Handling med errors


Hey guys, 

I am a new RN working in assisted living and I have a delimma. Today I was doing some chart audits and noticed some missing medication administrations from the same person this weekend. it appears that 8-10 people or more didn’t receive any medications for the morning shift both days. She says she “forgot to document” because of some crazy staffing issues. I continued to do an audit for all of October and found more. It appears that she is not charting or giving these meds either but she swears she gave them. All non narcotics. I just started in July so I really haven’t dug into anything like this before other than the med error here and there. I reported my concerns to the don who just started today, and the manager etc. my question is.. out side of med error forms and let the md and family know what do I need to do to make sure this never happens again and to protect my self? Is there anything else that I should be doing? 


2,453 Posts

6 hours ago, Goaldigger80 said:

. out side of med error forms and let the md and family know what do I need to do to make sure this never happens again and to protect my self?

The only way to make sure that this never happens again is to stop dong chart audits.  

You are in no position to make somebody else do their job.  

As far as protecting yourself- do your assigned task correctly.  If you are assigned to audit charts, follow whatever the written procedure is.



6,465 Posts

^ Agree. Do the audits if that work is assigned to you, fill out the audit tool and give it to whomever is actually in charge of what other employees do or don't do.

8 hours ago, Goaldigger80 said:

She says she “forgot to document” because of some crazy staffing issues.

Her reason is none of your concern, nor is whether or not her reason is plausible or acceptable.

8 hours ago, Goaldigger80 said:

let the md and family know

The only thing to which you can factually attest is that there is missing documentation.  And it is questionable whether that is your duty or not. It seems like it might be most appropriate to simply report to your superior (exceptions exist, of course).

8 hours ago, Goaldigger80 said:

what do I need to do to make sure this never happens again

You can't. And it is not your job to make sure it never happens again.

8 hours ago, Goaldigger80 said:

protect my self

You are not in any danger from anything based upon what you have written so far.


Marie Ryan

2 Posts

Specializes in home health. Has 7 years experience.

Hi - I can relate to you and wanted to tell you my experience in hopes of supporting you.  My first job as a nurse was at an assisted living facility.  I was the only nurse (the rest of the staff were CNA's) there at night, responsible for giving meds to 54 people.  If I had questions or problems, I had to call my supervisor at home.  It was very stressful, as most clients had more than one med, different types of meds, and at different times.   I made 4 errors in the space of a couple of months.   No patients were injured, Thank God.  The other nurse was downright mean and totally unsupportive.  She never tried to help me since I was a new nurse.  They gave me warnings and then they let me go.  The facility made me feel like a criminal.  It was awful and humiliating.  I thought I should quit nursing.  But after that I worked in home health and did very well, even earning Nurse of the Month!!  My point is that it could be the job is not right for you or something going on in your life.  Also the vicious cycle of errors creating anxiety, creating more errors.  In trying to see why I made mistakes, I realized I was terrified of not having a job (I was a single mom at the time), the workplace was hostile and not supportive of new nurses, and it was just too much for me to be giving meds to 54 people.  Right now, I am in an RN program and seeing how the hospitals are set up is amazing.  It is almost impossible to make errors because of the way its set up.  Scanning meds on the computer, fewer meds to give and better systems set up to double check meds with other nurses.  Please don't give up!!   Maybe do a different type of nursing for a while and realize that there could be stresses that you don't realize.  Wishing you all the Best!

Specializes in Nursing Education, Medication Errors. Has 43 years experience.

Marie Ryan-- LOVE your post and you are absolutely right.  I'm sorry you were traumatized by a hostile work environment and that you have found a place more fitting for your abilities and humanity.  

My heart goes out to you and to any other nurses, because we are all second victims of our errors. My research is focused on nursing medication errors and I can tell you this:

1. You were probably given the message in school that, if you are smart enough and care enough, you will not make errors.  WRONG. 

2. All humans make errors continuously-- I just made two typing errors while writing this post.  It is not reasonable to believe that, as nurses, we will suddenly get perfect.  

3. What really needs to happen is: nurses need to be taught how to spot the systems risks that make it easier to commit the all-too-human and inevitable error.  We can then alter systems to reduce the risk of errors. I bet that, if we talked about your incidents, you would find that packaging is dangerous, you were in a hurry, patients had similar names, you had a migraine, etc. -- all things that affect humans' ability to be perfect. We are not robots, a good thing,  but that also leaves us vulnerable to errors. 

4. All errors should be treated as learning experiences, nothing more. It's not win or lose, it's win or learn.  That's all you can do at this point-- and forgive yourself.  You cannot be blamed for being human. 

Anyone who tells you they don't make errors is lying.  I have 40 years behind me and have made plenty of them.  People who name, blame, and shame nurses for making errors are unethical and destructive to the profession. 

It's high time we started to support one another instead of committing horizontal violence at every turn!

Melissa Davis DNP RN

jlv613, RN

16 Posts

Specializes in Critical Care. Has 8 years experience.

This means so much to me. 
I just made a mistake today. Third one since working on my unit. Well, truth be told, I’ve made several but seem to put more weight and shame on the “big” ones regarding medication. 
the other mistakes we known and discussed. I was counseled. This mistake may never been known.... unless someone looks into the pump history.  The patient is OK. In a round about way I investigated possible scenarios and consequences. The drip remained running. For a shorty time, the drip ran at a higher dose, accidentally. 
with my previous two known mistakes and the general culture of shame and punitive punishment for medication errors, I felt terrified. Am I a terrible nurse? Another mistake? Is this the wrong unit? The wrong type of nursing? 
Reading this made me feel better. 
I can’t imagine other mistakes won’t happen. I’m human. To err is human. Yet where I practice doesn’t allow for multiple mistakes. 
I’m doubting myself. My competence. My safety. 
I wish all nurses and nursing units shared your sentiments. 


6 Posts

jlv613, RN...

I so appreciate your honesty, your reflection about what happened, and that you are suffering with this.  You are correct... we will always make errors.  In everything. 

There is something wrong in the system where your error happened. Use this occasion to think about what it is... are people rushed, not trained properly, inadequately prepared in school? is the pump not user-friendly? were you distracted by something?

The name of the game is to learn from our errors-- that's all we can do and frankly, I believe that absolves us somewhat.  Ideally, you could alert the staff about the risk, since it happened to you.  If all RNS had immunity when reporting errors or near-misses, there would be so much improvement in the system.  However, I appreciate that you don't feel safe enough to do that. Maybe someday when you're in management you can spearhead that effort-- a just culture of safety.

Try to make your own practice better by learning from this instance. And I'm glad you acknowledge that you are human, that these things happen.  I am here if you need more support.  And pass the word on to others-- you don't have to confess, but try to enlighten them. Especially when you hear them putting someone down who made an error.  It's always a SYSTEMS issue, not just one isolate person's doing. 




17 Posts

Specializes in Multi area, Behaviroal heslth , Infectious Disease. Has 16 years experience.

Hello, I have a similar issue I can’t seem to “start” a thread . Howver hope someone will see this. 1.) My pharmacy called me at 2:45 demanded I didn’t chart an Aitvsn 1MG for CIWA proton. I did I saw it my boss saw it and I said I don’t know what to say. I’ll call u back I had a lost note needed handing in, 4 pts at the desk and of COURSE the ONLY NURSe of 4 working. All are chatting about their weekend in the back shirt staffed by 1 to begin with. Lunches were altered and Neither if the med room nurses looked at their assignment and assumed their lunches were like the same as they were for the last 30 years they have been enjoyed same unit same place type deal. I called out for help , I was told no I am taking. I’ve asked the boss who confirmed that indeed this Ativan was charted. However , the pharmacy questions 1.) why I took it out( no no) and were is it why didn’t I wast “it”? I stated I don’t I have it to thr patient. Ohrch further demanded, I mean demanded that I fix my issue now. I can’t fix an issue that I didn’t have. I did chart he med. I charged it early but didn’t give it for another 45 minutes due to tasks and help and lunches etc. 

I went back to look. I charged a med early. I took out and Ativan at 1310 and then again 1345 a half our after. I did that so on my way to lunch I could get vitals and give this man what he needed. That was one hour and 15 minutes later putting me in proper protocol.  This man was sick as dog needs q1 he Ativan Because he didn’t have a 2 MG CIWA like he needed.

I went to charge nurse and MD several times. Documented that. I was asking for this change, and with fail it did not happen so I gave him 1 mg every hour per protocol , to cover my *** and this poor pt.
It ppears I gave it early and took it out. I didn’t I charted it in fear I would forget Becuse I was going straight to lunch a get idea it going down this mans throat. I knew with us having a 1 hour lunch which is silly, that he would be possibly DT risk.  The pharmacy forceful ly rude screaming, ASUMES that I gave that Ativan too early by 26 minutes. Reality is I took the med out had it in my hand Becuse I had no help and 4-5 requests and said I know no one Weill help this man on my 1 hour lunch which BTW I never even got. By the time I got back to the man gave the Ativan it was 2:10  I then went out fir 15 minute break. So here, the pharmacy calls me and DEMANDs I fix a charting issue when I indeed had charted it and the error reallly is I charted it before I gave it,it  took such a long time to actually give it to the PT. 
Pharmacy director is discriminatory and after me and treats me like NO other employee almost as if he audits me and looks for issues he can pick on me about. But that’s an issue of discrimination for another day. My manager : I said can u please help me u saw I charted the Ativan the pharmacist is saying I didn’t she is my witness’s. Then the issue now became oh it “was too early”what else am to do? 
 I changed the time to the time it was given. Which is allowed and done often at my place of work even this Should never happen and to me is fraud but often morning meds run late so have to change the time. 
 Moving on, my Manager suggests I get a 1x order from the DOC while she sits and fools around with other employees and talks about covid positive on another unit with another nursing instructor she knows from a college VS helping me in any way at all. She says get a 1x order from MD. I told her I didn’t need one I need to change my time to correct time. No scanners here folks. After 6 pages  49 minutes, and calls Dr called back I explain I don’t need it but the pharmacy and my boss demanding it. He puts it in, I chart it. I am about to go to HR and get fired 1.) my boss is lazy and knows nothing, 2.) I did I don’t need one and should have said no I changed the time all mistakes Becuse my boss failed to listen, I N turned questioned what was the right thing to do which would be change the time and make it what it was. I failed by listening to her! My boss was angry she had to get up of her lazy butt to do anything but socialize with her buddies in the chart room.
All other nurses doing the same in the chart room, no staff, short staff, mislead by my boss who said get a x 1order. So thr med never made it to the PT, until maybe 1.5 hours later within protocol but I made an errors charted too early out of fear I would forget at all due to workflow short staffed and no damn help or lazy nurses who entirely don’t do their own work and dump on me, I see my fault. We don’t have scanners, so when I chart a med I should wait. The pharmacy would still have an outstanding Ativan for their “report” which should be fine until th shift ends at 3:30 to begin with. So Becuse the pharmacy wanted to clear their slate at 2:45. And demand to know things none of their Work descriptions for their narcotics report and hand it in early or something? They decided  lI took Ativan out 39 minutes apart Assume things and now I’m screwed. . Assumed I gave it To the ot is disgusting, 

 I in fact didn’t for god another 45 minutes. minutes! 
I change the time to correct time. My boss says not good enough doesn’t listen or care says,  get 1x order and dumps me down a rabbit hole And going to HR to be fired for getting a 1x dowse after the fact when indeed as I stated to her and all I didn’t need one to begin with. She threw me under a bus to save herself when she never listened in the first place or misunderstood everything I said on top of pharmacy’s phone calls, shift notes list a new computer system in which I’ve worked on before but most others in my building have not. In fact most people here is the only place they ever worked and know no other real rules and laws workplace stuff than one PLACE.! In fact over the last three weeks I’ve counted 26 medications just for one nurse NOT charged including opiates. Never said a word, now all of a sudden Itkse out a med early and I am a criminal. This seems and I know it is unfair treatment. Harassment by pharmacy, and hostile workplace environment by aforementioned boss who picks and chooses who to listen too. I made a mistake  and listened to a boss who’s clueless and got a 1x dose after the fact. I admit that in fact I told her he didn’t need it. She didn’t care said in sst diem keot discussing food, pictured covid s they have nothing to do with my unit to another instructed she was friends with and other nurses vs taking any time to help me. Or she had to get up she was mad and that’s how it all went down leading me to HR to be fired still in progress I am out in stress leave I went out Cuse I sm beside myself. 
I didn’t need and even verbally told the doctor that order was bogus and didn’t understand it.  What should I do? 
I am indeed for some reason being discriminated against and can prove it. my boss is taking me to HR over the very thing she suggested and demanded I do. Set up? Or set up to fail? Feedback is so appreciated. 


6,465 Posts


You cannot put your own self and your patients in danger because of a dangerous, chaotic environment. Medications should not be charted before they are given. I'm sure there's probably some rare exception to that rule, but the bottom line is that it is generally not an acceptable practice for good reason.

When things are such that you cannot work safely, it's time to make decisions about whether it is an acceptable workplace--not time to find unsafe and inappropriate work-arounds. 

Your manager's demand that you obtain another order doesn't seem to make sense in the situation best I can tell, so I wouldn't have done that either.

When others (or circumstances/workplace culture) are a big part of the problem, it isn't your job to try to make up for that by any available means. I'm sorry you are in this situation.


17 Posts

Specializes in Multi area, Behaviroal heslth , Infectious Disease. Has 16 years experience.
21 hours ago, KKstillcares said:

Agree. It was ridiculous and my fault was doing it. I do go through meds chart and give as if scanning system Howver if I didn’t chart meds as they were given then many many meds wouldn’t be charted so I go through look at EMAR my recipt chart and pt outside waiting or go find pt one at a time. If it refused then I I chart the med and out refused. This is the absolute only job I have ever had that’s doesn’t scan meds. Something I need to fix. Unsafe is more than the ameer and yes I am out of work. Deciding Becuse their process isn’t going to change. Other people wait to chart their meds, have three peoples meds 40 meds all given and NOT charted. Equally wrong and dangerous with three diefderent people doing things. So the answer really is the place is awful and dangerous and I look bad for saying anything and of course the one who made the mistake so on ME. 



17 Posts

Specializes in Multi area, Behaviroal heslth , Infectious Disease. Has 16 years experience.

Update. It is eveident I do not fit the culture at my workplace. 
the accusations brought about forth were humiliating, defaming, harassing, FALSE! Union fighting  it. I never seen a more uncomfortable unprepared boss in my entire life. Who steps she has witnessed theirbwere none!! A drifter and one of her best friends of 25 years of working together. So it is evening my boss is nervous and unprepared with all hearsay BS. I couldn’t beleive my ears. I will be pursing state level charges and have documentation of them all. Hired my own lawyer Becuse thi my union reporesented me he too was unprepared. No Med error occurred…. All that came out of this mess. TY lesson to never ever work hard mentality and sacrifice charting for patient care due to short staffing. My boss had no freaking idea who was in charge snd that we were indeed short staffed and lunches were altered and that indeed is an issue in itself snd sets the example of how this unit is going down the tubes to be haptic and dangerous while she chats about life all day in the back thrn takes her other job as clinical instructor and works while we are on shift causing her to be further unfocused from her job. List is so long and sad and never ever in my wildest dreams imagine the lies that we’re said and I can never turn Becuse of that scary and never experienced this ever 100 great reviews now my work performance is bad? Bahahahah! Joke.