HOMEWORK** others thoughts on incident reports

[BrnEyedGirl, BSN, MSN, RN, APRN]

Yes,...this is homework,....I have recently returned to school to complete my masters with the goal of FNP. I'm working on a root cause analysis paper and have noticed that I get different answers depending on whom I ask about how incident reports are handled. Yes, I have looked up my policies and spoken with risk management, however I need to discuss some differences between how we were all taught to handle situations vs the "real world".

If you have the time and would like to share I would love to hear others opinions on two different scenarios:

1. Pt has order for Morphine 4 mg IVP X one. The nurse caring for the pt, (for whatever reason) gives Fentanyl 50mcg IVP X one. The pt is not allergic to Fentanyl, has no adverse side effects and pain goes from 8/10 to 1/10 in 20 minutes.

2. Pt has order for Zofran 4mg IVP X one. Nurse (again for whatever reason) gives Morphine 4 mg IVP X one. Pt is not having pain, has Morphine listed as an allergy and states that Morphine "made me crazy", but denies rash or SOB from Morphine.

My questions to you are, are these situations handled differently? If so how and why? Do you tell both pt's what has happened? Do you fill out an incident report on both?

I'm curious if where you work and/or how long you have been working will guide your decision, so if you could include that info in your response that would be great!

Thanks to anyone who has the time to play with me!

[Rose_Queen, BSN, MSN, RN]

Both would get incident reports. Reason? There would be a heck of a lot of big time errors- getting the wrong med out of Pyxis (and why are you pulling something that isn't profiled?), narcotic discrepancies if pulling from the wrong cubby in Pyxis, somehow overriding the alert from the computer when documenting that the scanned med doesn't match anything pharmacy has profiled.

Both docs get notified. Who knows, the first might want to change the order since the fentanyl was so effective. Both just in case something happens, the doc knows a possible cause (especially with second patient).

A med error is a med error regardless of whether something adverse happens. And the incident reports would help fix system errors that could have repeat scenarios.

[Pepper The Cat, BSN, RN]

Both should be dealt with in the same manner. The mistakes were identical. One person was just a lot luckier than the other.

[P_RN, ADN, RN]

Occurrence report is just the facts. Nothing you know only from hearsay. The patients have their right to privacy so you do not tell one what happened with the other. Any thing you did not observe or hear does not go on the report.

For example a fall (Hospital patient): "Entered patient's room and found patient on floor. Patient has bathroom privileges. Bed in low position, siderails down on side nearest bathroom. Assessed patient, called physician who gave order not to move and to get stat hip and arm xray."

ANYthing else is handled by management or lawyer.

[BrnEyedGirl, BSN, MSN, RN, APRN]

Thanks everyone.