About a month ago I got written up for the first time, for a mistake make by the pharmacist that I reported. I've been at my job for about a year and a half working my first acute care nursing job on a TELE/ICU Step-down unit at our regional STEMI center. I work night shift and we are fairly understaffed and the administration "to streamline admissions" instated a policy that nurses on the floor are not entitled to report from the ED, we are just supposed to read through what minimal documentation is in the chart and hope for the best.
About a month ago I had a night where I got an ICU downgrade transfer and an ED admission at essentially the same time, the ED staff dropped the patient off while I was getting my downgrade patient settled and didn't notify me that the patient was here. Well the ED patient had come up on a Heparin gtt (hooked up and pump running) and between getting both of my patients settled, assessed, and safe, I wasn't able to really look into the heparin gtt other than confirming that the set units/hour on the pump was as stated on the order in the MAR, for about an hour. Once I had a moment to think, I realized that the heparin order made absolutely no sense as it was way way way too low to be appropriate. I double checked with a more experienced nurse that I was seeing what I was seeing and then called the on pharmacist and got the order corrected. In following with policy I filled out an RL6, our incident reporting system.
When I came in for my next shift about three days later, I was called into the clinical coordinators office and presented with a write-up for a medication error and put into mandatory heparin education (I don't disagree with the education). I agreed to sign that I had been presented with the write up, but I didn't sign acknowledging wrongdoing. I know I shouldn't be so bothered but now I have a write-up in my file for an issue that I really don't consider my fault, and that I did the necessary things to get rectified, the pharmacist had even admitted and put in writing that the error was on her side and not on the nursing side.
Any ninny knows that transitions are hot spots for errors. Not to give report is plain foolishness. The research on that would not be difficult to find. I would think Joint would take care of this bad practice.
Not your error. Pharmacy and the ER nurses error. Additionally, my experience as an ER nurse was i stayed at bedside til a RN showed up so they were aware their new patient had arrived.
The fact they left a patient on a heparin got without you being notified should be written up. We always do a bedside handoff wkt 2 rns to ensure it's not a mistake.
Exactly. You're kept too busy defending yourself to speak out about poor management practices. That's why I say keep a record of everything like this. You might not want to rock the boat while you're employed, but you can toss a few grenades on your way out the door.
And be sure to toss a few grenades towards Joint Commission and your BON.
These actions are so nonsensical and so obviously demeaning and discouraging that there is no explanation except that they are simply part of a culture of routinely doing things in ways that ensure employees feel powerless and effectively remain disempowered. That's all there is to it.
I feel this way about my current working environment, and this is so well articulated I just had to quote it. Thank you.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
On 6/9/2019 at 5:01 PM, ThatNurseThough said:
About a month ago I got written up for the first time, for a mistake make by the pharmacist that I reported. I've been at my job for about a year and a half working my first acute care nursing job on a TELE/ICU Step-down unit at our regional STEMI center. I work night shift and we are fairly understaffed and the administration "to streamline admissions" instated a policy that nurses on the floor are not entitled to report from the ED, we are just supposed to read through what minimal documentation is in the chart and hope for the best.
About a month ago I had a night where I got an ICU downgrade transfer and an ED admission at essentially the same time, the ED staff dropped the patient off while I was getting my downgrade patient settled and didn't notify me that the patient was here. Well the ED patient had come up on a Heparin gtt (hooked up and pump running) and between getting both of my patients settled, assessed, and safe, I wasn't able to really look into the heparin gtt other than confirming that the set units/hour on the pump was as stated on the order in the MAR, for about an hour. Once I had a moment to think, I realized that the heparin order made absolutely no sense as it was way way way too low to be appropriate. I double checked with a more experienced nurse that I was seeing what I was seeing and then called the on pharmacist and got the order corrected. In following with policy I filled out an RL6, our incident reporting system.
When I came in for my next shift about three days later, I was called into the clinical coordinators office and presented with a write-up for a medication error and put into mandatory heparin education (I don't disagree with the education). I agreed to sign that I had been presented with the write up, but I didn't sign acknowledging wrongdoing. I know I shouldn't be so bothered but now I have a write-up in my file for an issue that I really don't consider my fault, and that I did the necessary things to get rectified, the pharmacist had even admitted and put in writing that the error was on her side and not on the nursing side.
2 very serious red flags for this hospital.
1. Making a policy that you are not entitled to report. You really should not accept a patient without report. This is a lack of respect for your process as a nurse.
2. Write up for reporting something unsafe.
Either one of these is a reason to get out of dodge.
"Realistically, even though everyone is saying that I should be mad, I understand that the way the administration and power system at my hospital currently is, nothing I say or do is going to change anything. I'm just trying my best to change what I can, and accept what I can't so I don't make myself crazy in the meantime."
You must still fight the write- up. It was not your error. Write- ups will effect future job offers.
When I was a new grad, I worked on a floor that had a lot of politics going on. We had two managers, one of whom had been brought to the floor (for poor management) to work with the second manager. They hated each other, and we paid the price. On my first shift, I was told that "bad manager" would probably write me up at least once. She somehow thought this was making her look better, and showing up "good manager". Sure enough, week three. I can't even remember what the issue was, but I refused to sign it, told her I wanted an administrative review. She later dropped the write-up.
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Forest2
625 Posts
Any ninny knows that transitions are hot spots for errors. Not to give report is plain foolishness. The research on that would not be difficult to find. I would think Joint would take care of this bad practice.