Med. errors

night owl · Jun 26, 2001

unless they are obvious med errors, i'm willing to bet that most errors are not reported. it seems that when you tell the truth that you either gave the wrong drug, or forgot to give a drug, the reprocussions that go along with it are not worth it. who wants to damage their performance record? the incident report is filed right into your folder, and there it stays. i have one incident where the pt requested his restoril 30 mg cap. for sleep. i pulled out the restoril and no more 30 mg caps left so i had to give him two 15mg caps. pt sat at the med room door in his w/c waiting for it . gave it to him right there. meanwhile another pt came to the med room with a nose bleed. locked up the narc box quickly went to take care of the nose bleed. got him settled and another pt was yelling that he needed to be changed took care of him. after i finished with him, the other nurse that i was working with told me that the on coming nurse called out and she'd stay over to wait for the nurse who was coming to float to our unit and give her report. when i was finished i could leave early. well, i was happy. but did you see how i became sidetracked after i gave the pt the two restorils? one thing i did not do was chart on the narcotic sheet that i took out those two capsules of restoril. when the nurse came on and found the two missing meds, she had to call the supervisor and the police had to become involved because it was a narcotic. although i had mentioned in report that i gave restoril to the pt, charted it on his prn flow sheet in his chart, i did fail to chart it on the narcotic sheet in the med room. they could have called me at home to verify that i did give the meds, but they did not and alot of unnecessary work was created. the police were even pissed off because as they said if you know where the meds went to (even woke the pt up to ask him if he received the two caps of restoril which he repliied that he received them) why on earth did you get us involved if the nurse forgot to document it on the sheet?" because it was protocol was the answer. had the on-coming nurse not called out, she would have left me a note saying,"don't forget to chart the restorils that you removed for mr. so and so on the narc sheet" plain and simple and nothing would have been said to the supervisor, the police or even to the don. unfortuneately, this still goes on alot only it doesn't get reported like my incident was. nothing actually happened to me. i had to make out an incident report about the med error. pheeeeeeeeew !!!

P_RN, ADN, RN · Jun 27, 2001

'Tis why I LOVED the Pyxis med machine. NO drug counts!!

As far as med errors, I agree they probably all don't get reported. When you have a time frame, say 30 min before and 30 min after a due time, sometimes you go over that 30 minutes. No harm done and everything is OK. BUT technically that was a med error.

On the other hand if you hang a minibag of penicillin insted of Kefzol on a patient who IS allergic to PCN then there is no doubt that is an error. No amount of coverup is enough. You have to admit and report it.

Frankly I think nurses CATCH more med errors, prescribing and transcribing errors that is, than they commit. Not a day went by we didn't catch something that could have been an error. That's teamwork.

P

Smitty,RN · Jun 27, 2001

Precisely why we have a "near miss report" at my facility.

"Near Misses" are mistakes that have not reached the patient yet- i.e- wrong med transcribed on MAR, missed orders caught by nursing or pharmacy etc. We enter the problem into the computer and it goes to pharmacy, quality managment and risk management for immediate fix and tracking.

We have also have a completely NON PUNATIVE system for med errors- and unless there is a pattern- you will NOT be penalzied.

We write up the incident- not the nurse.

willie2001 · Jun 27, 2001

Wow! What a hassle over something that could have been avoided with a little communication. We just recently went to a non-punative system for reporting med errors and it seems to be working. We are all human and prone to error. A mistake shouldn't cloud your performance record for the rest of your professional career.

ohbet · Jun 27, 2001

No-punitive! Ive heard about that idea before and its a great one.If I suggested to the head of quality assurance where I work ,I wonder what she will say?

thanks for the response.