Do you chart medication errors?

[MikeyJ]

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?

[TrudyRN]

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.

Not picking at you, NJ, but you've only been working a year! There is a lot of bad stuff that you have not yet seen. I hope you never do but at least acknowledge that you are still pretty new at this dangerous profession.

[TrudyRN]

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.

The trouble with charting ANYTHING is that an astute reader of the chart, such as an attorney/nurse/paralegal/law clerk will pick up on it. They are trained to do exactly that, to look for exactly that type of note. Why say you called a doc if it was a routine dose?

I just write "Pt. inadvertently received..., MD notified, client A&O x3, no new orders, etc." Chart VS. Why pussyfoot around?

[TrudyRN]

OOHHH MAN, now what am i suppose to do

i start my first job tomorrow..

which is correct so i can prepare myself

are nurses notes or charting hard to write or does it come easier with time since i am new

It gets easier with time. What I have found to be best - the less said, in the chart or orally or in writing to ANYONE, the better. A doc taught me that and he is RIGHT. I used to chart every detail, as taught in school but he disabused me of this notion and I have never regretted it.

You have no friends at work - remember that. Not your boss, the patient and family, your fellow staff - they are all out to wreck you - or at least make themselves look good, even if at your expense. Keep your mouth shut, your eyes and ears open. Be cordial but don't get close if you want to survive. It's hard and it's lonely but it works. Good luck on your new job.

[talaxandra]

I was always taught not to refer to an incident report in the notes, because then it is subject to subpoena and can become part of the official record.

Whether or not I document it in the notes depends on what the error was, and what (if any) sequela resulted. I'd be much less likely to write that a patient was given their metronidazole two hours early (no drama, other times subsequently amended or staggered) than an accidentally overdose of narcotic with subsequent drowsiness/altered consciousness etc.

Slightly off topic - If I make a drug error (like last week, when I gave 0.5mg oral clonazepam instead of 5mg diazepam) I disclose the error to the patient, apologise, and explain what the potential ramifications might be. I do this partly because I think the patient has a right to be informed about what's going on, partly to reinforce the role patients can play in reducing drug errors through vigilance, and partly because so much research supports the position that litigious patients most often want acknowledgement of and an apology for errors - nurses are often specifically excluded from claims because of good rapport, even when the harm was caused by a nurse.

My experience has generally been that patients appreciate the honesty, are reassured that any other errors will be disclosed, learn that even "good" nurses are human and able to make mistakes, and become more interested in knowing what their meds are for etc.

[talaxandra]

are nurses notes or charting hard to write or does it come easier with time since i am new

Both - documenting accurately, concisely and logically is a skill that can improve and get easier over time, if you're thinking about it. For some people it's not really a priority, and their notes are disorganised, too brief or lengthy, or confusing. But if it's something you think is important, take note of the documentation of nurses you respect; when you read particularly good notes, take a moment to think about what aspect were good, and try to incorporate this into your own documentation, and you'll be fine.

Hope this helps :)

[sirI, MSN, APRN, NP]

I just write "Pt. inadvertently received..., MD notified, client A&O x3, no new orders, etc." Chart VS. Why pussyfoot around?

I would leave out, "inadvertently received", and just chart the facts as traumaRUs pointed out.

What I have found to be best - the less said, in the chart or orally or in writing to ANYONE, the better.

Agree........

[CyndieRN2007]

the trouble with charting anything is that an astute reader of the chart, such as an attorney/nurse/paralegal/law clerk will pick up on it. they are trained to do exactly that, to look for exactly that type of note. why say you called a doc if it was a routine dose?

i just write "pt. inadvertently received..., md notified, client a&o x3, no new orders, etc." chart vs. why pussyfoot around?

no. wouldnt chart that. if a lawyer wants to pick up on it, then let him.

[NJNursing, ASN, RN]

By charting that it was given at the correct time and then reporting the mistake to the next shift, you have created false documentation and reported to others conflicting information. Aside from what is legally or professionally appropriate, there are several nurses that I've worked with in the past that would run with this info to a supervisor or the DON trying to cook your goose and/or make themselves look good in the eyes of the supervisors. You have to be careful about what you say or do concerning mistakes, actions, or statements, because not all co-workers are to be trusted. And you really should consider what Suzy Q., who took report from you, would say during a trial. She might tell the truth and then the attorney would be asking you to explain the discrepancy between the documentation and what you reported to the next shift. Too risky.

Wow, so quick to throw me under a bus. I had meant to chart on the MAR the time it was actually given, not the right time it was due, but the right time it was given. I, by all means, would NOT encourage falsifying the MAR. Oh my god. Have a typo and everyone jumps down one's throat.