Do you chart medication errors?

NJNursing, ASN, RN · Nov 25, 2007

I never have. I, like your preceptor, have filled out incident reports, but I have NOT actually put a note down. You're just looking to end your license that way in a law-suit. I understand wanting to be honest, but it was an antibiotic and he had a ruptured appy, so an extra dose of antibiotics never hurt anyone. If it were an absolutely wrong med and wrong patient (like giving a cardiac med to someone without cardiac problems or a med that someone was allergic to) then I would document the med given and interventions given and outcomes.

chocokitten · Nov 25, 2007

In nursing school our professors have told us to never chart a medication error. You do an incident report for quality assurance where you do identify yourself, you take proper measures to ensure there was no harm to the patient and continue to monitor, and you call the physician/resident if need be. However, I have been taught that you never chart it on the nursing notes for legal reasons.
Last night I was working with an RN (I am an apprentice nurse) and we had a young boy recovering from a repaired ruptured appy. He was on flagyl q8 and mefoxin q4 (I think.. cannot remember exacts about mefoxin). Well anyway, she ended up giving the flagyl when she was supposed to give the mefoxin. Thus she ended up giving 4 doses of the flagyl instead of 3. She realized her mistake a few hours after the infusion had completed, and she did an incident report and spoke with the resident on-call. There was no harm to the patient but we continued to montior. However, I was looking at the nursing notes and realized she charted her mistake and I questioned her about what I was learning in school about not charting medication errors and she said she has never heard of that.
So the very simple question after my long unneccessary story -- do you chart medication errors in your nursing notes?

as a new nurse I defered your question to the two senior nurses sitting beside me here at the nursing station. their respones were "no" and "no". I think that if you fill out an incident report, notified the MD, and monitored the patient for any complications and none were noted that you probably shouldn't put it in the nursing notes. However, I would definantely pass this information on in shift report so that the next shift can continue to monitor for side effects.

joprasklpn · Nov 25, 2007

no. I was always told to make an incident report only, but to chart any observed effects without stating that an incident happened.

mhr2133 · Nov 25, 2007

Ok, let me start this out by saying I'm not a nurse, just studying for my Nclex PN but I just happened to have been doing this question on the NCSBN neclex review right now.

They said...you chart just the facts..gave Flagyl 0800, 1200, whatever, nothing more. Just exactly what was given, and a note about the patient vitals, condition but no mention as to a mistake or why.

TrudyRN · Nov 25, 2007

I never have. I, like your preceptor, have filled out incident reports, but I have NOT actually put a note down. You're just looking to end your license that way in a law-suit. I understand wanting to be honest, but it was an antibiotic and he had a ruptured appy, so an extra dose of antibiotics never hurt anyone. If it were an absolutely wrong med and wrong patient (like giving a cardiac med to someone without cardiac problems or a med that someone was allergic to) then I would document the med given and interventions given and outcomes.

Why do you think charting the one is ok but the other is just looking to end one's license? They're both wrong. And I am not at all sure that no one was ever harmed by an extra dose of abx. Like all other meds, abx have side effects - renal damage, 8th n. damage, etc.

Trauma Columnist · Nov 25, 2007

You MUST chart the facts. For instance, in the above incident:

"Flagyl 200mg IVPB administered at 1200. Dr. So and So notified at 1255. No new orders received."

You don't document that you made a mistake but you do chart the facts.

NJNursing, ASN, RN · Nov 25, 2007

Why do you think charting the one is ok but the other is just looking to end one's license? They're both wrong. And I am not at all sure that no one was ever harmed by an extra dose of abx. Like all other meds, abx have side effects - renal damage, 8th n. damage, etc.

I could see if you gave 2 doses back to back say q 2 hours when it was a q 8 hour med or giving Vanco after 4 hours instead of 6 or 12, but one extra dose out of 4 total doses? I've never had a patient go into renal failure or have any nerve damage by having one extra dose of antibiotics. Ever. I could see if they were allergic to it and it was the 2nd dose or even the first dose. But the 3rd? No.

And i agree with the above. I'd chart it on the MAR that it was given at the right time, but I wouldn't go saying that a mistake was made. And I also agree to report it off to the next shift as well.

caliotter3 · Nov 25, 2007

You MUST chart the facts. For instance, in the above incident:
"Flagyl 200mg IVPB administered at 1200. Dr. So and So notified at 1255. No new orders received."
You don't document that you made a mistake but you do chart the facts.

This is also the way that I have seen that a med error is supposed to be charted. Additionally, as previously stated, an incident report.

EmmaG, RN · Nov 25, 2007

You MUST chart the facts. For instance, in the above incident:
"Flagyl 200mg IVPB administered at 1200. Dr. So and So notified at 1255. No new orders received."
You don't document that you made a mistake but you do chart the facts.

Exactly.

For those worried about lawsuits and their license, think about what would look more incriminating to a jury or the Board--- simply charting the facts, or deliberately covering up a mistake by not charting the medication had been given. Like he said, no need to state an error occurred, but if you administer a medication you are obligated to record it.

EmmaG, RN · Nov 25, 2007

I could see if you gave 2 doses back to back say q 2 hours when it was a q 8 hour med or giving Vanco after 4 hours instead of 6 or 12, but one extra dose out of 4 total doses? I've never had a patient go into renal failure or have any nerve damage by having one extra dose of antibiotics. Ever. I could see if they were allergic to it and it was the 2nd dose or even the first dose. But the 3rd? No.

There's a reason why they are ordered at specific intervals. It's not within our scope of practice to determine the risk or harm done to the patient with a med error. That's why it is reported to the doc.

And i agree with the above. I'd chart it on the MAR that it was given at the right time, but I wouldn't go saying that a mistake was made.

I'm a bit confused; it wasn't given at the correct time. Why would you chart that it was? Or was that a typo in your post?

P_RN, ADN, RN · Nov 25, 2007

I agree with trauma,

10:15 Pt is very uncomfortable Patient received Morphine 8 mg at 1020am. Dr Jhklh made aware. Orders received to change Morphine to 10 mg q 3 hours IM. The the occurrence report would also be filled out using the SAME phrases. And NO NAMES except the patient

As far as abx iv we were told to follow the pharmacy standard times. So if they got Ancef at 1pm in PACU and it's every 6 hours,,,,BUT the pharmacy says q6 is6-12-6-12 then the first dose will be at 6. Most but surely not all drugs have a fairly wide administration time.

Chart honestly.

Do not put glitteer and little gold stars for pete's sake around the mistake. If someone wants to find it let them look.