Documenting Med Errors- NCLEX

Interesting...I just recall Ive encounter 2 questions on my nclex review about this. The way I understand it is that you shouldn' t document/attach the incident report on the patients chart however you should note that an incident report is completed it in the nurse's note. Hmmm..not so sure that's just what I remember. Please correct me if im wrong.

Now a dumb question if for instance you gave the wrong med after checking the pt, reporting it to MD and filing an incident report if there was no harm done to pt do you still tell the patient that a wrong med was given to him?? I would assume yes but not to sure.

So glad I came upon this. I was called in to the BON for not documenting in the chart that I gave a patient the wrong medication. Furthermore the patient required follow up (it was a BP med) and that was not done either. It seems to me that facilities tell you not to documetn an error and foolishly nurses listen. I just had another nurse recently tell me 'we are not supposed to document errors". I told her that is not what the state would say and that it depended on what the error was. I document errors in a very general manner. I wish health care facilities did not do this. Makes it look like information is being hidden.

So glad I came upon this. I was called in to the BON for not documenting in the chart that I gave a patient the wrong medication. Furthermore the patient required follow up (it was a BP med) and that was not done either. It seems to me that facilities tell you not to documetn an error and foolishly nurses listen. I just had another nurse recently tell me 'we are not supposed to document errors". I told her that is not what the state would say and that it depended on what the error was. I document errors in a very general manner. I wish health care facilities did not do this. Makes it look like information is being hidden.

Don't confuse the two, what you are NOT supposed to do is document that it was an error.

For example, let's say that the order for the medication was 1 mg of Morphine.

Let's say you gave 2 mg of Morphine in error.

You are NOT going to chart that you gave 2mg of Morphine by mistake or even "2 Mg of Morphine given instead of 1 mg"

You are going to SIMPLY chart the amount you gave, the fact that there was patient follow-up. I have been told to refrain from putting "MD Notified" instead chart "Discussed patient with Dr. Smith, no new orders". (as "MD notified" is a red flag that there was an issue)

Let the attorney's find the error....don't draw attention to it.

Referencing "incident report completed" or anything to that nature, is an incorrect answer.

So what if MD notified raises a red flag. If the patient has a right to know then charting 'md notifed' should not be an issue. clearly everyone has their own opinion. The BON says otherwise.