Wrote an incident report on a co-worker

  1. I just need some advice about if what I did was the right thing.

    So the story is I received report in the morning about a patient I had given to the night shift nurse the night before. We were going over skin assessment as the patient had relatively a lot of wounds, and after going over the assessment, she commented about the full bag of IV antibiotics that was spiked but not started or connected to the patient. She told me she couldn't started the antibiotics because it was not compatible with the other IV antibiotic that was running at the same time. So she had spiked it and she had documented on the MAR that it was given. She told me she would waste the spiked antibiotic and document in the MAR that she did NOT give it before she left. So she left to the computer room to finish charting and I went and did my usual morning rounds. It wasn't until about 2pm or so when I actually had time for myself to chart that I noticed that the night shift nurse didn't do what she said she would do, and left the spiked full IV antibiotic on the IV rack. I initially told the charge nurse, and the charge nurse said that I should file an incident report about it since the IV antibiotic was not given. So I filed an incident report and wasted the medication like the charge nurse told me to.

    I'm just wondering if what I did was the right thing to do or not. Just feeling guilty about writing an incident report on her and my first time writing one on a co-worker too.): But I can't help but think I needed to write one, since she didn't give the medication even though she documented she did. And the patient in question was my only concern at the time, since the patient didn't get the medication. Should I tell the nurse I wrote an incident report on her?
    Last edit by yukiixiaojie on Mar 17
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  2. 71 Comments

  3. by   jennylee321
    Keep in mind that incident reports are really there so that systemic issues and repeated errors can be picked up. They really aren't meant to be punitive against a person. For example if the quality managers are seeing a spike in the rates of IV burns, they need to provide an update in education about this issue to staff.
  4. by   LovingLife123
    I would not have written an incident report. I would have documented myself in the system that the med was not given and went about my business. I would have immediately run a new antibiotic so the patient got it and rescheduled future doses.

    Things can get crazy at shift change and things can get forgotten easily. Personally, I would have asked you to start the antibiotic as I had scanned it and gotten it all ready and all that needed to happen was for you to start it once the others finished.
  5. by   yukiixiaojie
    My only thing about that was that I thought she would have changed it to not given as she said she was going to do. And when i realized she didn't, it was already 2pm and almost time for the next dose to be given. The said antibiotic that was spiked was documented for 5am in the morning, I don't come in until 7am, I was told by other RNs to never chart on the previous nurse's time frame (if that makes sense), and medications should be documented in real time. And like you said, things get crazy, especially on our floor. But the more I think about what you would do, you're right, I should have done what you just said :/.
  6. by   smf0903
    I will play devil's advocate and ask why you didn't give the antibiotic? Whether or not it was charted, the previous nurse told you that it wasn't given d/t incompatability with the running antibiotic. Even if the patient had a long-running antibiotic already hanging, like vanco, it would have been completed before 14:00. Clearly the running antibiotic was already running when you got there, so I feel pretty confident thinking that it was done some time in the morning and the second antibiotic was never run, equating to an entirely missed dose.

    I personally would not have written the other nurse up. And I'll be honest, I would be really irritated if I came back to a write-up for something I passed along at shift change. Even if that nurse forgot to unchart the med, you knew about it.

    I've had instances when they previous RN didn't run something charted because an IV infiltrated and it took a while to get a new one put in. I retimed the doses to reflect the late dose and charted a note as to why the timing was changed.
  7. by   yukiixiaojie
    You're right, I'm already feeling super guilty right now. I should have ran the antibiotic. I should have just done it myself. But there's nothing that I can do at this point. I already did what my charge nurse told me to do. So what can I do now? Tell the nurse?
  8. by   smf0903
    Quote from yukiixiaojie
    You're right, I'm already feeling super guilty right now. I should have ran the antibiotic. I should have just done it myself. But there's nothing that I can do at this point. I already did what my charge nurse told me to do. So what can I do now? Tell the nurse?
    I didn't mean to make you feel more guilty! If I were in your shoes, I would write up an incident report on myself for not starting the antibiotic. Whether or not you tell that nurse you wrote an incident report on her is up to you. She's going to find out one way or another.

    Live and learn and adjust based on your experiences! Don't beat yourself up
  9. by   Everline
    I've been in similar situations. I ran the antibiotic and called the pharmacy to reschedule the next doses and I made a note as to why I was running it late without mentioning the nurse before me...just that there were incompatibility issues. That being said, you did what you were advised to do and what you thought was right at the time. You didn't mean harm to anyone. But the saying "live and learn" goes well here. Next time you might deal with the situation in a different way. Learn and move forward.
  10. by   RainMom
    Since the abx had still not been given by 1400 when it was due at 0500, then yes that warrants an incident report imo, but it would have been regarding both of your roles in how the med was missed, not just the noc nurse.

    I agree with PP that the best thing to do would have been for you to go ahead & start it once the previous abx was completed, but suggest to the noc nurse that it is never appropriate to scan a med as given when it is not.

    First IR I ever wrote was for a missed med by a prior shift & it does make you anxious 'cause it feels lIke petty tattling (even when it was a legit concern). The nurse approached me next time she saw me, so you might be prepared for that.
  11. by   llg
    We all need to change the way we think about incident reports a bit. They should be written about events, not people. Writing an incident report should not be about hurting your co-worker. It should be about reporting a safety event -- one that needs to be analyzed so that similar problems can be avoided in the future and patients kept safe.

    A deviation in practice occurred and that needed to be properly documented and reported. Period. You did the right thing by reporting the incident. Now ... the next step is to analyze what happened and why so that everyone can learn from it.
  12. by   Atl-Murse
    She told her what happened, crazy shift change makes stressful and forgetful times. you straight threw her under the bus, Don't you worry you will forgot something important and it will bite you hard
  13. by   llg
    Quote from Atl-Murse
    She told her what happened, crazy shift change makes stressful and forgetful times. you straight threw her under the bus, Don't you worry you will forgot something important and it will bite you hard
    That's exactly the type of attitude we should NOT have. It prevents us from improving practice ... promotes bad feelings and sabotage between nurses ... and generally makes us look unprofessional. Professions "police" themselves and strive to improve by analyzing practice.

    At my hospital, we even report "near misses" -- in which an error is caught before it reaches the patient. We celebrate the "good catch" and the people who worked together to resolve a problem before a patient got harmed. But we still complete the incident report so that the situation can be analyzed so that errors can be prevented in the future.
  14. by   Spidey's mom
    llg - exactly.

    This isn't punitive. Incident Reports are put in place to make our practice safer. There should be no repercussions for you following what your charge nurse asked you to do. It is the right thing to do.

    I am wondering about the missed dose though? That should have been reported to the physician or pharmacy and another dose given ASAP if warranted.

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