Do you write up med errors?

[NurseyPoo7]

During report yesterday I was told a pt who came in with N/V was ordered a KCL supplement the previous morning for a K of 2.8. Pt was apparently NPO for a procedure and day shift nurse "selected out" the med (we use computer charting) because pt was NPO. No meds were given when pt came back from procedure *idk if pt was maybe vomiting/refused to take meds after procedure.

Long story short, the error was found by the night shift nurse during chart check and pt was given the KCL supplement at 0400 yesterday morning.. As charge nurse yesterday I wrote up the incident as it is hospital protocol.

Today I get a txt message from the nurse who didnt give the KCL that was ordered. She asked "Why did you write me up?" I told her it was hospital policy and KCL abnormalities can cause cardiac issues. She said she didnt think me doing the incident report was "necessary".

Thoughts?

[natashacurtisrn]

Well, i think that this was an education opportunity rather than a write. One did the md write npo except meds? If not the nurse should have clarified, two, if the md did write npo except meds then yes it is a med error and the nurse should have been written up

[NurseyPoo7]

Idk if the MD wrote NPO except meds. But I didnt see any documentation of an attempt to get MD to change meds from PO to IV even if the pt couldnt tolerate PO meds

[caliotter3]

This was not a tylenol tab that she forgot to give. You were right. Too many nurses develop that, "It can't be known by anyone that I really do make mistakes. I expect everyone to cover up for me." attitude. Funny she is more concerned that her error was dealt with, than with the condition of her patient. I would not want her as my nurse.

[AnaCatRN]

I have made two med errors in my career, and I wrote myself up both times (computer incident reporting system), as I was the one who caught the errors (almost immediately). I have also reported errors made by others, and they weren't happy. I don't care. If an error is made, it needs to be reported by whomever discovers it.

If we let small errors go unreported (although the example by the OP was NOT a small error!), it can lead to larger errors going unreported, and we owe our patients better care than that! Yes, we are human, and yes, we can and will make mistakes once in a while, but we need to take responsibility for our mistakes. We need to put our patients' well-being ahead of our own egos!

Incident reports can uncover problems in processes in the facility, and communication issues. No one likes being written up, but if the policies and protocols can be made to enhance patient safety and outcomes after theses incident reports are written, then we should be glad to have those opportunities. Just MHO.

[shiccy]

There is another route that is call "ivpb" and it only takes a phone call. Totally incident report worthy.

What we tell ppl is we aren't writing the person up but the incident (ours ARE called incident reports).

Unless this happens a lot for this person it shouldn't matter. It's something to live and then learn.

[loriangel14, RN]

Where I work incident reports are written by the nurse that made the error. The purpose of the reports is not to punish or discipline the staff member but as a means of tracking incidents and identifying risk factors. If a certain type of incidence is happening with some frequency then action is taken whether it be a change in procedure or just a memo to be careful. You did the right thing by recording the incident. As a nurse you must be willing to stand behind your actions and admit when you made a mistake.

[leslie :-D]

as charge, i would've talked w/the nurse 1st, to hear her side of the story.

if i felt s/he showed poor judgment (which in this case, i think she did...she didn't even check w/md), then i'd tell him/her that i needed to write this up.

so while it's not always black and white (which to me, it isn't), most often it is warranted.

leslie

[clemmm78, RN]

the purpose of writing up incidents is so superiors can see if there are patterns. The patterns could have more to do with something other than nursing care itself, or it could be the nurse. Whatever the outcome, incident reports are the only way the managers can find out there is a problem.

[LouisVRN, RN]

I write up pretty much every error that is against policy. I see no other way of patterns changing or additional education being offered. I also make every attempt to let the person know I wrote them up and why.

[SuesquatchRN, BSN, RN]

I would've asked her about it before I wrote it up. She didn't forget it, she opted not to give it because the patient was NPO, and she noted it.

[NightNurseRN]

I write myself up if I catch any med error I've made. Our hospital has a "blame-free" policy which means usually there is an error some where in the "system", as opposed to the nurse themselves. However I must say this did seem sort of careless on the nurses part! You did the right thing.