especially when you could have swept it under the carpet.......a short while back, l went into the pt room to give an IM inj. Almost always, l draw up meds in the med area, for some reason, that evening l did it in the pt room....l change needles after l draw up the med, so when l re-capped the firs needle, l laid it on the counter, turns out the cap was loose. Next thing l know, a visitor was stuck with this needle... thankfully it was not contaminated biohazard-wise....pt did not want to see a doc, wasn't upset, and no one else knew....but l wrote it up, didn't feel l had a choice. If anything had come of it later it would have been much worse and the injured could have made false claimes. So l got a "verbal". My NM was great about it but stopped short of commending me for my honesty, which l found dissapointing.
Yes, several times. I, too, feel honesty is the best policy. I really feel incident reports are a learning experience. I use them as such and try not to make the same mistake again. Even us "Sr" nurses do boo-boos when we are overworked and understaffed. I try to check all my meds at least 3 times, once as I am pulling them, again to make sure I have all of them, then again as I am opening them. Then of course identifying the patients etc. All this when you have a time frame to give them. lol.
All you guys must work in more philosophically advanced facilities than the ones I have worked at in my career. I have NEVER worked at a facility where incident reports were NOT looked at as punitive. IRs are a guaranteed trip to the office and troubles follow as surely as night follows day.
One facility marked off on your biannual eval for each and every one. Once we were told to write up an IR for each episode of a particular resident's verbal/physical abuse of the staff to get him out of the faciliity and when eval time came, they counted off for that, brought it to their attention and they ignored me.
I own up to my mistakes, but try extremely hard not to make any, because I have such a phobia of getting my tail chewed clear off from past experiences.
I have written myself up many times over the years. Most recently I had a patient who literally got medications every hour. The pharmacy staff had been decreased on nights to just one person. I would have to check to make sure all meds were there. The TPN was not so I faxed the order (same for days) and called.
It was brought but the previous was not empty and 24 hours had not elapsed. Since the patient had a fever I put it in the medication refrigerator in the patients bin.
An hour later in a rush I got the large yellow bag from the top of the bin and hung it. After cleaning the patient up I panicked that I had not checked the name and so on. It had another patients name on it.
So I called the doctor (who ordered labs and since the other TPN had a different glucose concentration glucose testing Q hour X6. )
Called the pharmacist to report what I had done so the other patient could get another TPN.
Then wrote the incident report. When I write one about myself or another person I state facts only, what the response was (MD call, labs ...)and do not state who made the error. The medication admunistration record (MAR) gets the truth with the given med charted. Nursing narrative states the facts too.
Management can look up the person if needed.
I had already filled out my unions version of the ADO form (link below). I had let the supervisor know that in my opinion this assignment was not safe because this patient needed more nursing attention than the staffing allowed.
I did not get in any trouble. Nothing was said at all except the nurse whose patient was to get the other TPN said it was not necessary to fill out a report. The MD also said the same. He thanked me for calling so quickly. The wrong TPN was running at 100cc/hr for about 30 minutes.
Link below for short staffing and other unsafe situations. Use at your discretion. It may save your license. It may conversely anger management or bring about retaliation.
My most recent med error was merely due to me working too many days and just simply being exhausted but still my fault: about 3 years ago when I was working long term care I got pulled to the Alzheimer's unit (I was employeed on the minimal care unit) and I was passing my meds, everything was going fine, and I walked up to this resident and gave her the wrong person's med. She took it, then I went back to the MAR and came to the name of the person I had just given meds to and thought "oh shit". Well I went to the desk got out a med error report filled it out, called the resident's son and then went to the minimal care unit where the PA was and was just literally bawling (did I mention I was exhausted, I cry at the drop of a hat when I'm real tired), she looked at it laughed and tore it up. The med I gave to the wrong resident was Lactaid, no big deal but a med error all the same in my opinion, later that evening when this resident's son came to feed her dinner like he did every meal, he brought her a banana split and joked to me "oh well at least mother can tolerate the ice cream tonight" and he brought me one cause he thought I could use it.
sure have, and have worked in some VERY punitive places........agree with the thinking that incident reports should be a training and tracking tool, not a punishment guide...........wish all the places i have worked for thought so, can be so useful for tracking recurrent problems.
Yes I have, not to many lately and the one that was really the worst I thought was that they pulled me to the alcohol/drug unit one night to releive for the nurse to take her break. Well I went in to give this guy his meds while she was gone. They don't have arm bracelets on them and the way they numbered the beds there was different than on the floor. They had pictures of all the residents but it was night shift.
I went into this room and gave a guy 1500 mg Choral Hydrate and after he took it, he said. " I have never had that medication before." Well I went back to the nurses station and realized that I had give the wrong patient the medication. I went in and gave meds to the right medication and then I called the doctor. He was a really sweet nice guy and when I told him what I did he said, "That guy has been complaining that he hasn't got a good nights sleep since he has been in the unit. Just make sure to wake him up in a little while and make sure he wakes up and check his blood pressure and then leave him alone.
I felt so bad that I put in a incident report but the doctor told them that all the nurses need a better orientation before they work there and nothing else came of it but for me I have been more careful with right medication, right patient, right mode etc since then......
incident reports incident reports why is it that some of these med errors and incident reports, result in disciplinary action, or official reports to the board of nursing, resulting in any variety of discisplinary actions?---also dependent on who and their work relationship to their superiors---why isn't there a level playing field, where all nurses are treated equitably instead of arbitrarilly? where are your rights as a nurse, if there are no bad patient outcomes, why do you still receive disciplinary action. why are physcians held less accountable, many times we as nurses never choose to write up physicians on incident reports, why is that? why do we treat ourselves and others so punitively? why is administration on a constant fault finding mission with nurses and are so antagonistic? these same administrators seem to overlook their own & physician shortcomings. ---------what abnormal psychology is poisoning nursing.
Specializes in Interventional Pain Mgmt NP; Prior ICU and L/D RN.
Sure have...my first one was when I was still fairly new...gave a pt 2mg morphine instead of 2gms magnesium..MS04....MGso4...the hospital has actually changed it so that type of abbreviation is not allowed (just did it this year though)....
thankfully it was not contaminated biohazard-wise....pt did not want to see a doc, wasn't upset, and no one else knew....but l wrote it up, didn't feel l had a choice. If anything had come of it later it would have been much worse and the injured could have made false claimes. So l got a "verbal". My NM was great about it but stopped short of commending me for my honesty, which l found dissapointing.
copperd
17 Posts
Yes, several times. I, too, feel honesty is the best policy. I really feel incident reports are a learning experience. I use them as such and try not to make the same mistake again. Even us "Sr" nurses do boo-boos when we are overworked and understaffed. I try to check all my meds at least 3 times, once as I am pulling them, again to make sure I have all of them, then again as I am opening them. Then of course identifying the patients etc. All this when you have a time frame to give them. lol.