caught a med error. ...stress. ..

Nurses Medications

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Hi.this is my first time posting as I generally kisg browse this site. I actually became a member so that I could seek some advice. Please, nurses, share your infinite wisdom with me!

I have been a nurse for nearly 7 years. Within the last year I took a position at a small rehab/ LTC facility. It seems that there is this strange, unspoken policy of "hiding" issues. Be it New wounds, change in condition, med error, whatever- most everyone seems comfortable with sweeping issues under-the- rug. This inevitably results in a mountain of paperwork and multitude of phone calls/order changes/ incident reports nearly every time i work (for issues occuring on other shifts) . Whenever there is an issue, it seems its ignored until a 'float nurse' stumbles upon it and adresses it.

The last shift I worked was on a unit. And shift I had not worked on in quite some time. As I was pulling meds for a pt, I noticed that the correct dosage of a med (narcotic) was unavailable . Upon further investigation I discovered that the pt. Had been receiving double the prescribed dosage for several weeks. I wrote up the med error, obtained correct dose and carried on with my shift. Later, i was informed by coworkers that i shouldn't have documented this med error as "no harm was done' as the nurses who gave the incorrect dose could" be in big trouble! ". I honestly feel as though I did the only thing I could in my position. Although, admittedly, .the patient did not suffer any ill-effects, an error was made ( not just once but for weeks). The patient is fine, but that does not negate the error made. Also, selfish as it may sound, I have a license to protect. I would have undeniable liability had I not reported the issue- it was obvious i noted the discrepancy and began the administration of correct dosage. Im not really sure what im looking for here except maybe some validation that I did the right thing (despite the anger ive inspired in many of my co-workers

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Oh man. Welcome to LTC. You absolutely did the right thing. So the other nurses could be in big trouble for their negligence? Well they should be! I work PRN in LTC and catch things like what you described. If it was something like, I don't know a Lasix that the other nurses could have been "borrowing" the correct dose (not saying it's right, but it happens), I probably would have quiety ordered the right dose from pharmacy and gone about my business. But in this case with a NARCOTIC, where it was glaringly obvious the incorrect dose was being pulled, when you would expect nurses to be extra diligent... I would have done the same thing in a heartbeat. And I would have been too fired up over the blatant negligence to give a rat's behind if anyone was upset with me.

I'm going to wager you weren't the first person to notice, either.

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I worked LTC for five years as a nurse. And while it may seem the norm to sweep things under the rug it never makes it right! You totally did the right thing!!!

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Specializes in Critical Care/Vascular Access.

The thing about this kind of attitude is that I (and the general public I would imagine) don't really want them to continue practice in this way, seeing as it will almost inevitably end up badly at some point or another. If it were one incidence, or maybe even something other than a narcotic, I would feel a little differently, but considering it had been going on for weeks, I'd say you definitely did the right thing. It does suck that you'll probably be seen as a snitch now, but sounds like the facility needs a little change in the way things are done anyway.

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In each and every LTC facility where I have worked, the same type of "sweep under the rug" culture existed, in particular, for particular nurses. Rest assured everyone involved knows that you did the right thing, but be prepared for the backlash should you consider continuing to do your job correctly. Be very, very careful from here on out. Can almost bet a paycheck that somewhere, sometime, one of your coworkers will have "set up" a serious error for you. Remain diligent. Only advice one can give since you will most likely encounter the same at a new place of employment.

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Specializes in Med Surg.

Get out of LTC ASAP. I did two years at one of the worst in my state and got a hospital job as soon as I could.

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How did the mandatory monthly pharmacy review miss this? The state board of pharmacy would be as interested in this as the board of nursing and I trust you will make sure they find out too.

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Specializes in MDS/ UR.

All LTC doesn't act like this.

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You did the right thing, which is not always an easy thing to do.

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Thanks for your responses and for for listening.i really hope that the situation will be over and done with before i return for my next shift. I know that the nurses who made the error are angry and I do feel bad for any consequences they receive as a result of this but that doesn't negate my ethical responsibility. An error was made. The appropriate protocol was followed. It should really just be that simple.

As far as notifying the board of pharmacy or BON, i dont feel its my responsibility to do so. I filled out the appropriate reports, Dr., family and patient were notified, the reports were sent to management. As far as I know, thats where my role in the process ends. Management has their own protocol as far as repoting, Quality improvement, etc. Is it really my place to notify boards?

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Also, to my knowledge , there is no mandatory monthly pharmacy check done. Pharmacy has come and done an audit of the carts twice since I have been there. Its considered night shifts job to audit the carts but it Just doesnt get done.

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Specializes in LTC Rehab Med/Surg.

I'm a pretty honest person, but even if I weren't, I've always found life is easier if you just tell the truth.

May not easier. Simpler.

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