Nurse went "ballistic" over her medication error.......

Nurses General Nursing

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Hi all,

Just want to talk about why it is some Nurses (not all for sure), go absolutely "ballistic" when another Nurse has to make out a medication error report when an error is found.

Last weekend I found an error in a pre-op med that was to be given four times a day, for two days, prior to this resident's surgery on Monday morning. (The day shift Nurse did not give the med on her shift, for two days.)

I contacted the Doctor, who stated, "not a big deal, just get two doses in before the resident leaves for the hospital on Monday morning. We did.

But, I realized that this was an error that needed to be documented according to policy and procedure, so followed through on the right thing to do.

When the Nurse involved saw the report she went absolutely ballistic!! Started making all kinds of claims, accusations, and went into a tangled scenario as to why "this just cannot be so."

She's one of these Nurses and persons who can "do no wrong" and has been at the facility for 100 years now.

:rolleyes: But I have seen this same "reaction" by other Nurses during my lengthy tenure in this profession. What is that all about anyway???

Any of you experience the same with your peers?

Wondering, in Minnesota.

I think most nurses see the incident report as punitive rather than constructive. I realize it is policy, but the nurses who take things to heart feel very criticized when they get "written up".

Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

Also, unfortunately, there is sometimes a "tit-for-tat" mentality. Just as soon as you write a report, you have to be on the lookout for them writing one on you . Therefore SOME just never write the first one at all. Then there are some who write up only their "enemies" and never their compadres.

P

If the error is one that can easily be seen by anyone reviewing the chart, I write an occurance report-no matter WHO made the mistake-even myself. I figure if I don't, it could be seen as an attempt to cover up the error, especially if I am the one to fix it. If it can be fixed w/o anythoing actually having happened, I fix it and ignore it. ( Although I have occasionally written up someone with a pattern of serious errors, even if nothing happened).

I have never written someone up punitively or because I dislike them or had a disagreement with them.

some nurses see it as punitive because it is.

thisnurse,

How so? Occurrence forms do serve specific purposes. I agree that the "punitive" part enters in where people are entrenched in the power struggle game. It should never have to be that way - but we make it that way.

There are plenty of instances where occurrence documentation is definitely not necessary, but reaching that conclusion calls for good judgment skills.

Specializes in Pediatric Rehabilitation.

I never write anyone up for a minor error. I notify the doc. If it's no big deal, I fix it and let it go. All my coworkers do the same. We're all human and each of us WILL make a mistake sooner or later. The only "specific purpose" I've seen from writing up someone is it benefits management by keeping nurses bitter at one another. I've never heard management say, "you know, they are having alot of med errors on this floor...I wonder if they need additional staffing???". Nah, they DO use it to punish. If you need to know what causes med errors, just ask nurses. Keeping track of who and how many does not prevent more from happening.

I usually only write up incident reports on the things I do wrong and those things that happened prehospital. I have to agree with nurse4kids, these things are used by management to their advantage, not the staff's. Gary

I

In all the years I've been at this, I've never known a Nurse to be "punished" for making a med error.

However, I have seen management use it as a "tracking" tool for uncovering or fortifying evidence of a deeper and underlying problem that might exist. (an impaired Nurse, etc.)

I just think that if a Nurse is competent, and secure in her own skills she/he is able to recognize that the human element is always going to play a role in what we do, and having to document med irregularities is just a part of it all..........and there is no need to go "ballistic" over anything, unless the error is truly so horrendous the patient is harmed in some way.

Specializes in ER.

We use incident reports to track problems and to hlp us find ways of reducing errors. Recently we adjusted staffing on 3p-7p because of increased errors during that time.

We also deduct a percentage of the annual merit increase if someone has a pattern of errors- this is after counselling and reeducation have not worked.

:D

Good points canoehead.

A good case can be made for documentation of med errors.

The majority of Nurses understand the rationale for doing so, but I think the ones who get so damn defensive about it react that way for several reasons:

1. There are the ones who "can do no wrong", and when their humaness jumps up and smacks them in the face, it's too much of a reality check.

2. There are the ones whose expectations of themselves (perfectionist) is beyond reach, and the disappointment of discovering that "perfection" is an ideal to strive for, not a goal that can be reached, sends them into the stratosphere.

3. There are the ones who "might" even want to be "hiding" something....(diversion??).....and have reasons to be defensive.

4. There are the ones who are narcissistic and can't live with the fact that the "me, myself, and I" they worship is really only one french-fry short of a Happy Meal. like all the rest of us human beings.

5. And last, but not least, is the power-house Nurse who is the last bastion of "I have all the answers" on this Unit or in this facility, don't ya know.......who can't stand their achilles heel being exposed.

It's just interesting to observe human nature in action in our settings, that's all.

I'm not judging anybody, .........I'm the first one to admit that when that form has my name on it.......it "feels" rotten for a few seconds, but when I see I indeed screwed up, I own it, and move on..........always thankful that no harm was done!

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