RN medicated my patient without documenting!

[poppy07]

I need some help regarding a situation in which another RN medicated my patient without documenting. This patient was seeking medication when I came to see them, and it had been well enough time before they were allowed medication (according to the computer documentation), so I administered the med. The other RN came by later on to inform me that they were going to chart on this medication that they gave earlier and noticed that I gave the med just a little while ago (and had never told me they gave it.) Now, this makes it seem as if I gave the medication too early after the other RN had done so because this person is able to adjust the time in the computer when they document. Best advice?

[otono]

I am having the same problem where the CNO made and order and gave it to the LVN for a medication that was not supposed to be administered to this pt. Now shes giving everybody a competency test for not catching her error. Shouldn't the LVN that was involded get tested and not everybody?

[RNgonewild]

Poppy, you're having quite the week. Good luck.

[leslymill]

This is one reason I want a preceptor that has gone through a class on how to do it.

[FireStarterRN, BSN, RN]

Does not much matter whose pt it was, bottom line is that a med was given and not charted, so the OP had no reason to suspect that the pt had been medicated. When medicating a pt I have NEVER checked to see when a med was last pulled, rather I have looked at the chart to see when the last dose was charted.

There's your answer. Your preceptor made a mistake and is trying to evade any blame and embarrassment.

[EmmaG, RN]

there are scanners in each pt's room. the other RN did not chart the med when administering. I have no idea why.

So, that means she didn't scan the med and patient... no wonder didn't think it was necessary to file an incident report

[Dolce, RN]

I hope you filled out an incident report. The bar code medication administration systems are designed to prevent this from happening. Research has shown that they have sharply reduced the incidence of medication errors. However, when a nurse bypasses the safety mechanisms of the system errors like the one you are describing happen. It sounds like the nurse did not use the system and is trying to place the blame on you, possibly because you are new. One of the hospitals that I work for has a policy that a medication error as a result of bypassing the bar code system is grounds for termination.

It sounds like you were in the right. Please fill out an incident report documenting what happened. Also, remember that even though the computer will input the time that she says the med was given it will also document when she charted that the med was given. This will prove that she charted after you gave the PRN med.