I am a float nurse in a large hospital. I have been working there for over 19 years. I was working today and actually went back to the same unit I had worked the day before, which doesn't happen often. During a quick update during report from the prior nurse on a certain patient who had some confusion with the dilaudid I had given him the day before, she reported to me that he hadn't asked for pain medication at all during the night. He had a very uneventful night, she said. During my am med pass I noticed that Dilaudid actually was given to him that night, but not by the nurse who was assigned that patient. He had an order for Q2 Dilaudid, 1 mg. The patient had prior to that only been given the medication once by me after a procedure. Like I said, the reaction was not favorable. So I was wondering why this med was documented in the emar as being given twice by a nurse who did not even have patients in the same area of the unit. I looked up the administration record and discovered the nurse had taken the Dilaudid out of the pyxis at 6 am. The emar stated that the patient was given the med at 8pm, then again at 10pm. This nurse had taken the med out hours after she charted it as given!!
I then asked the patient if he had any pain meds the night before. He said no, and he was completely alert and oriented. Also, this nurse charted the meds given as a late entry at the end of her shift, med was not scanned and neither was the patient id band, was a manual entry. I am so sure this nurse diverted meds. I told the charge nurse of my findings and she tried to rationalize it, but soon discovered she couldn't. I am distraught about reporting someone, as I have never had to do this before. Did I do the right thing? This is a fairly new nurse and she is well liked on her unit.
