Med Errors

Nurses General Nursing

Published

  1. Do you report every error you find?

    • 7
      Always
    • 40
      Sometimes
    • 9
      Never
    • 6
      I use another approach--please discuss.

62 members have participated

OK, so you're working along and you come across an error made by your fellow nurse. Let's say it's an omitted dose. Maybe the med was given, maybe it wasn't, but you can't tell because it wasn't signed off.

Do you report it every single time?

Specializes in Geriatrics, Transplant, Education.

Our computer med-pass system has a component called an omissions report. At the end of our shifts, we're supposed to check our omissions report, therefore if you missed a med, the ball is in your court as far as how to deal with it. On my shift, the usual med-pass times are 1600, 1800, 2000, 2200, but things can be easily missed if people don't check all med pass hours on your shift.

I once reported a fellow nurses med error..a patient reported to me (actually, the pt was a retired RN) that she had rec'd a pill on day shift that didn't look like something she usually took. She had rec'd another pt's BP med, thankfully with no ill effects, BP was stable, no new orders from her MD. I felt awful having to fill out the report, but it would have been on me if I never did anything. The nurse who made the error saw me the next day and actually thanked me for catching it. The patient herself said she felt so stupid because she knew her meds and knew she shouldn't have taken it.

Specializes in tele, oncology.

It depends on the med and on what I had to do about the situation. If I had to call and notify the doc about it, it's getting written up. If it's a Colace, well, I can just give that on nights and no harm, no foul. I always check the pyxis to see if the med was pulled or not first.

Specializes in cardiothoracic surgery.

Sometimes I just ask the nurse about it and sometimes I will filll out an incident report. For example, I found a narcotic drip programmed wrong and the nurse fixed it before she left. I still filled out the report because 1)I had found a similiar mistake a couple weeks prior (not the same nurse) 2)at the time, we weren't required to have a dual sign off when initiating narcotic drips, PCAS, etc. and I strongly believed that two nurses should be signing off when initiating medications like that. Incident reports should not be looked at as a way of getting your coworkers in trouble. They should be seen as a way of improving things. By this I mean, if there are certain errors getting reported more often than others (as in me finding these 2 drips programmed wrong within 2 weeks), then I would think that is a sign that something in the process needs to be changed. Why are the mistakes being made? What is wrong with the process that this nurse made this mistake? Another example is finding IVPB meds clamped and find they never infused. (I know every nurse has seen this) If this is never reported, nobody would know this is a problem and therefore would not look at reasons why it is happening and what can be done to make sure it doesn't happen. So my point is, incident reports should not be feared by nurses and I believe facilities should not be using them as "punishment" for nurses. Because if this is the case, nothing will get reported and nothing will get improved on. Now if there are multiple reports that involve the same nurse making mistakes, well, that is a different story. Oh, and we are now required to have a dual signoff when starting narcotic drips, PCA's, and heparin drips/boluses.

Specializes in Med/Surg.

Unless it's something major....I just speak to the nurse.

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