Fentanyl Patch med error

[nursesaysay]

I am a LTC nurse. To make the back story short, pt has Fentanyl Patch to be changed Q3days, only applied to upper back out of reach, old patch must be discarded(wasted into sharps container) by two nurses & signed in narc book by both nurses. One day, I went to change patch as ordered, the previous patch was not on patient but was signed out in narc book (next to signature reads "old patch wasted" but no co-sign from second nurse). I then found an even older patch. Did full body audit with second nurse, could not locate patch that was supposed to be on pt.. Filled out appropriate med error paperwork, left with supervisory staff.

Next day...I am called to director of nursing office. She says "It seems like you only find med errors when per diem nurses work, call me crazy..." I am pretty upset/offended. I am full time on my unit, and yes mistakes happen BUT this mistake is a narcotic error! The nurse who placed the older patch on the pt was a PRN nurse yes, and likely just discarded the new patch innocently. However, that is not my job to figure out. There have been two other occasions where per diem nurses have incorrectly placed the Fentanyl patch on this particular patient IMHO, why is my director coming down on me? I feel the concern should be with the per diem staff members who are not educated on proper placement of the patch!

Just wanted some input - would you be offended if your director said this to you? How would you respond? I was dumbstruck, so I just nodded my head at the time.

[BeenThere2012, ASN, RN]

I've been a nurse for 4 years and I never have worked anywhere where RN/LPN does not get a co-sign from a second nurse when discarding an old Fentanyl Patch. I thought this was nursing 101. Basically, my director says since I am a "senior nurse" I should be "educating staff" rather than reporting them. I am totally OK with educating, however, a controlled substance error isn't something I can just approach another nurse about later on - this is a reportable issue, as I was not discarding the patch from 9/19/16 but rather the patch from 9/16/16. Plus, my poor patient did not have proper pain management as the patch on her was no longer working, thankfully no adverse effects were noted. I have now decided to check the placement and date on the patch every shift when I come in...perhaps I will ask our on-site APRN for an order to have all shifts check the patch on the patient during shift change. Seems like a ridiculous thing to have to do, but I'm at a loss here and I have no help from management, clearly. Yes, I could go above my director, but she is very well liked within this corporation, and this will likely backfire on me. Again, thank you all for your support!

Thank you for clarifying. And, you are correct in how you have been handling this. It is not an option for us to NOT report on narcotic discrepancies. Yes, DO teach also, but you can't just leave it with that. I am surprised that the DON was not supportive to you on this subject.

[BostonFNP, APRN]

Wait the same nurse has had this before? With a missing unused patch?

[TriciaJ, RN]

I did speak to my director more, she said "as a more senior nurse you should be leading by example". I suppose this is just not going to go my way & I will never understand. Thanks for letting me vent!

What kind of example was she hoping you'd lead by? Ignoring gross med errors? Looks like she wants to keep her head in the sand and shoot the messenger.

[TriciaJ, RN]

This woman is out to lunch. I think she needs to give you her paycheque if she expects you to do her job.

[NotAllWhoWandeRN, ASN, RN]

I do think it's a valid concern if it was the same per diem nurse more than once and whether it's a pattern of the new patch vanishing. It could be an innocent mistake or it could be a diversion issue. I've worked at places that have required patch checks and it helps, so long as staff aren't falsely documenting the check. You'll also learn exactly now many nurses don't understand anatomical position.

Your manager is out of line telling you not to report, particularly since, as you've pointed out, the error affects the way you must handle your own patch administration, disposal, and documentation. I believe the best option would be if you can find facility policy regarding med errors, demonstrate that you are following it (I'm 99.9% sure you are, because policies never say "It was probably an innocent mistake, so use it as a teaching moment, but nothing more"), and tell her that until policy changes, you will continue as you have been doing to protect your own licensure and integrity.

[traumaRUs, MSN, APRN]

ADMIN NOTE - several posts have been edited due to privacy concerns. Thanks everyone.

[SororAKS, ADN, RN]

Thank you ALL for your comments & reassurance. I am honestly concerned about the lack of concern, although my director did state she will be speaking with that nurse. I don't know...I don't report little nit-picky errors like a dressing not being changed or something...but a narcotic error must be reported....it's my license on the line too for false documentation! I did speak to my director more, she said "as a more senior nurse you should be leading by example". I suppose this is just not going to go my way & I will never understand. Thanks for letting me vent!

You ARE leading and being the example. There's a difference between nit picking and objectively stating your findings. You even had another nurse doing a more thorough exam with you.

This is your Director's issue, not yours. I can't see where you made a mistake. It appears that your Director, who really should be the leader and practice being an example herself, is choosing another route.