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Discussion

How many is too many? Medication errors

I work with a nurse, we'll call them Leslie, (not their name btw). This person has had a ton of medication errors, mostly not giving narcotics. We still use the paper sheets for narcotics, not a computer pixys system. The MAR will be signed, but not the narcotic sheet and therefore, if the count is correct, the med wasn't given. I know of at least 19 medication errors in a few months. Myself and others have gone up the chain of command to the director of nursing and administrator. Leslie has had several write ups by their own admission. How many is too many? I'm in no way implying that I am perfect. I have had a medication error or two in my career. Some staff dread seeing Leslie on the hallway, because we can almost bet there will be mistakes. I could totally understand one every now and then as we are all human, but 19? I'm not understanding how Leslie still has a job and a nursing license.

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To be honest- that's none of your business. If you've presented the FACTS to management then it's out of your hands. You need to stay in your lane and not speak about this nurse on the floor to other coworkers, that is gossip- you can find yourself in hot water over that.

If this is such an issue for you that you find it difficult to do your own job bc you are closely watching this other nurse, then maybe you need to work somewhere else. Like I said, unless you are management there is nothing more to be done on your part.

I think the previous post was a bit harsh, but it is true...really there's not a thing you can do about it once you've passed the facts on to the right hands. If his/her mistakes are affecting you then that's what you need to be concerned about. As a nurse, I've learned - just protect YOUR license and the patients. If coworkers are making mistakes, report it professionally and step back out of the way and stay out of it.

I think the previous post was a bit harsh, but it is true...really there's not a thing you can do about it once you've passed the facts on to the right hands. If his/her mistakes are affecting you then that's what you need to be concerned about. As a nurse, I've learned - just protect YOUR license and the patients. If coworkers are making mistakes, report it professionally and step back out of the way and stay out of it.

I did not mean to sound harsh- for someone to count a coworkers errors is harsh, and quite frankly it sounds like a witch hunt on this nurse at this point. People get too concerned with what others do and cause tension- but it's just like you stated, it's about protecting your own license and focusing on what you are doing.

There are two sides to every story, and then the truth lies between those two points. I have a hard time believing that when narcotics are involved, management has not intervened.

  • Admin

It's quite possible that management is working behind the scenes. Disciplinary records are between the employee being counseled/written up/etc and the manager and HR. They are not at liberty or required to inform the rest of the staff of what may have happened behind closed doors.

I did not mean to sound harsh- for someone to count a coworkers errors is harsh, and quite frankly it sounds like a witch hunt on this nurse at this point. People get too concerned with what others do and cause tension- but it's just like you stated, it's about protecting your own license and focusing on what you are doing.

There are two sides to every story, and then the truth lies between those two points. I have a hard time believing that when narcotics are involved, management has not intervened.

Very true. I agree. A lot of times we don't always see what mgmt is doing behind the scenes.

To be honest- that's none of your business. If you've presented the FACTS to management then it's out of your hands. You need to stay in your lane and not speak about this nurse on the floor to other coworkers, that is gossip- you can find yourself in hot water over that.

I disagree with this based on your reasoning, although I would still reach the same conclusion because I don't want to be "that person." As licensed nurses, we are held to the standard set by the BON, not just the management of a location you work at. If management isn't doing anything about a nurse who is still continuing to commit an excessive amount of medication errors, it isn't "wrong" to take this up another step. However, if you take it further, you will develop a reputation at the place you work at and management will definitely not like you. When we are dealing with facts that can be proven, those facts are not considered to be gossip as long as they relate to the job at hand.

I work with a nurse, we'll call them Leslie, (not their name btw).

When referring to a singular person, use "him or her," not "them." "Them" makes reference to multiple people.

My own response to this would be based on the degree of the error committed and the frequency of errors committed. If a nurse is making an error every single shift he or she works, I would consider that to be excessive regardless of the degree of the error. Outside of some obvious parameters, I would say that discretion is important when deciding when to escalate something.

  • Author

When i go to the narcotic book to sign out the dose I have to give, and I see that the previous dose wasn't given, what am I supposed to do? The responsible thing to do is bring it to a managers attention, which I do. I apologize that it appears I'm on a witch hunt, I am not. I have found my own medication error and brought it to the managers attention.

When i go to the narcotic book to sign out the dose I have to give, and I see that the previous dose wasn't given, what am I supposed to do? The responsible thing to do is bring it to a managers attention, which I do. I apologize that it appears I'm on a witch hunt, I am not. I have found my own medication error and brought it to the managers attention.

Narcotics are serious business. Even the smallest thing is a "must report." Because if you don't report it and the person after you does report it, guess who is taking the heat?

When i go to the narcotic book to sign out the dose I have to give, and I see that the previous dose wasn't given, what am I supposed to do? The responsible thing to do is bring it to a managers attention, which I do. I apologize that it appears I'm on a witch hunt, I am not. I have found my own medication error and brought it to the managers attention.

Isn't an incident report the next step, along with notifying physician? Also, if this nurse is missing narcotics I am wondering about other missed meds such as BP, DM, antibiotics that have been missed. Are you finding extra doses of these meds?

When i go to the narcotic book to sign out the dose I have to give, and I see that the previous dose wasn't given, what am I supposed to do? The responsible thing to do is bring it to a managers attention, which I do. I apologize that it appears I'm on a witch hunt, I am not. I have found my own medication error and brought it to the managers attention.

I think this is a question to direct to your manager.

  • Author

Extra doses of psych meds have been found on occasion.

I have several questions about this situation.

Do you do narc count after each shift? Are the narcs missing or is she just signing that she gave them but not actually giving them? (My previous facility had the same type of system, paper MAR, paper narc count). From reading your post, I'm gathering that she is possibly hurrying when she signs off on her meds and is signing that she is giving the narc, but not actually giving it, correct? So the narc count is correct but not the documentation?

As long as you have reported it to the powers that be, there really isn't much more you can do. I dealt with something similar and the nurse in question eventually quit. If you feel the client's rights are being compromised, you can always report it to state. This is a drastic step, but sometimes what it takes to make something happen.

To me, it sounds like she needs to slow her roll a bit, especially if extra pysch meds are being found. She's not taking the proper amount of time to give meds correctly.

Oh, and as a comparison, I was in charge of writing med errors at my facility. I wrote 52 in one WEEK on a nurse and she kept her job. Med errors were considered separate from disciplinary action (they were actually considered a "teaching occurrence" and the med aide/nurse was supposed to document steps to prevent the error from happening again). I wanted to bang my head on my desk multiple times.

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