Worried...caught med error but only CNA

bethin · Nov 15, 2005

Oh and you are NOT ever an ONLY anything. You are somebody who cares.

Thanks P_RN. I needed that. :)

Marie_LPN, RN, LPN, RN · Nov 15, 2005

That's why I assumed it was an error. The fact that the saline bag was empty but the powder was in the bottle. Is there a reason you would hang such a small bag of saline, other than as a flush? The nurse who hung it is a very thorough, caring nurse so I think it was just an oversite on her part.

I'd get a plain saline bag if all i needed was saline. I wouldn't use a med bag, and just use the saline part.

LoriAlabamaRN · Nov 15, 2005

I would like some nurse's opinions on this. About 2 weeks ago I was cleaning a pump after a pt. was d/c. I tore off the label that was on the saline bag w/antibiotic from pharmacy. I didn't get a chance to clean it at the time as a call light was going off. I went back to the pump and noticed that the antibiotic was not activated. I don't remember exactly who it belonged to, but I have a very good idea who. When I noticed it I went to the charge nurse who wanted to know who it came from. I explained to her I didn't know exactly as I had put the sticker in the shredder(which is kept locked). She told me to ask another nurse. When I went to that nurse with the antibiotic in my hand she told me to forget about it and throw it away. I feel that I made the wrong decision doing this. The pt. diagnosis was pnuemonia/bronchitis and had chronic lung problems. The antibiotic was unysyn. A week later it was brought up (not by me) and I was told to fill out a med error form. I am not a nurse(only CNA). Did I over step my bounderies by filling out this med error? I was pretty upset the day it happened. Not only did the pt. get charged for an antibiotic that was not recieved, but this pt. also has chronic lung problems. Should I just have forgotten about this? I know the nurse who hung the 'antibiotic' and don't wish to get anyone in trouble. I'm not trying to play nurse but I feel that I was completely disregarded by these nurses. Did I do the right thing? I feel that an error is an error and everyone makes mistakes. I'm torn. Any thoughts on this?

I would speak to your charge nurse (the one who told you to ask the other nurse which patient it was) and tell her that when you asked her, she told you to "forget about it and throw it away." Since the charge nurse obviously cared enough to want to know who it was, I would not have then followed the order of a floor nurse to do differently-the charge nurse is higher up in the chain of command, right? I just don't want you to then be blamed for throwing away the antibiotic, especially since now you have to write the incident up for (I'm assuming) the supervisor's files. You should also be very proud of yourself for catching this! I know that its hard to report an error on a nurse you work with, and sure, everyone IS human and everyone DOES make mistakes. She won't get fired over this, but since the health of the patient is the most important thing, the mistake must be noted. You done good!

HappyJaxRN · Nov 15, 2005

Hi there. I think you did the right thing. And I also think you should have been involved in filling out the report since you were involved. It doesn't put a black ball on your record though. Not to fear, it's your facilities' way of covering their behinds. Unfortunately mistakes are made and meds are missed. It DOES happen, but don't fret over it. Just be more careful next time. No one likes being written up or written about. I've been a nurse for almost a year and I've been written up once. I didn't like it either. It gets your attention and I can pretty much say, that same mistake will never happen again.

I used to be a CNA too and I think you handled the situation correctly by reporting it to your charge nurse.

rn/writer, RN · Nov 15, 2005

hi there. i think you did the right thing. and i also think you should have been involved in filling out the report since you were involved. it doesn't put a black ball on your record though. not to fear, it's your facilities' way of covering their behinds. unfortunately mistakes are made and meds are missed. it does happen, but don't fret over it. just be more careful next time. no one likes being written up or written about. i've been a nurse for almost a year and i've been written up once. i didn't like it either. it gets your attention and i can pretty much say, that same mistake will never happen again.
i used to be a cna too and i think you handled the situation correctly by reporting it to your charge nurse.

what is she supposed to be more careful about?

to the op:

this was a good catch on your part. the only thing i would recommend you do differently is that if you should run across something like this in the future, you call the nm or the charge nurse in to look at the pump and whatever bags are hanging before you tear off labels or discard anything. don't make any assumptions. just say something like, "i don't understand what i'm seeing. could you tell me if there is a problem here?" that passes the buck, but that's all right because it's their buck to handle.

it's not your job to protect the nurse in question. we all make mistakes and hopefully the nm will take a reasonable approach with the offender who will learn from her mistake. the best nms use errors made by good people as opportunities to educate the entire staff about booby traps waiting to happen. this particular type of antibiotic mixing bag can be tricky. first off, you have to remember you need to pop the cork. then you have to wrestle the sucker free and make sure you get all the powder down from the little bottle. this whole situation can be seen as a reminder that we have to be clued in to what we're doing, even on busy days, or the patients will suffer (not to mention pay horrendous charges for abx they didn't even get!).

regardless of your nm's reasonable attitude or lack thereof, you still have to alert her to the problem. she would be the one to know whether or not this is an isolated error with this particular nurse. if there's a pattern developing, she needs to see it and take appropriate action.

maybe more than one nurse has made this same mistake. then the nm should report to pharmacy who would in turn need to give feedback to the manufacturer. med packaging and labeling has undergone important changes after a number of perfectly capable people made similar errors with the same med. i'd like to see these antibiotic bags incorporate an inert dye that would make it very clear that the powder has indeed gotten mixed.

again, this was a good catch on your part. i'll bet that from now on, whenever you enter a patient's room, you'll give a second glance to those pesky antibiotic bags. if i were a nurse on your unit and you gave me a heads up about a bag i didn't mix properly, i'd be grateful for the opportunity to fix the problem while something could still be done about it.

HappyJaxRN · Nov 15, 2005

What is she supposed to be more careful about?

I think I misunderstood as to what was being said. Sowwy.

rn/writer, RN · Nov 15, 2005

I think I misunderstood as to what was being said. Sowwy.

No pwobwem. :)

bethin · Nov 15, 2005

Hi there. I think you did the right thing. And I also think you should have been involved in filling out the report since you were involved. It doesn't put a black ball on your record though. Not to fear, it's your facilities' way of covering their behinds. Unfortunately mistakes are made and meds are missed. It DOES happen, but don't fret over it. Just be more careful next time. No one likes being written up or written about. I've been a nurse for almost a year and I've been written up once. I didn't like it either. It gets your attention and I can pretty much say, that same mistake will never happen again.
I used to be a CNA too and I think you handled the situation correctly by reporting it to your charge nurse.

Thankfully, I did fill the report out. I named everyone involved. I don't feel so bad anymore thanks to you guys. THANK YOU!:balloons:

**RosesrReder, BSN, MSN, RN** · Nov 15, 2005

Not a nurse, but seems to me like you are very responsible and did the correct thing. :)

gypsyatheart · Nov 15, 2005

I agree w/the person who suggested having you go get the Charge Nurse if/when you come across this situation. My issue is, that you do not know for sure, which patient or even which nurse this was. You have a suspicion, but maybe it was from a dose previous to the shift you were even working on. I have come on to find abx, hanging, not given, (for a number of reasons), from the last shift. Just b/c I d/c'd the IV or pump or whatever, does not mean that I am the nurse who did not give the abx. See what I mean?

So, IMO, the correct thing would be to get the charge and put it in her lap. As for a med error report....again, how can one be filled out w/out knowing the pt's name or even the nurse who did it? If the charge investigated and found something to in fact warrant the write up, I think she is the one who should do it, listing you as the employee who found the med in question, adding your signature, as well.

Just my .02....

bethin · Dec 2, 2005

I agree w/the person who suggested having you go get the Charge Nurse if/when you come across this situation. My issue is, that you do not know for sure, which patient or even which nurse this was. You have a suspicion, but maybe it was from a dose previous to the shift you were even working on. I have come on to find abx, hanging, not given, (for a number of reasons), from the last shift. Just b/c I d/c'd the IV or pump or whatever, does not mean that I am the nurse who did not give the abx. See what I mean?
So, IMO, the correct thing would be to get the charge and put it in her lap. As for a med error report....again, how can one be filled out w/out knowing the pt's name or even the nurse who did it? If the charge investigated and found something to in fact warrant the write up, I think she is the one who should do it, listing you as the employee who found the med in question, adding your signature, as well.
Just my .02....

You bring up some good points. I tried to put it in the charge nurse's lap and she wanted nothing to do with it. Another nurse told me to throw it away and I left it at that. A week later it got out what had happened and the ICU nurse (who's also PT nursing supervisor and on several hospial committees) told me I should fill one out. I agree with you, I don't see why one had to be filled out because all I had was supsicions regarding pt., nurse, etc. It was a pretty vague report. The charge nurse nor the other nurse are aware that I filled this report out. I don't think that it will do any good. It can't be used in statistics since it's so vague. It's over and no one has said anything else to me about it. The next time though, the charge nurse is handling it because I don't do medications. Someone else who has the experience with meds and is running the floor needs to check it out, not a CNA.