Do you chart medication errors? - page 3

In nursing school our professors have told us to never chart a medication error. You do an incident report for quality assurance where you do identify yourself, you take proper measures to ensure... Read More

  1. by   TrudyRN
    Quote from Kendel
    OOHHH MAN, now what am i suppose to do

    i start my first job tomorrow..

    which is correct so i can prepare myself

    are nurses notes or charting hard to write or does it come easier with time since i am new
    It gets easier with time. What I have found to be best - the less said, in the chart or orally or in writing to ANYONE, the better. A doc taught me that and he is RIGHT. I used to chart every detail, as taught in school but he disabused me of this notion and I have never regretted it.

    You have no friends at work - remember that. Not your boss, the patient and family, your fellow staff - they are all out to wreck you - or at least make themselves look good, even if at your expense. Keep your mouth shut, your eyes and ears open. Be cordial but don't get close if you want to survive. It's hard and it's lonely but it works. Good luck on your new job.
  2. by   talaxandra
    I was always taught not to refer to an incident report in the notes, because then it is subject to subpoena and can become part of the official record.

    Whether or not I document it in the notes depends on what the error was, and what (if any) sequela resulted. I'd be much less likely to write that a patient was given their metronidazole two hours early (no drama, other times subsequently amended or staggered) than an accidentally overdose of narcotic with subsequent drowsiness/altered consciousness etc.

    Slightly off topic - If I make a drug error (like last week, when I gave 0.5mg oral clonazepam instead of 5mg diazepam) I disclose the error to the patient, apologise, and explain what the potential ramifications might be. I do this partly because I think the patient has a right to be informed about what's going on, partly to reinforce the role patients can play in reducing drug errors through vigilance, and partly because so much research supports the position that litigious patients most often want acknowledgement of and an apology for errors - nurses are often specifically excluded from claims because of good rapport, even when the harm was caused by a nurse.

    My experience has generally been that patients appreciate the honesty, are reassured that any other errors will be disclosed, learn that even "good" nurses are human and able to make mistakes, and become more interested in knowing what their meds are for etc.
  3. by   talaxandra
    Quote from Kendel
    are nurses notes or charting hard to write or does it come easier with time since i am new
    Both - documenting accurately, concisely and logically is a skill that can improve and get easier over time, if you're thinking about it. For some people it's not really a priority, and their notes are disorganised, too brief or lengthy, or confusing. But if it's something you think is important, take note of the documentation of nurses you respect; when you read particularly good notes, take a moment to think about what aspect were good, and try to incorporate this into your own documentation, and you'll be fine.
    Hope this helps
  4. by   sirI
    Quote from TrudyRN

    I just write "Pt. inadvertently received..., MD notified, client A&O x3, no new orders, etc." Chart VS. Why pussyfoot around?
    I would leave out, "inadvertently received", and just chart the facts as traumaRUs pointed out.

    Quote from TrudyRN
    What I have found to be best - the less said, in the chart or orally or in writing to ANYONE, the better.
  5. by   CyndieRN2007
    Quote from trudyrn
    the trouble with charting anything is that an astute reader of the chart, such as an attorney/nurse/paralegal/law clerk will pick up on it. they are trained to do exactly that, to look for exactly that type of note. why say you called a doc if it was a routine dose?

    i just write "pt. inadvertently received..., md notified, client a&o x3, no new orders, etc." chart vs. why pussyfoot around?
    no. wouldnt chart that. if a lawyer wants to pick up on it, then let him.
  6. by   NJNursing
    Quote from caliotter3
    By charting that it was given at the correct time and then reporting the mistake to the next shift, you have created false documentation and reported to others conflicting information. Aside from what is legally or professionally appropriate, there are several nurses that I've worked with in the past that would run with this info to a supervisor or the DON trying to cook your goose and/or make themselves look good in the eyes of the supervisors. You have to be careful about what you say or do concerning mistakes, actions, or statements, because not all co-workers are to be trusted. And you really should consider what Suzy Q., who took report from you, would say during a trial. She might tell the truth and then the attorney would be asking you to explain the discrepancy between the documentation and what you reported to the next shift. Too risky.

    Wow, so quick to throw me under a bus. I had meant to chart on the MAR the time it was actually given, not the right time it was due, but the right time it was given. I, by all means, would NOT encourage falsifying the MAR. Oh my god. Have a typo and everyone jumps down one's throat.