Doing the right thing

[ZootRN]

I caught a huge med error made by other nurse. When I confronted her, she admitted doing it, but refused to file incident report, saying "that day was totally crazy, let it go". She is a charge nurse also, and a buddy-buddy with mgr. I feel this is so wrong. There is a lot of cover up going on there (if you belong to the right crowd). I've tried to speak up to nurse mgr before, she basically said to mind my own business.

What should I do? Should I just let it go, like I've done before?

[Mulan]

What was the med?

[nyapa, RN]

I'm quitting from there. It is not even the med error itself but the atmosphere of covering up "right" people and reprimanding others for much smaller offenses.

I was almost going to suggest that but didn't feel it was my place. It sounds like its only a matter of time before something serious happens, and you could be caught up in the mess...

[ZootRN]

What was the med?

For BP.

[Mulan]

For BP.

Do you have pyxis or unit dose? How could that happen?

[UM Review RN, ASN, RN]

Do you have pyxis or unit dose? How could that happen?

Easily, if it was an IV push....

We've had that happen too. But we caught it immediately and wrote it up and actually comforted the poor (very very very upset) nurse that did it.

I should add that the dosage was not unrealistic, and the patient actually improved, but it was just not the ordered dose.

[Mulan]

Easily, if it was an IV push....

We've had that happen too. But we caught it immediately and wrote it up and actually comforted the poor (very very very upset) nurse that did it.

I should add that the dosage was not unrealistic, and the patient actually improved, but it was just not the ordered dose.

Right, but we don't know that. We don't know all the facts.

We also don't know how it was known that it was 10 times the dose, and who knew it and when.

[classicdame, MSN, EdD]

you may need to initiate chain of command. that is why it is there.

[caliotter3]

Worked in a place where what you described was going on. If so and so made a mistake, everybody covered for her/him. But if someone else did it, the whole world found out. And they were quick to keep a tally for firings and such. To top it off, we had a nut case who went around creating med errors for other nurses. It was a very strenuous place to work, for all the back watching one had to do. The strain of trying to be perfect because one didn't know who would keep quiet and who would go running to the boss, actually contributed to some people leaving. Nobody has ever reported med errors simply for the sake of trying to improve the quality of care, as far as any place I've worked at. It has always been a case of tattling on each other or not tattling on one's "friends". I'm glad I don't work at those places any more.

[bigsyis]

Administering 10 times more of the med prescribed.

10 times more of anything is frightful. I hope that you went ahead and wrote up an incident report.

[lindarn]

we have a week to file an incident report.

of course, they want it sooner than that, but they do give us a week.

you know, administration wants every single med error, or near med error, written up so they can investigate, determine what caused it, and come up with five new policies/procedures/pieces of paper we then have to fill out.

i realize i sound cynical, but if i wrote up every error i came accross, i'd never do anything else. literally.

i think, though, that deep down, you know what you should do.

if any harm came to the patient (either temporary or permanent) then you certainly have to report it.

otherwise, ask yourself this: if it wasn't the charge nurse/nm's buddy, would you still hesitate to write the incident report?

it may be best (as another poster suggested) to report it to pharmacy, so that your nm can't "lose" it.

don't forget to make copies for yourself of all the paper work/reports that you submit! and make notes of conversations with the don, administration, etc.

lindarn, rn, bsn, ccrn

spokane, washington