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.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
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.
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.
Specializes in ER, ICU/CCU, Open Heart OR Recovery, Etc.
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.
TriciaJ, RN
4,328 Posts
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.