Is this really a med error?

U.S.A. Kentucky

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  1. Is this a med error?

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      Would you sign one?
    • 2
      Would you call your union rep?

3 members have participated

Specializes in OR and Wound care, Med/Surg, etc, etc.

Hi!

I work at at Methadone Center. Mon 6AM the 2 RNs (myself included) attempted multiple times to open our safe and retrieve the necessary medication to begin our daily doing of outpatient clients (they call them clients rather than patients here). After multiple attempts by both nurses, we were unable to unlock safe. We contacted our supervisor at home via cell and were given instructions to contact a locksmith and have them come ASAP to open the safe. The locksmith arrived at approx 06:40, by 0930 they had opened the safe and we began our routine of daily doing. Clients that had arrived while safe was NOT open were informed of situation, given the clinics number, instructed to call back to see when/if safe was open and they could return to dose later in the day. At the end of our work day, 2 clients had called to let us know that they would not be able to make it back to clinic- two never informed us of their decision to not return that day. This information was communicated to DON by our supervisor. She (the DON) then insisted that we were to fill out medication error forms for these clients. We told our supervisor that we would be very glad to fill out whatever Occurrence/Incident form they desired to document what had happened that day, but would not fill out med errors as we did not believe there was a med error! Our supervisor informed me that the DON had told him it would be insubordination if we do not fill out a med error for each client that did not dose on Moneday., and I quote, "Any beginning nurse know that this is a med error"- I have been a nurse for >29yrs, my co-worker have been a RN for approx the same # of years. I guess my question is....IS THIS A MED ERROR? WOULD YOU SIGN ONE? WHAT SHOULD WE DO? She expects this from us on Moneday. Help!!!

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Specializes in Med/Surg,Cardiac.

It doesn't seem like a med error to me. Why should a faulty safe deem you worthy of incurring a med error, especially when you gave the clients the option of returning later?

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

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Who is above the DON?

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of course it is a med error. But not fault of nursing. what was wrong with the safe?

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That is not a med error anymore than my not giving a patient a medication because he/she had left the building with family for a few hours is a med error. A med error implies that the problem could have been prevented by you, which is clearly not the case here. I think it would be reasonable to ask to talk to the DON yourself before filling out any paperwork beyond an incident report. I've found that sometimes managers invoke the DON's name whenever they want to add weight to whatever it is they're saying, even if the DON would actually not agree with them. I'd like to think that's the case here.

There's also the possibility that a regulating agency might cite the clinic for the safe not opening. I say that because when I worked in rehab, if a patient with an alarm of any kind got out of bed and fell without the alarm going off, heaven forbid we actually chart that the alarm didn't go off! Surveyors don't like that sort of thing, so something similar may be going on here. It might explain the, "Well duh, of course that's a med error, why don't you know that?" line. The effect would be to make you feel awkward and stupid, on top of the fear of being written up, which would ideally just make you shut up and do it.

Or, they're both just clueless.

I wouldn't fill out a med error form in either case. If they continue to push it, is there a grievance procedure you can follow?

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it is a med error because I believe you said four people did not get the medication on time? Not at the fault of you.

I would ask why they believe it is a med error?

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it is a med error because I believe you said four people did not get the medication on time? Not at the fault of you.

I would ask why they believe it is a med error?

It would be an omission d/t faulty safe! Not a med error.

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It's a med error, the doses were missed. Med errors do not have to be the nurse's fault. We frequently have to chart "med not available" as a reason for missed/late doses when the pharmacy can't bring things up right away. Those are errors in med administration, but they aren't blamed in the nurses.

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It's not a med error. It's an incident, I agree, and an incident report would be applicable. But a med error form puts the fault with the nurses, which isn't the case here.

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Specializes in Peds/outpatient FP,derm,allergy/private duty.

I found a couple of references that state this is a med error, specifically "error of omission" which is described as a patient/client not receiving a scheduled dose of medication before the next dose is due.

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I found a couple of references that state this is a med error specifically "error of omission" which is described as a patient/client not receiving a scheduled dose of medication before the next dose is due.[/quote']

An error of omission implies that nursing forgot to administer the med, which is not the case here, and I still think that reporting this as a med error is putting blame on the nurses for a situation beyond their control. More appropriately reported as an incident, I feel. Not a med error.

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Specializes in Peds/outpatient FP,derm,allergy/private duty.
An error of omission implies that nursing forgot to administer the med, which is not the case here, and I still think that reporting this as a med error is putting blame on the nurses for a situation beyond their control. More appropriately reported as an incident, I feel. Not a med error.

The original purpose and what I was taught is that the error reporting isn't meant to assign blame even if you interpreted the error as being caused by the nurse forgetting as opposed to an unavailable med due to something outside of the nurse's control. The reports are supposed to be used to analyze data and identify system failures. It wasn't supposed to be punitive, because that would discourage people from making reports and providing the input needed to reduce error rates.

It seems that more and more they are seen as a punitive action, even managers use them in that way, unfortunately. Anyway, that wasn't my opinion, but that of a few references I found that came from credible sources.

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