Controlled med not documented

steven007, BSN, MSN · Jul 17, 2019

What did your assistant manager say about the situation?

Chances are it was just a user error on your part. You say you scanned the patient and med, I am not sure what system you are using, but usually after you scan a medication you still need to sign it off as given, either with a pin code or some other computer intervention. But this is highly speculative, I don't know which system you are using and its intricacies. But I would suspect that the most likely cause is a simple user error on your part.

In which case, don't freakout. I am sure it happens and I am sure you are not the first. It is always scary when these errors happen with a controlled medication, but don't freak out too much about it.

My best suggestion would be to follow your institution's policy on a medication error. I know you administered the medication, but because of the error in transcribing it, I would write up an incident report or whichever type of reporting your facility uses, explaining the details of what happened "you got the med, you scanned the patient and the med and you administered the med" and the end result "the med is showing as not given". This will cover your basis.

Again, relax. It's one discrepancy. You will be fine!

JKL33 · Jul 17, 2019

Don't freak out or get defensive. Maintain your composure by remaining pleasantly assertive and keeping the facts in the forefront: I scanned the patient, I scanned the med, and I gave the medication to the patient according to the order.

Encourage the idea that the situation should be looked at with a mind toward "what step did I miss"/"what went wrong with the documentation piece" and not "what happened to that medication?" We know what happened to the medication, so try hard to stay cool and pleasantly not entertain that line of discussion. Just keep bringing it back to the facts.

I think an incident report as described above is a good idea.

Is this being handled reasonably so far, in your estimation?

Chocolate1, BSN · Jul 17, 2019

31 minutes ago, steven007 said:
What did your assistant manager say about the situation?
Chances are it was just a user error on your part. You say you scanned the patient and med, I am not sure what system you are using, but usually after you scan a medication you still need to sign it off as given, either with a pin code or some other computer intervention. But this is highly speculative, I don't know which system you are using and its intricacies. But I would suspect that the most likely cause is a simple user error on your part.
In which case, don't freakout. I am sure it happens and I am sure you are not the first. It is always scary when these errors happen with a controlled medication, but don't freak out too much about it.
My best suggestion would be to follow your institution's policy on a medication error. I know you administered the medication, but because of the error in transcribing it, I would write up an incident report or whichever type of reporting your facility uses, explaining the details of what happened "you got the med, you scanned the patient and the med and you administered the med" and the end result "the med is showing as not given". This will cover your basis.
Again, relax. It's one discrepancy. You will be fine!

She advised me to be honest in my explanation.

My system requires us to verify the med information and click submit/accept. If I don't click "submit" the administration doesn't record/save. I most likely forgot to click "submit" ?

Swellz · Jul 17, 2019

9 minutes ago, Chocolate1 said:
My system requires us to verify the med information and click submit/accept. If I don't click "submit" the administration doesn't record/save. I most likely forgot to click "submit" ?

On the plus side, you will never make that mistake again.

Chocolate1, BSN · Jul 17, 2019

19 minutes ago, JKL33 said:
Don't freak out or get defensive. Maintain your composure by remaining pleasantly assertive and keeping the facts in the forefront: I scanned the patient, I scanned the med, and I gave the medication to the patient according to the order.
Encourage the idea that the situation should be looked at with a mind toward "what step did I miss"/"what went wrong with the documentation piece" and not "what happened to that medication?" We know what happened to the medication, so try hard to stay cool and pleasantly not entertain that line of discussion. Just keep bringing it back to the facts.
I think an incident report as described above is a good idea.
Is this being handled reasonably so far, in your estimation?

I will definitely make an incident report.

So far this situation has been handled reasonably. I submitted an explanation of the facts to my supervisor and hospital pharmacy.

I guess I am afraid of being accused of medication diversion or reported to the board and going through the process of proving I am not.

Chocolate1, BSN · Jul 17, 2019

6 minutes ago, Swellz said:
On the plus side, you will never make that mistake again.

I will definitely not. I learned my lesson.

steven007, BSN, MSN · Jul 17, 2019

8 hours ago, Chocolate1 said:
I will definitely make an incident report.
So far this situation has been handled reasonably. I submitted an explanation of the facts to my supervisor and hospital pharmacy.
I guess I am afraid of being accused of medication diversion or reported to the board and going through the process of proving I am not.

This is so unlikely. This is one incident. If it was happening a lot and always with controlled substances, then I would definitely worry and it would definitely raise suspicion.

This is a one-off incident and I would assume and hope (as a nurse manager myself) that they understand.

Also, don't be afraid of getting reported to the BON because of this. Reporting to the BON requires extensive resources and ground covering on the part of the employer. An employer cannot willy nilly report you to the BON unless they are ABSOLUTELY POSITIVE there is a cause of action. There is insufficient evidence from what you are saying to support a report of "med diversion". To report such a thing, the employer would need to prove a track record of continued incidents of medication discrepancies and/or obvious or suspected impairment while at work. They would need to back this up with documentation which would be achieved after meeting with you, your manager and an HR representative (and union rep if you are unionized). If you have never had a meeting with you manager and an HR representative to discuss concerns about your performance or your competence while at work, then reporting to the BON is the last thing you have to worry about.

Instead, I would just invest my energy in learning from the incident and planning how you can prevent it from happening again. Also, if the system use is not intuitive, maybe discussion with your manager about how the system can be changed to be easier to use or more intuitive for nurses (this is unlikely to actually yield any changes, realistically, but it shows to your manager that you are being proactive. Just frame it in a way that is not confrontational and does not come off on trying to shfit the blame, i.e. I would say something like "This was totally my fault and I definetly will won't do it again, but I wonder if we changed blah blah blah, if this may prevent a similar error from happening to others in the future").

Relax, you will be fine! It sounds all positive thus far from the info you are saying about your supervisor!

159Nursesrule, ADN, BSN, CNA, EMT-B · Jul 25, 2019

Been there done that, use it as a learning experience. Make sure in any write up that you state what you are going to do to keep it from happening again.

Such as I have changed my practice after scanning the patient, I scan the medication and I submit the medication within the system, I then administer the medication. I then double-check to make sure the time of administration is there and record the time so that I know when the next dose is due.

Crash_Cart · Jul 26, 2019

On 7/17/2019 at 9:08 AM, Chocolate1 said:
She advised me to be honest in my explanation.
My system requires us to verify the med information and click submit/accept. If I don't click "submit" the administration doesn't record/save. I most likely forgot to click "submit" ?

Human error or technology flaw?

I am thinking there must be a way they can program the "scanner" you used to scan the med and the patient's armband, to instantly submit confirmation electronically to the eMar the med was given, instead of doing it all as a separate step.

I mean you know how it is, things get crazy and you might not be able to go back to the eMar to do that right away because something else comes up. Then the required task gets forgotten about by sheer mistake simply because you had other priorities come up that got in the way etc.

So i'm thinking the solution to these kind of problems could be in the way the scanner works itself.

It could be programmed not only to confirm the injection was given directly into the eMar, but it could also be used by the nurse after scanning the med, the armband and before any actual injection occurs to instantly alert the nurse in the event an order doesn't exist for this pt. in the eMar too!

Seems to me it would make more sense if the scanner and the eMar database worked autonomously with one another and it would resolve a lot of these kind of problems.

Just something you and your manager might want to think about. Mabe your manager can get with the vendor of the scanner equipment to see what they can do.

Rionoir, ADN, RN · Jul 26, 2019

I'm still an extern, so I'm just asking this out of curiosity: Do they give you a chance to take a drug test or anything in a situation like this? I would think if it was a one-time occurrence and you passed a drug test they would be able to believe your version pretty easily?