med error

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    I apologize for this being short, but my option for typing right isn't easy.Nurse A fails to document a med given on MAR. In report it was stated that the med was due to be given. Nurse B gives med based on report and MAR. Sees in nurses notes later that med was given by nurse A and not signed off in MAR. Opinions?
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  3. 8 Comments so far...

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    At the agency we used, this is a reportable med error. Nurse A would not be working for me anymore. Also, our agency would probably drop her as well after reporting her to the BON. What was the med? While I realize all med errors are serious, some meds that are given twice in error are much worse than others.
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    Nurse A still has a job as far as I know. I was nurse B. I don't want to name the med in case it makes it obvious to identify. I can PM you on it. But it luckily wasn't a med that could cause as much harm as many others could. Scared the mess outta me. And I still feel horrible even though it wasn't my fault. I was still the one that administered it. gotta face nurse A after this. And I'm concerned that she won't take it well. But I had to report it so that action could be taken for the patients safety and because med errors should always be reported. We are all human and we all make mistakes. I don't fault her for being human. But its happened before and been caught before the med was given. So of course now I can't trust Nurse A. But I don't want to be retaliated against either for doing the right thing.
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    Quote from ventmommy
    At the agency we used, this is a reportable med error. Nurse A would not be working for me anymore. Also, our agency would probably drop her as well after reporting her to the BON. What was the med? While I realize all med errors are serious, some meds that are given twice in error are much worse than others.
    Yikes. Why would they report her to the BON? Med errors happen all the time in acute care settings. (Esp. this particular type of med error, apparently. My preceptor is on the board of our hospital unit that deals with med errors.) You report it. File the paperwork. Probably get some sort of remediation and move on. The general rule in nursing is not IF you will ever make a med error in your career, but when.

    The error does need to be reported to the agency. I would probably let the agency tell the family if you didn't already. Obviously, dialogue about whether the family wants to keep on either of you.

    One of the other nurses who also covers one of my PPD kiddos made an error (forgot to give the kid his scheduled insulin) -- and then charted about it in his nursing report! Didn't seem like a wise move on his part, but maybe a more experienced PPD nurse could correct me on that.
    NJRN33 likes this.
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    I know that the agency we used reported med errors. I think that it was less about the med error and more about the untruthfulness/paperwork/giving report issues.

    I had a nurse that came a couple of times about 2 years ago. I didn't really enjoy her personality but she seemed like a decent enough nurse that I could safely nap. She didn't sign the MAR for an entire day. So I spoke to her about it (because I'm generally nice and don't want people to get in trouble). She did it again. I spoke to the DON at the agency. DON left a note at the house, spoke to her personally and emailed all the nurses on my son's case (and CCd me). She did at again. I called the agency. She got canned and her license eventually got an official reprimand.
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    I would think your agency would want to keep a very close eye on someone who has one patient and manages to tell you one thing and write down the opposite in a nurse's note. I can see someone failing to initial the little box on the MAR. But to tell you it was due when she actually gave it is troublesome to say the least.

    Sorry you have to deal with it - hoping the nurse will behave responsibly when it's brought to her attention.
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    The nurse did it again. But I caught it. Hard to work as a team when you can't trust the nurse you are supposed to be a team with.
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    Quote from SDALPN
    The nurse did it again. But I caught it. Hard to work as a team when you can't trust the nurse you are supposed to be a team with.
    To CYA you might want to consider reading all of her documentation to see how it jives against what she told you during report before administering any meds. I agree with the above poster. It's one thing to omit the entry on the MAR, but to write one thing and give report saying another when you only have one patient is pretty odd, especially if someone's familiar with the case. Private duty is not rocket surgery most of the time. Sure, things can get quite interesting, but it sounds like it must've been a pretty routine shift.
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    Her documentation is awful. But all it said was report was "giving" to me and the patient was safe and healthy. She doesn't cover for herself well at all. And again it almost happened the other day. I'm now documenting everything in report to cover my @$.. Scary how things get swept under the rug so easily. The nurse also does tons of false documentation and precharting. She'll get caught one day. I just hope it doesn't mean a patient has to suffer because of it.


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