Need opinions please

  1. Hi everyone,
    Here's the story, one night I was crazy busy and I some how charted I gave a medication when in fact I did not. I really thought I did. I gave report in the morning to the oncoming nurse who basically told me she was going to write it up. I said ok and figured that would be done and everyone would know. Then a few weeks later I was pulled into the office and was told that I tried to hide my mistake by not going to my supervisor right away and telling her!? In my mind it was already reported when it was written up. I did not try to hide anything! So because of that I should not get a verbal warning I should be written up because I made the mistake then tried to hide it so that's a double offense?
    i don't see it this way and this by no means was my intent! What do you all think? Maybe I'm not seeing clearly? Thanks
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    About Caroline123

    Joined: Aug '16; Posts: 89; Likes: 159

    13 Comments

  3. by   Jolie
    I detest "write-ups" because they connote a punitive rather than a problem-solving mindset.

    I understand your belief that your "offense" was duly reported, since the on-coming nurse stated that she would write it up. It is a misunderstanding common among newer nurses who, unfortunately spend an inordinate amount of time and energy doing things "by the book" rather than being encouraged to understand the big picture. With a med error, often there is more concern for a missing signature in the MAR (to be discovered by patients, insurers and lawyers), than the implications for the immediate and long term effects on the patient's health, and how best to alleviate them.

    The on-coming nurse may or may not have actually followed thru (promptly or at all) on writing the incident report. Once written, it may have been a day or so before a supervisor read it and was able to go back and track what happened and how it was resolved. What was really far more important in the immediate term was for someone to assess the patient, determine the effect of the missed medication, collaborate with the prescriber, determine what action to take, and revise the care plan/MAR accordingly. This is what I believe your supervisor is getting at. You may have done those things. Your post isn't clear, so I can't say for sure. But when you realized your error, this is what I would have recommended that you do so that all aspects of the situation (patient outcome and your own learning) were clearly defined. Then, by completing an incident report yourself, you could have indicated in writing that you had done everything possible to protect the patient and hospital.
  4. by   macawake
    Quote from Caroline123
    one night I was crazy busy and I some how charted I gave a medication when in fact I did not. I really thought I did. I gave report in the morning to the oncoming nurse who basically told me she was going to write it up. I said ok and figured that would be done and everyone would know.
    At what point in time did you realize that the medication you'd charted as administered had in fact not been given to the patient? Was it as you were giving report to the oncoming nurse? Did you inform her about the fact during report?

    I'm not sure what "basically" telling someone something means? Either the oncoming nurse said that she was going to write it up, or she didn't say it. Anyway, if you make a medication error (and every nurse will at some point in time), I think that the nurse who made the error should be the one to inform the supervisor (or whomever the hospital policy states one should report errors to). It's something that in my opinion shouldn't be left to someone else to do. Reporting yourself shows accountability and that you accept responsibility for your actions and it also ensures that the supervisor gets all and the correct information/pertinent details.

    Didn't you wonder about or ask questions about the outcome of the incident during the weeks that passed between the med error and the time when you were pulled into your supervisor's office?

    I know exactly how crazy shifts can be and the stressful environment we work in can certainly contribute to medication errors being made. You can't change your past actions but if something similar happens again, make sure that you're the one who informs the supervisor.
  5. by   Caroline123
    Yes I did not find out about the error till I was in my car going home and the nurse called me and said the medication was not taken out of the Pyxis. I was surprised and told her that she then has to go by what the Pyxis says.
    Also, the medication was a scheduled Toradol, the patient was not harmed and the med was then given by the oncoming shift.
    i feel horrible about what happened and I have worked there for 10 years and never had an error or write up. I recently transferred to a new floor and my supervisor made sure to let my new supervisor know that I "tried" to hide it. So now I am put in this light of having questionable morals and it's very upsetting.
  6. by   oncivrn
    I am more worried about your colleagues' behavior than the fact you forgot to give a toradol injection. Sheesh. I can't count the number of times I got report from night shift and the 0600 meds weren't given. Happened all the damn time and I never once thought of writing someone up for it. Just gave it when I walked in the room. And I sure would never notice if something was or was not pulled from the omnicell.
    I guess if he patient was in pain and the oncoming nurse decided to investigate I can see why she called you. Otherwise, move on. Do your job and you'll be fine. Really.
  7. by   loriangel14
    [What was really far more important in the immediate term was for someone to assess the patient, determine the effect of the missed medication, collaborate with the prescriber, determine what action to take, and revise the care plan/MAR accordingly. ]


    OK this is overkill I think. It was just one missed dose of a med. I wouldn't sweat that much over it.
  8. by   kaylee.
    I agree, now that we know it was a missed toradol that this was overkill. The chain of events and the actions of the oncoming nurse were really intense.

    If it was a critical timed drug that if missed could endanger the patient, then yes, set off the alarms...but things like a missed toradol, or the 0600s are not given, happen ALL THE TIME. She could have just given the toradol, do the incident report, and moved on!

    I mean what did she say that made the mgr conclude that you were trying to cover it up, when it was far more likely an oversight?

    I would have my guard up about this nurse, she is either really punative and competitive, or just really anxious and irrational.

    I would go try to clear things up with the manager. explain the mistake and you can write an incident rept too, to explain on your end, and it should hopefully blow over!
  9. by   BSNbeDONE
    I would not make a big deal over a missed medication. If I find a missed dose at change of shift or shortly thereafter, I give it and send a communication to the pharmacy for a schedule change for subsequent dosages...over and done!

    As for a nurse covering it up or appearing to, well, we'd need to know what kind of documentation system the OP's hospital uses. If it's like ours (EPIC), there are quite a few steps and hard stops to overcome in order to document a medication as given without having actually scanned the medication.

    Each one of these steps is a reminder that hey, it's easier and quicker to just go get the darn drug and scan/give it, than to go through all this red tape to explain why you are here at the computer without the drug in hand....unless the med barcode is simply unreadable by the scanner.

    If the latter is NOT the case, then yes, it would look like a cover-up. If the documentation is via pen to paper, oversights are much easier....hence the induction of the eMAR.
  10. by   Caroline123
    Thank you everyone for the responses!!!
    i really do feel bad about the mistake and the thing is if I did something that harmed the patient such as give the wrong med or too much I would have stayed over and told my director right away! I just did not think it was that huge of a deal. And yes I know this nurse very well and new for sure she would write it up! She is known as the unit bully!
    The thing that bothers me is that my supervisor even had to tell my new boss what happened? I guess to put a flag on my character or whatever. Kinda crummy I think. Oh well nothing I can do.
  11. by   Nurse Beth
    Do you have bar code scanning? I'm thinking not.

    Be sure and identify "how" such an error can occur to help prevent it in the future. Follow the same process every time, which includes documenting medication administration after the med is given.

    Safety checks and standardizing your practice will save you on days when it's so busy that you are almost set up to make an error.
  12. by   Caroline123
    Yes we do have barcode scanning but I must have just hit administer without scanning. I must have because I never even took the medication out of the Pyxis. What I have learned is that when it is really crazy that is the time I must slow down.
    i may have made a mistake but I in no way tried to hide it! AND for someone to imply that I did I reject totally
    A mistake is one thing, lack of integrity is entirely a different story.
  13. by   AutumnApple
    Quote from Caroline123
    Yes we do have barcode scanning but I must have just hit administer without scanning. I must have because I never even took the medication out of the Pyxis. What I have learned is that when it is really crazy that is the time I must slow down.
    i may have made a mistake but I in no way tried to hide it! AND for someone to imply that I did I reject totally
    A mistake is one thing, lack of integrity is entirely a different story.
    It's important to look at this as a learning experience. You're not fired, and if you avoid having a track record or repeated episodes of the same behavior, you should be fine. Not being fired means you have a chance to grow from this. Jumping over the verbal and going straight to the write up means something else entirely.

    It means they want you to know this is not a slap on the wrist, its more than that. Something happened that they are not going to fire you for, but they are not going to tolerate this becoming habit either.

    Look at your write up abstractly, not concretely. Ask yourself what is the spirit of the lesson they want to teach you. Don't get caught up in the lettering of the write up or the rules of verbal vs written.

    Going by what I highlighted up above in your quote, I can see why the write up. "Just hit administer instead of scanning". There is a term for that: Bypassing system safety features.

    Bypassing system safety features is a habit many of us fall into. Once you're in that hole, it's hard to climb back out of it. And its one of the things accrediting agencies love the slam administration about. There are committees that focus much energy on this exact issue, not scanning meds (and other bypassed safety features).

    Your write up is probably a result of them being under the impression that you do much of this, not just with med passing. The spirit of what they are communicating to you is to clean up the bad habits, eliminate short cuts and perform efficiently without mistakes such as this one.

    Ironic part is, most of the short cuts people invent to speed things up end up slowing us down more than anything else. Then you end up in this endless loop of working twice as hard to avoid the little bit of work that would have taken half as long in the first place.

    This time around nothing happened. But, if you continue with shortcuts such as not scanning, more likely than not, something eventually will. And when the facility sees the mistake may have occurred because you were taking shortcuts...........they will have no way of defending you.
  14. by   Caroline123
    I guess that would be true if a person habitually does that! Except that I have a 92 percent accuracy in scanning according to the hospital. And have no track record period over 10 years.

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