have you ever "written up" yourself in an incident report?

ahill1000 · Sep 7, 2003

I work nights and one night I made a med error. I hung an IVPB of a med I was not familiar with. Even so, prior to hanging it, I looked it up in our micromedex so I would become familiar with it. Turns out, it was the same med, just in IV form, as another medication she was taking po. The order was written to give the IVPB only if unable to take po. The nurse that put in the order had placed it as a scheduled med so it turned up on my MAR to be given. I did not catch it because in the IV book, nowhere did it have the same name as the po med. Although it was similar. I should have caught that though. I caught my mistake on chart checks when I saw the actual order and the way it was written. The patient's doctor came in about an hour later, early am, and I immediately told him of my mistake and what I had done to fix the problem. I changed the med to prn instead of scheduled and passed it on to the day nurse. Also I held the po dose of the medication that was due for 5 that morning. The patient already had a drug level for that drug to be drawn at 5 also. He was very polite and admitted that we are only human and all make mistakes and what I did to rectify the situation was appropriate. I also wrote myself up. As others have said, by doing this can help us to look at the process in which orders are put in and prevent other med errors such as this. Needless to say, the patient suffered no ill effects and believe it or not, her drug level was actually below the therapeutic level.

GRETTY · Sep 7, 2003

:rolleyes:

Yes I believe in honesty also so I have also taken the route of self discipline and written myself up. I did this not only to be honest but to make sure that I never repeated the same error again. It Works! It makes you not only a better nurse , but a better person.

Debbie, RN · Sep 10, 2003

Yes, I like to think of "getting written up" as a learning tool instead of something to be used as punitive. I have indeed written myself up for errors - hoping that including myself, my co-workers could learn from my mistake. Unfortunately, it was not used in that way. Management thought we were writing up too many, so the variance reports stopped. Now mistakes just happen and unless its a grave one, it just gets slid under the carpet so to speak. So sad.....

VA_CCRC · Sep 11, 2003

At my place of employment we refer to 'incident' reports as Quality Reports. I think this conveys a less disciplinary-type image. I do not hesitate to 'write' myself up. I feel that USUALLY a report needs to be completed due to a SYSTEMS fault and that completing this document calls attention to things that need to be tweaked out to prevent further errors. Completing QR are important in instances of near misses as well. If I find an error from someone else I usually talk to that person and try to leave it up to them to complete the QR themselves. Still so many of us automatically associate reports with negativity.

Let's use these tools to make our working environment safer for nurses and patients!! Take the time to complete these reports.

kimmicoobug · Sep 11, 2003

I will be writing myself up the next time I go into work. I made the error the other night, and would have filled it then and there, but I was swamped that night and last night was pure hell. What happened was that I grabbed patient A's MAR and proceeded to the med room to get her abx piggyback. Well, I grabbed the right piggyback and right dose, but labeled with patient B's name. Both patients had the same surgery, same doctor, same orders. I even double checked everything...except the name. I was very lucky it was the same med, but it could have easily not have been. I felt like doo doo for the rest of the night.

ejm99 · Feb 17, 2004

I"m not a nurse yet....

but my first semester of clinicals was in a nursing home. I was assigned a Great nurse and Lvn team and they had me doing ALOT of skill work, care..things you just don't get to do in the lab. Well a big huge no no was giving meds..didn't matter what kind, to who...you just didn't unless your nurse was w/ you..and PREFERABLY your instructor...ours kept dissappearing and reappearing half the time we missed out on lots of skill work because she would just dissappear for an hour or 2...it was frustrating.

I did get to cath a 90 yr old woman...w/ my instructor overseeing my technique...but later when med time rolled around my nurse wanted me to give the pt. her insulin.

I REALLY wanted to do it..because I have a thing about things sticking in my or anyone ELSE'S skin...whether it be an iv, shot..whatever...and needed to get over that fear.

My instructor was MIA AS USUAL.....

so well the team (BOTH) went over the procedures w/ me for checking medications against the order etc... and then we went on in to do it.

Well the LVN was REALLY REALLY NICE....took her time w/ me...very encouraging... so I did it.

I turn around and realize the RN had left the room...oh crap..I was in deep do do....

so I told the LVN ...I wasn't supposed to give meds esp a shot w/o my RN present...

she ran and got the RN

and together they decided it was HER mistake..not really mine..yea okay..and that it would be better not to mention it...or record it...because something like having your RN walk from teh room 10 seconds before you administer an injection isn't worth getting kicked from the ADN program.

I was lucky....and will be holding the RN's hand next time just to be sure!

Shannon Grey · Feb 17, 2004

:balloons:

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.
Anyone care to share?:) .........LR

Shannon Grey · Feb 17, 2004

:balloons:

after thirty years in the field, I have filed more incident reports on myself than I can remember, anything from giving the wrong tray to a patient to failing to clock out or in due to a computer malfunction (yes this is an incident at our facility) I don't expect anyone to acknowledge my honesty, I simply do what the policy dictates and go on, so you are commended for your honesty, by another nurse keep up the good work and maintain accountability for your actions or misfortunes, the reward comes after this life :blushkiss

lpnman · Feb 17, 2004

to be praised for doing the right thing in adulthood is redundant-virtue is its own reward

Brian, ASN, RN · Mar 3, 2004

l meant to post a poll.........oh well, don't know what happened.

Hi l.rae,

I've added the poll to your thread. Hope that helps :)

TraumaQueen · Mar 4, 2004

Respiratory Therapy writes us up for all self-extubations.... so far, I've only had one patient self-extubate.... but they first give you the chance to write yourself up, so you can tell the story, not them. :)

I also wrote myself up for not catching an error the nurse before me made. There was a bag of cardizem, I looked at it, and saw the tubing flowing downward (it was a little dark in the room)... I checked it for concentration and rate...... but never actually put my hands on the bag..... a little later in the shift, the patient went into a-fib again.... then I looked at the bag, and there was a same sized bag behind it, of Vanco running at the cardizem rate.... doc wasn't mad, just said to give them PO cardizem instead and not to worry about it. So, this patient probably didn't get their dose of vanco either... (the nurse before me never owned up to the mistake either)..... So, lesson learned.... -everytime- I go into my patient's rooms, I physically touch the bags and follow them to their destination..... it's not always enough to just eyeball them :)

Shannon Grey · Mar 5, 2004

:rolleyes: wi, please don't react so , you appear to have been on the wrong side of a desk and evidently received harsh counseling while another got off scott free. this is the way of the world my friend, after some thirty odd years of the game, i have found that the reports are used by people in various ways, some not conducive to the well being of the staff as a whole. please just take it with a grain of salt, sometimes the whole box and don't let it get your blood pressure up so.

i have found that to dwell on something causes me to become as petty and bitter as theperson who wrongly used information to chastise me. i simply learn from mistakes and move on.

i round at our facility with each physician, for several reasons, our director demands it, "it is something the physicians want" sort of special attention secondly to make sure they see the patient and evaluate them and foremost to make sure any questions are answered for the patient and informaiton is comminuicated to the physician that the patient had requested. also to assure they[the demi-god} follows through on problems that have been reported to him. this is contraversial at our facility and i catch flack for it but it is irrelavent, patients needs are met and i sleep at night. praying for you .

shannon:balloons:

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.