New nurse still on orientation and first med error?

[sleepdeprived1]

Let me just start off by saying im extremely cautious about giving meds and checking and double checking them because I dont want to make a med error but on my last shift a patient got up and requested her "warm pack" (that she already had in room)be warmed up and a cna working (who is also very new) warmed it for her i thought nothing of it and charted a nurses note on my patient including the note about the "warm pack" she received. My orientator read this and said does she have an order for a "warm pack"? when it dawned on me OMG:cry: u do need an MD order for heat. well the patient didnt have an order (huge lesson learned for me and the cna and no harm done to patient). my orientator helped me modify my note to remove the "warm pack" part. I said what if I didnt take it out of note?? she told me i would have been written up!! well im obviously terrified of that and especially any harm to be done to patient and feel like a honest person and always hear stories of risk management control in hospitals..and how they are there to not reprimand but try and prevent future errors so being an honest person I feel bad for leaving that out and im sure patient will be asking for another "warm pack" on next shift and say oh i got one last shift...ANYWAYS just want to know from other experienced nurses who maybe made an error like mine..do u really get written up if no harm done to patient and first type of error. hope this is my LAST error but just in case...

[nurseprnRN, BSN, RN]

"there is no such thing as nursing judement. you need an order to do things." (sic)

you do not need an order for everything you do for a patient. there most certainly is such a thing as nursing judgment, and you'd better be able to demonstrate it. this is one reason nursing students leave their programs: they think all they have to do is "follow doctor's orders" and they're all set. alas for them, the autonomy that registered nurses bring to the practice of nursing is not going away anytime soon.

as to the warm pack, you cannot falsify the record by eliminating mention of it once you've charted it. you can draw a line through it and mark it "error" and initial that, but then the assumption would be that you charted it on a wrong patient and this one didn't really get the warm pack. then if there's some problem later, the question arises, "why did you cross that out?" better to leave it in, call the physician, get an order for it, and write it all down in the occurrence report (or whatever you call them).

if there wasn't an order for it, i see no reason why a prudent nurse couldn't assess the patient for safety (alertness, risk factors for injury, etc.) and apply a warm (not hot) pack (to intact skin with normal circulation and sensation) for comfort, and check the area frequently until it gets cool. personally, absent patient risk factors for injury, i think the physician is gonna laugh him/herself silly when you call about a dang warm pack. this is the sort of thing that gives nursing a reputation for lack of judgment.

[shipmanmisty]

In my facility we are allowed to give warm packs w/o an order. We are also allowed to put in foley's if the pt. needs one as well as take one out. The doctor states that f/c's are a nurse thing...we put them in then he writes the order.

[VictoriaGayle]

Am I the only one who thinks the biggest problem is that your preceptor wanted you to modify (falsify) the record by removing reference to the warm pack? That bothers me more than the error itself.

Yes, you should have gotten an order for it after the fact, since you didn't have one before the fact, but falsifying the record is NOT a good idea. Perhaps I missed something here.

OP, no this will not be your last error. We all make them for a variety of reasons, the key is to learn from it.

That's what I was thinking!

[Scarlette Wings]

If you make a mistake it is still a mistake whether or not the patient is harmed. Technically, the reporting of errors is to be a learning experience and not a punitive one. Patients can be severely burned by "hot Packs" even though it seems so benign. If you patient was a diabetic with neuropathy and numbness receiving pain meds.....fell asleep on a hot pack they didn't know was too hot and got badly burned, got a staph infection that would not heal or turned into a flesh eating staph.......you are liable.

Think carefully before doing ANYTHING. Ask questions. You will make mistakes...it's whether you learn form the that make the difference. good luck :hug:

Esme I always enjoy your answers. They are solid, well grounded, and offer solutions as well as the reason. It is so easy to rationalize and push the issue under the table, specially if that one slight error no one was harmed, but there may be a process issue that caused it or staffing availability, or failure to verify. We can learn so much from near misses and maybe fix things as we discuss them and look for ways to fix the problems.

Doctors have peer reviews when situations or cases have to be brought before their peers. I think we nurses need to have the same thing so we can learn from one another, share the pain from the one who made the error, and look at how it happened. I think if Risk Management would allow nurses to do their own peer reviews we would function a better team and maybe, just maybe we can learn from each other and stop devouring and chewing up one another.

We can either be part of the problem or part of the solution. I think peer reviews for med or process errors would help all of us.

[Esme12, ASN, BSN, RN]

Thanks Chey....

[CherrySyrup BSN RN CPN, BSN, RN]

I have never heard of needing an order for a hit or cold pack. What happened to non-pharmacologic measures like that, repositioning, etc?

[wooh, BSN, RN]

I have never heard of needing an order for a hit or cold pack. What happened to non-pharmacologic measures like that, repositioning, etc?

Too many stupid nurses have made the powers that be dumb down things for everyone.

[GitanoRN, BSN, MSN, RN]

at this level, we need to realize that conductive heating is defined as heat transfer from one point to another without noticeable movement in the conducting medium. moreover, typically, direct contact takes place between the heat source and the target tissues, superficial heat is usually conductive heat like hot water baths, hot packs, electric heating pads, warm compresses. therefore, i sincerely hope that everyone takes notice and never let their guard down regarding this procedure it might sound harmless but it could turn into a disaster if not monitored properly.

[CherrySyrup BSN RN CPN, BSN, RN]

At this level, we need to realize that conductive heating is defined as heat transfer from one point to another without noticeable movement in the conducting medium. Moreover, typically, direct contact takes place between the heat source and the target tissues, superficial heat is usually conductive heat like hot water baths, hot packs, electric heating pads, warm compresses. Therefore, I sincerely hope that everyone takes notice and never let their guard down regarding this procedure it might sound harmless but it could turn into a disaster if not monitored properly.

Understandable, but I find it offensive that nurses are not considered competent enough to evaluate a cold compress/hot pack.

[Bringonthenight]

I know this thread is old now but I'm from Australia and I find it fascinating that nurses need an order for heat packs in the US! Over here that's a nurse initiated treatment. I couldn't imagine calling a Dr for something like that.

Our nursing cultures are soo different!

[Vinniesguy]

Aus nurse here also - I'm gobsmacked you need an order! We're deemed competent enough to initiate such a treatment, evaluate its effectiveness etc.

I'd get laughed at at if I called a doctor over it!

[Esme12, ASN, BSN, RN]

In America we have a very litigious society.....and some of the male MD's feel nurses are not capable of a "medical order. Depending on the facility.......We can apply warm moist clothes for IV starts etc....but for treatment or if it is electrical? That's a MD job....