Bullied for reporting a med error by another nurse

[StaffNurseMcS]

Ive just been called a number of names and criticised for incident reporting that a colleague made a drug error despite it being clearly prescribed. This isn't her first error in fact its one of many but this one i felt needed to be reported so i submitted an incident report form to my manager. My colleagues now think I'm the devil and say i should of spoke to my manager first. Firstly my manager was on holiday at the time secondly i have voiced concerns previously with no action taken. I even triple checked with the doctor that it was indeed a medication error. Has anyone been in a similar position? Im leaving this job as a result of this many other things.

[LaRN]

Staffnurse, are you the only one who has noticed these med errors?

[KelRN215, BSN, RN]

If you catch a medication error, be it your own, your colleague's or a nurse from another unit (ER, OR, ICU, etc) you report it. End of story. I have reported errors other nurses made as well as errors I've made.

[LisalaRN99, BSN, RN]

I caught a med error where the wrong med entirely (a seizure med) was given instead of an antibiotic. It was a look-alike issue with the names. Anyway, the patient got 2 or 3 doses before I caught it. The root of the problem was a pharmacy tech who filled the med order for the floor. The two meds were positioned near each other in the pharmacy bins. The pharmacy did not catch the error, and nurses did not catch the error before administering the med. But that's not the rest of the story....

The same thing happened again with the same look-alike meds. This time, 2 of the 3 nurses who committed the error, were the same ones who made the same mistake months earlier! One ended up getting fired.

I was bullied indirectly by various staff. Things like, "Whoever got so-and-so fired should be ashamed of themselves!" was said in my presence. I did not take the bait.

And then the day came when I made an error, not with meds, but in missing a lab result. Things like, "so you're not so perfect after all!" were said to me. I never claimed to be perfect.

We are all patient advocates. I agree that med errors are an opportunity for education. It can be a process error. It's not personal.

We need to learn from these mistakes...not keep negative contracts to keep things quiet. That helps nobody.

[The_Optimist]

Ideally med error reports should be for continuous improvements in job efficiencies. But we know that what should be is not always so; for some it becomes a vendetta...and other reasons for others. Its intent should be trending and another,to prevent a future recurrence.

[iwanna]

All med errors should be reported. Some nurses are more worried about their jobs than the patient. I am a human first and care for the patient. I would risk my job before I'd risk a person's life. One time I made a serious error and gave a patient 45 units of Novolog instead of Lantus. I could not believe it when people said that at least I was honest about it. I could not understand how anyone would not be in that situation. I could not go home knowing that my patient was about to be in serious danger if said nothing.

We are human and make mistakes. Not owning up to them is worse than the actual med error. And, I think that anyone blaming another colleague for filling out incident report to improve care, should be disciplined. I have had drs. make mistakes with my care and were honest about it. I respect them for being honest with me.

Incident reports are made to examine what you can do to make improvements. It leads towards quality care. Once an incident report is filed, then you meet with clinical supervisor to see what can be done to prevent this in the future. It is not meant to be a punitive action.

[amoLucia]

hen medication incident reports are wielded as punitive weapons by management and this is known to be by the staff, then staff will be reluctant and/or hesitant to report a peer or themselves out of fear for retaliation.

As others have noted, incident reports should be instruments for improvement. Inasmuchas they usually ask "what contributed to the incident" and "recommendations to prevent further occurences", these pieces are often left out and/or ignored by mgt.

I have been the recipient of vindictive, retaliatory aftermath, so I choose very carefully when to write up an incident report. As a professional, I have a responsibility to solve problems. Not to say that I don't alert the responsible parties (that means the offender and anybody else who should've, could've, would've, might've, needed to, wanted to, etc) because I do let them know. I really look for the who, what, when, where, and how the error occurred. And I share the info with all.

[KyleLVN]

The way I'd treat it if I ever found another nurse who made a med error, how would I want to be treated. Think about that, your messing with someones ability to pay their bills and provide for themselves first and their family, were all human and make mistakes. Also think about the situation and is the persons life in direct danger, yes or no, do they need an antidote? Now the seizure medication that one person talked about, again an honest mistake of well it was bin drawer 3 bin 2b, the pharm tech messed up and meant to put bin 2b but put bin 3b. So just ask yourself, and admitting you messed up is a little better than someone else telling your boss that you screwed the pooch.

[horselady]

I too got harassed at work for reporting a med error. It was my own med error. I reported it because it was a med error, it was a classic oops wrong route for a supp. I got ridiculed and laughed at for reporting it but the patient new I made an error too. Wrong route is still a med error, and a med error is a med error no matter how small or insignificant or non harmful, If nurses stop reporting med errors because they use their own judgment and decide oh its not a big deal. Not me but some other nurse can make that decision. It's always better to do the right thing. My mother always said "It takes less tmie to do something right, than it does to explain why you didn't." And still listen to my mother.

[wprivera]

I must confess up front that I am an old crotchety nurse, and have worked in many states across the country. In my travels I've learned that reporting of medication errors vary greatly from region to region, and from facility to facility. Reporting of medication errors is supposed to be about finding the root cause, to prevent it from happening in the future. However, many facilities find it easier to use a punitive approach, "blame the nurse", rather than examine how existing medication delivery systems failed to avert the error.

The only time that I have ever reported a medication error by another nurse, is when I observed willful neglect by the administering nurse. If I observe something that is not copacetic, I always step up and say something before it happens. I am not shy. My favorite line is: "This isn't K-Mart or Wal-Mart. We all worked very hard for our licenses..." Those words always seem to just linger. Of course I have self reported - several times - and it's always uncomfortable. But necessary for me to sleep at night.

As far as being bullied for reporting a colleague, I don't know the details of the error, nor the various factors that contributed to the error. And there are always contributing factors. And I don't know the culture of your facility. I would have to ask, if there were other professional shortcomings that contributed to the manager's decision to terminate the nurse. Perhaps your report was the tipping point. Was the nurse already working under a corrective plan, from her previous med errors. I just don't know.

For me, the bottom line is to point out to my colleagues when I see them practicing in a way that could adversely affect the patient. I am vocal, persistent, and convincing. But I always come from a place of caring, for both the patient and my colleague. No one wants to loose their livelihood. "An ounce of prevention is worth a pound of cure." It's always better to prevent the mistake than to allow for it to happen...

[HouTx, BSN, MSN, EdD]

Very interesting discussion - one of the many reasons that AN is such a great place.

I can 'feel' the compassion of PPs toward their colleagues who may be adversely affected by reports of an error that they may have committed. However, I also feel that our primary concern must be patient safety. Obviously there may be instances where a judgment call is required, but we are legally, ethically and professionally bound to always advocate for our patients.

As to whether we should just gloss over a colleagues error because it wasn't 'that bad' . . . do we really know that this was a one-time occurrence? Maybe there has been a consistent pattern of problems that we aren't aware of since this information is confidential. What if you are confronted about withholding the information or failing to act - thereby violating your Nurse Practice Act? How could you defend your actions?

Early in my nursing career, it became very apparent that the best decisions were those that could pass the "red face test". . . ones that I could defend without becoming ashamed or embarrassed about my actions.

[withpurpose]

Sounds like you are in an organization that views incident reporting and actions taken as a result as punitive which is usually a reflection of how leadership deals with incident reports. Incident reports help us identify trends and systems problems that need corrected to support the employees and keep the patients safe. Occassionally, it sometimes highlights an employee that makes frequent mistakes and either needs some sort of additional assistance or is being careless and progressive disciplinary action is needed. The trick to ensuring employees don't view the reports as punitive is to use great caution with taking any disciplinary action based on the investigative findings from an incident report. While staff don't like to see incident reports used against their peers in a punitive fashion, most staff also don't want to see a staff member that is putting patients at risk because nothing is being done about their mistakes. Read about the "Just Culture" approach to understand how best for managers to respond to staff errors. In my prior experience as a nurse manager, I found that usually it was unnecessary to use the incident reports in a punitive (but just) manner, even on the problem employees because there was usually enough other issues to use to address the employee's behavior and/or performance. Ideally, the employee that made the mistake and the other employees shouldn't have even been aware of the incident report. Sounds like this organization has a long ways to go to embracing patient safety as a core value. Good luck!

[CSARmedic]

The first thing that occurred to me after I read your heading was "How did you know it was a med error?" Are you the charge nurse or just another "really involved colleague" i.e. nosy. In all the places I've worked, I've never had the opportunity to get that involved in another nurses business unless I've been orienting another nurse.

One of the hallmark philosophies I've come to realize in nursing is "Nursing's biggest problem (and we have many problems) is nurses".

I'm playing devils advocate here but isn't taking the time and effort to second guess another's work and then investigating their mistakes usually left to supervisors or managers (even if they are on vacation)? Who appointed you the charge nurse or manager in their absence? When done by a coworker (like yourself) without the approval or recommendation of management or HR you're inviting retaliatory-like behavior from co-workers.

It's human nature.

And now you've ostracized yourself as "the snitch" and can't be trusted.

All in the "name" of patient safety. Which really isn't safety at all because the patient received the wrong medication not just that one time but many times as you pointed out. You didn't prevent the error from occurring (not your fault) but it still happened, apparently, many times.

My personal feeling is that the term "patient safety" is getting really old. Nurses use it for every little problem they encounter in the workplace from staffing problems to having to clean up patient rooms (google the story about Vanderbilt University hospital nurses cleaning patient rooms), to forced overtime or not enough hours, or whatever. It's just getting really old.

The truth is you probably didn't like that person, got too nosy and thought you could get back at them for some little thing they may or may not have done to you. You took it upon yourself to be the great savior of your workplace and now you can't understand why you are being treated badly by your coworkers.

Get a life.