't, as this was a new med order and I am the one who put the order in the computer and there were no other residents that had this med in a box on my cart.

I didn't want to write her up, this is the first time i have had to do it. This nurse works the days that I don't so I have never even met her. I do know however, that there have been complaints filed against her from others and aides that have had to stop her from giving someone somebody elses meds (they would hear her say "here 'so and so', here are your pills", and it wansn't even the correct resident. She can supposedly finish a med pass of 28 people in 45 minutes or less. I truly feel she is being careless and that is why i felt i needed to write it up and bring it to the DONs attention. If she gets careless with the wrong resident and the wrong med there could be a great deal of harm done to the resident.

It is not a nice situation to be in, but i did what i thought was right. I guess I'll see as i am getting ready to leave for work now.

Thanks you guys for all your input, I appreciate all of it!!

Have a good one, will check back when i get home from work!!

I'm very disappointed in your actions. I certainly wouldn't want to work with someone who writes up other nurses with no evidence. Time of a med pass hum, I pass over 100 people in about one hour (I work corrections) so it can be done (I id every person). And your taking heresay as gosple . Bad move in my opinion. Larry in Fla

[StNeotser, ASN, RN]

Oooh, not giving a multivitamin three days in a row could have caused a fatality!!

If this is LTC, then this nurse is giving some 10 odd meds to about 30 people. She missed a multivitamin. Had I been in your shoes I just would have mentioned it to her. She'd have been glad you caught her mistake.

Had it been insulin not given, a B/P med, an IV ATB my actions would have been different. But this was a multivitamin for christs sake. No, I don't think you were right, I wouldn't have done it, and I wouldn't want to work with someone who does this.

[TazziRN, RN]

Doesn't matter what the med is, a med error is a med error. And if the LVN truly does have a history of med errors, then this is no small matter. And she didn't miss a multivite, she missed three and charted them as given. Report it to the BON and see how inconsequential they think it is.

Do I think the OP handled it in the best way possible? Initially I didn't, but after reading her second post about her supervisor's initial response and the fact that it was a new order, I think approaching the LVN would have been the wrong way.

[mizzou_ivy]

Not to start a fight but how do you have time to check up on another nurse and berate her skills if you are doing your job? I know that when I work I do not have the time, energy, or ranking to check up on what everyone else is doing. MVI are stock at our facility and while it is against policy to borrow it does happen if we run out. Help to you now that you have written the colleague up because I am positive you will be looked at with a fine tooth comb whether or not you do anything wrong it's a tough environment to work in. Medication errors are bad, do the 5 rights and they might still happen once in your career but please help the nurse instead of hindering her. Just my two cents.......

[SuesquatchRN, BSN, RN]

Hey, corrections guy, can you pre-pour? How many meds does each inmate get? DO they line up for you? Can they swallow or do you have a little restaurant on top of your cart because Mr. X will only take pudding and Mr. Y applesauce? I need the magic you work to pass meds that quickly!

As to reporting med errors, I was recently reported just about every shift over the past two weeks. I oriented to two new units and made some small time of admin errors. But one thing that came up consistently is that *I* was consistently missing new orders. Being reported was of real value because I figured out what I was doing wrong and have been able to correct it.

Now, that isn't to say that some of the stuff wasn't just picky nonsense of the sort that I would not report myself, but the process, when used properly, can be a learning experience.

However, I wouldn't have written it up after mentioning to my supervisor and having her blow it off. That isn't because I'm perfect, but because I want to survive.