How to handle suspected med error?

[tokebi]

I did not think twice about it but now I wonder if I should've handled it differently.

Wrong medication was given during the previous shift. MAR was signed off correctly, but narcotics record showed otherwise. I talked to my supervisor, and we filled out an incident report. That was several days ago. Next time I went to work, I heard DON was investigating it. Then a co-worker asked me if I had called the nurse in question before writing the report. Talking directly to that nurse didn't even occur to me at the time.

I was just reading an old thread about med error and it came up again -- clearing up with the nurse in question directly before writing them up. I don't think filling out incident report is same as "writing her up" but regardless, should I have talked to the nurse first? Is that professional courtesy?

[Sparrowhawk]

Yeah ya should have....always talk to the other person first if possible...

[Double-Helix, BSN, RN]

Speaking to the nurse first probably would have helped you better document the situation and figure out the reason for the error. I'm sure the nurse would appreciate getting to share her side with you before being investigated by the DON. The incident report could have included what the nurse said, as it might help identify why the error occurred. But ultimately the incident report only needs to include what was witnessed by the nurse writing the report. Anything that the nurse said to you would have to appear in quotes, since you don't know that it is true. However you are right that am incident report is not the same as a write up. Incident reports are an internal tool for quality improvement. Write-ups are disciplinary.

[BeenThereDoneThat74, MSN, RN]

In hindsight (which is always 20/20 ), yes it wpuld have been a good idea. Although as a staff nurse, it may have put you in an awkward position. OTOH, she may be thinking you are a snitch. But you did what you had to do, and when you are talking about narcs, it's harder to 'fix' the issue.

IMO, an incident is different than "writing her up". An incident report states only the facts; no blame is supposed to be placed. O)f course, the pertinent names will be on there (hers, and most likely yours, for doing the count). The percieved "punishment" is what stops people from filling out incident reports, when in reality, they are supposed to be used as a PI tool.

[Esme12, ASN, BSN, RN]

Yes....you should call the nurse in question to enable you to get a good handle on what happened and whether or not the patient need to be re-medicated or medicated. BUt an incident report was the right thing to do. A lot of nut=rses view them as punative bu they are just the paper trail to ge to the root of a problem....

[tokebi]

I really wish I thought it through... The more I think about it, and after reading your replies, it would've turned out better for everyone if I called her, explained what happened, and had her report it herself if needed.

It's pretty sad that yes, the purpose of incident report is for improvement, but it often becomes the ground for disciplinary actions nonetheless. Wouldn't it be lovely to see the day when the non-punitive environment becomes reality and nurses are not scrambling to "fix" or cover up when mistakes happen? And so that there won't be any hostile feelings among co-workers when mistakes are discovered...

[miss81, BSN, RN]

Yes....you should call the nurse in question to enable you to get a good handle on what happened and whether or not the patient need to be re-medicated or medicated. BUt an incident report was the right thing to do. A lot of nut=rses view them as punative bu they are just the paper trail to ge to the root of a problem....

Depends on where you work. Where I work they sure can be punitive! And right now there is no consistency to how nurses are "handled!"

[noahsmama]

I really wish I thought it through... The more I think about it, and after reading your replies, it would've turned out better for everyone if I called her, explained what happened, and had her report it herself if needed.

It's pretty sad that yes, the purpose of incident report is for improvement, but it often becomes the ground for disciplinary actions nonetheless. Wouldn't it be lovely to see the day when the non-punitive environment becomes reality and nurses are not scrambling to "fix" or cover up when mistakes happen? And so that there won't be any hostile feelings among co-workers when mistakes are discovered...

I wouldn't beat myself up over it if I were you. Although I agree that trying to call her and get more information would have been a good first step, I don't agree that you should have left it to her to "report it herself if needed". You are the one who discovered the error, so you are the one that should report what you discovered. Calling her might have given you additional information that you could have added (in quotes, as someone else suggested) to your report, that's all. I think leaving it to her to report it would be a bad idea. What if she chose not to report it, but others later discovered the error and the fact that you knew about it and didn't report it? Saying "well, I called the nurse who made the error and left the decision about filing a report to her" would not cut it as an excuse.

Bottom line is you discovered an error, it needed to be reported, and you reported it. I see no reason for you to feel guilty.

[marthyellen]

The nurse in question needs to understand that EVERY nurse makes a med error at some point in her career. Any nurse who says they have never made a med error is either a liar or too stupid to know she made an error.

You found the error and you reported the error. It is the DON's responsibility to investigate.

[CapeCodMermaid, RN]

Anyone who finds an error or sees a fall or witnesses something can start an investigation. You don't have to wait for the DON.

[SuesquatchRN, BSN, RN]

Med errors need to be reported at the time of discovery for many reasons, not the east of which is patient safety.

We had a Coumadin screw-up a couple of months ago that involved five nurses over three days. It was an order entry error that multiplied. When we (the floor nurses and I) discovered what had happened we immediately figured out the why of it. I then wrote a med error for every nurse involved in the chain so we would have the entire system flaw mapped out. I brought it to the DON along with our solutions to prevent it from happening again. Within two days there was a new policy implemented and some of the people involved, specifically the LPN who discovered it and came up with the new system, were commended for their root cause analysis. No one was "written up," nor was it necessary to contact the originating nurse prior as we figured out how and why it happened.