med error--real world answer?

  1. So I caught someone's med error. I work night shift and have to check over the new orders. It was for pepcid, pt to get before each meal and at night, and the nurse who took the order off (we still use paper documentation) omitted the HS dose and therefore the next shift's nurse didn't give it, because it wasn't on the MAR to give as such. I felt like it had to e reported, because then whoever has to check the orders (me, in this case) would ultimately be held responsible for not reporting, and most importantly I had to end up fixing the order which of course couldn't be done without noticing the error. It wasn't a "big" error--no harm to pt, pepcid isn't that big of a drug, etc....but why should I put myself at risk for catching it and not reporting it.

    What would you have done? I just feel bad, I hate getting fellow nurses in trouble. Also, I'm afraid the nurse will find out who filled out the report (although I think they're anonymous....and the second shift's nurse could have caught it at the end of her shift and filled it out for all anyone knows) will find out I filled it out and she has been there forever and I'm pretty new and it seems the culture is "don't tell on your fellow nurses" where I work.
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    13 Comments

  3. by   k_gabelko_FNP
    Reporting it is the right thing to do. You pretty much have to. For one, the nurse who made the error needs to know to be more careful-- if this had been insulin, a seizure medication, vancomycin, a pressor... missing the dose WOULD have been a big deal. Even with Pepcid, if the pt's not responding to it, it may be because he's missing a dose, not because it's the wrong drug for him. Keep your reputation clean. And, as for the nurse who made the mistake... if she speaks to you, tell her calmly that your responsibility on night shift is to check orders, and that any missed order or missed dose automatically generates an incident report (or whatever form your facility uses). If she upbraids you for "telling," you can say something like, "I was thinking only of patient safety when I did, and if I had made an error I hope someone would point it out to me." It's not an issue of "telling" on your fellow nurses. We are here to support pts first and foremost. We also support each other... and think of it this way: she's better off having a small error found than later on down the line if she makes a big error.

    Also, as a veteran of numerous JCAHO surveys-- these things are all eventually caught. Then you'll be asked why you didn't correct it, since you signed the 24 hr chart check. Protect your pt, protect yourself, and support your fellow nurses by helping them do the same.
    Keep up the GREAT work!
    Katrina
  4. by   icyounurse
    This may not be a popular answer- flame me if you will- but if it was me I would have corrected it on the MAR and moved on with my life. I find that there are many many minor errors that day shift makes on the MAR often when a med is first ordered, which is why we do the chart checks. I am usually pretty busy and if I took the time to write up every small error then I would get behind. The only way I would do this is if it was a drug that would have caused harm that was missed, or if it was the facility's protocol to report such small errors. Just being honest here. I feel like when you are really busy and trying to provide safe care, you have to prioritize and it just wouldnt have been a priority for me to waste time fixating on an error like that one, where a single dose of pepcid was missed and no harm to the patient occurred and the mistake was fixed in a timely manner safely with the MAR and chart check per routine. Just my
    Flame away
  5. by   ******guest******
    no, i appreciate you honesty. i contemplated this--however, the nurse who didn't end up giving the HS dose (because it wasn't marked) is also working today and would have seen that this dose was added on by me and clearly wondered "wait--why I a giving an HS dose today and I didn't yesterday." The pt is on no other HS meds, so when the nurse goes to give her a dose tonight of a med, she's realize the error that had been made by the transcribing nurse. And this nurse coming on is VERY anal, so I didn't want thrown under the bus. Also, by my just having corrected what was written on the MAR, it could have made it seem like the nurse who didn't end up giving the HS dose (b/c none was marked) was in the wrong and forgot to give the pt their hs dose--and that's not fair, since the nurse was just following what was transcribed. Hope that makes sense. Thanks for your response!
  6. by   Jules A
    i'm with ya, icyounurse. if its paper charting and pepcid unless it happens often i'd probably just change the mar and give a discreet heads up to the nurses involved. if they want to do an incident report they can. the part that would really bother me is that the nurse that didn't know to give the med is the one that gets the error and that just doesn't seem right to me. i'll be interested to see the different opinions and maybe change my mind. :d
  7. by   suni
    You did the correct thing. The issue with incident reports is that we use to be penalize when we made an error. Now we have a culture of no shame , no blame. It is part of patient safety to fill out IR's for omissions. I also hate to do but yesterday I made a mistake with a med, a fairly significant mistake and I caught it, made out the IR and thankfully there was no harm.
    It is easy to become distracted when we are constantly being interuptted but if IR's are filled out, management will look for RCA and staffing may improve.
  8. by   Wund5
    This is a fascinating dilemna, and one which almost every RN will encounter sooner or later. In some hospitals and facilities, as long as you notify the MD- AND THE PATIENT of the missed dose,(as long as the pt. is cognitive) and neither party has an issue about it- you document that both parties are aware- and that there is no harm/adverse side effects- then there's no need to fill out an incident report. You d/c the original order on the MARS, and write the correct order. It seems every facility is different as to their policies and procedures concerning these type of occurrences, and even so, some nurse managers/supervisors will advise you to do something different from even the house policies. Usually you have to notify the house supervisor on night shift- and go according to what she/he says- sometimes, they will say-I'll take care of it or to proceed with policies accordingly. It seems you lose either way. Ultimately, the patient comes first, and your license second- you did the right thing. Hopefully the veteran nurse will be mature enough to not hold it against you or go for your jugular. Supposedly, "medication misadventures" are to be used as learning tools- not for purposes of punitiveness (unless of course, there was injury to the patient).
  9. by   TuTonka
    Quote from sweetie715
    So I caught someone's med error. I work night shift and have to check over the new orders. It was for pepcid, pt to get before each meal and at night, and the nurse who took the order off (we still use paper documentation) omitted the HS dose and therefore the next shift's nurse didn't give it, because it wasn't on the MAR to give as such. I felt like it had to e reported, because then whoever has to check the orders (me, in this case) would ultimately be held responsible for not reporting, and most importantly I had to end up fixing the order which of course couldn't be done without noticing the error. It wasn't a "big" error--no harm to pt, pepcid isn't that big of a drug, etc....but why should I put myself at risk for catching it and not reporting it.

    What would you have done? I just feel bad, I hate getting fellow nurses in trouble. Also, I'm afraid the nurse will find out who filled out the report (although I think they're anonymous....and the second shift's nurse could have caught it at the end of her shift and filled it out for all anyone knows) will find out I filled it out and she has been there forever and I'm pretty new and it seems the culture is "don't tell on your fellow nurses" where I work.
    At the very least you should have talked with your supervisor about the finds or nurse in charge.
  10. by   JB2007
    I would have to agree with the nurses that stated that they would not have done an incident report on this particular med and that they would give the nurse a discreet heads up. Where I work it is not unusual for someone to miss a dose of a med due to the med has not come from the pharm. or the family has not brought it in. If it is medications that there is going to be problems if one or more doses are missed I would probably write it up because I would have to call to doctor to change the dosing times. However, I am not going to waste my time or managements time writing up a missed dose of pepcid, ASA, or whatever med is missed when it is not going to cause problems with the resident. Sometimes we have to use a little common sense about these things.
    If this is a chronic problem with this nurse that is a different story. You have to start a paper so that he/she can get the proper education so that they do not continue to make the same error over and over.
  11. by   Straydandelion
    I would follow whatever the policy and procedure is of that facillity....if not done you can be in trouble along with others. A lot of P&P can point to facillity error, correcting reasons why there are mistakes can prevent future ones also. To be in a position where you go against the P&P would eventually point to you as someone not to be trusted by the facillity. Being open and honest never hurt anyone in the long run though sometimes can be uncomfortable short term. I would have let the other nurse know that I had to fill that out also reassuring her it was minor. Perhaps you can also discuss with the DON the policy of notifying the doctor and patient instead of an incident report for future reference. In my facillity only an incident report was filled out IF the doctor requested it after informing him of the error.
  12. by   NotFlo
    In this instance, I would have just fixed the MAR and left it at that.
  13. by   nurseeB
    I would have fixed it on the MAR and mentioned something to the nurses, but that is as far as I would have taken it. The whole point of chart checks is to catch anything that may have been missed. If missed orders/meds are a big problem on the floor then maybe they should go to q8h chart checks.
  14. by   MichelleB34
    You were certainly within your rights to feel out a report if that's what you felt was the right thing to do. At our facility our meds are profiled by the pharmacy. ie During pharmacy hours we can't take anything out of the pyxsis until pharmacy profiles the med (puts it into the computer). With the exception of a few select emergency drugs. We have computer generated MARS. When you come on to your shift you have to check your MAR against the kardex. If there is any difference or a new order is hand written you have to check the original order. Also at the end of our shift we have to run a report to check for any omissions. So technically the day nurse should also have an error for transcribing the order wrong. The evening nurse would have an error for omission and possibly for error in checking practice (at our facility) provided the order was transcribed correctly on the kardex. That being said I probably would have not made out an error report. It sounds like you work nights? If I had caught the missed dose early in the shift I might have chosen to give it. Otherwise I probably would have just fixed it and let the nurses know because it was only pepcid. But if it was an antibiotic or bp med that would be a different story.

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