Incident Reporting

canesdukegirl, BSN, RN · Apr 20, 2011

Oh wow. So instead of focusing on patient safety, this nurse decides to act like a child when you write an incident report. If this were NS or LR infusing, then I would probably have let it go. We all forget. But MAG?!? Oh, back up on that yellow brick road, Dorothy! Ain't NO WAY I am going to let that go! This nurse endangered her patient. Yeah, she forgot. She would remember when the pt starts having arrhythmias. When I administer Mag, I do so with the same vigilance as hanging blood.

You did the right thing. Unfortunately, you work with what sounds like an episode of "Nursing Mafia". There have actually been reports of cars being keyed? What's next? Planting drugs in your locker?

It concerns me that your NM did not take exception to this med error. You can't be sure if the Mag was infused or not. I can't believe that she told you that you should have just infused it. I also can't believe that the doc did not want labs drawn in order to establish current mag levels. I suppose his rationale was that the Mag was not infused...but what if it WAS and the NS just backed up into the bag hanging?

You did the right thing. I would probably start looking for a new position within the system you are currently working. It sounds like you are working with some questionable people who think that popularity is more important than patient safety. On the one hand, I hate that these immature nurses seemingly push nurses like you (vigilant, focused and SAFE) out of the unit, but on the other hand, I would rather work in an environment that encourages teamwork and the adherence to procedure in regards to medication administration.

NPinWCH · Apr 20, 2011

WOW, just wow! You were right in what you did. My first thought was that maybe the mainline had backflowed into the piggyback, but since you didn't get it in report, who knows. I probably would have tried to call this nurse as soon as I found the hanging MgSo4. If I couldn't get a hold of her, then notify supervisor and doc and see what orders he had.

Incident reports aren't supposed to assign blame. They are there to help ID process problems and prevent harm. You were right, the manager isn't. This is exactly the kind of reason an incident report SHOULD be filled out.

Maggie09 · Apr 20, 2011

I am so stinking SICK of childish behavior! Whatever happened to accountability and getting your butt called on something when you screw up? Augh, this makes me want to scream! Ok now I feel better. I had a bit of a rough day myself, so I needed to get that out. I don't think you were wrong at all in filling out the incident report. Hypothetically, if it'd been me, I would have tried to contact the nurse prior. But I have seen incident reports filled out for much "stupider" things than actual dangers such as failing to administer a med. This is one reason I kind of like bedside reporting--gives the oncoming nurse the chance to ask questions, look at IVF and IV sites, etc. And you'd better believe I'd raise bloody h*** if there's something in question and the off-going nurse is trying to play off a situation. Find a more supportive unit and a manager that has the you-know-whats to call people on their mistakes and shortcomings. No need to be punitive--anyone of us can and likely has done something similar, but I'll be danged if I'd stay on a unit that penalized ME for looking out for my patient's safety and let the nurse who made the mistake off the hook (and free to key cars! what a joke!).

Whispera, MSN, RN · Apr 20, 2011

I agree...this is exactly the kind of thing for which an incident report should be filled out. It might help correct a system error.

Everyone makes mistakes. Management should approach those who do, with a teamwork attitude of how do we make this better? rather than a rage that someone goofed. How does the latter help anything?

I think you did the right thing. It's a shame there aren't supportive people where you work, to back you up. Maybe there are some? If there aren't, please consider if this environment is emotionally safe for you, even if it would be safe from retaliation possibilies.

If I was manager, I'd be keeping my eyes wide open for any sign of threats and would confront as soon as I noticed them. I wouldn't let it keep on keeping on. I think your manager should do the same.

CompleteUnknown · Apr 20, 2011

Argggghhh don't you just HATE this sort of drama? And all for trying to do the right thing.

As for your manager screaming about it being a communication issue, perhaps as a result of the incident, ooops sorry the communication issue, she can institute a proper handover rather than the written thing where there is no opportunity to communicate with the offgoing nurse!

glutton4punishment · Apr 20, 2011

Thanks for sharing. If you feel you did the right thing, then you did. I would like for you to be my nurse, b/c you seem very thorough.

If that happened to me, I would have called the nurse first.

morte, LPN, LVN · Apr 20, 2011

It has been a lonnng time since I have worked acute care, so, how long would that mag bolus take to infuse? Since it was hung at 1042 and your floor didn't get the patient till ~1500, was the mag finished by then? Or would it have been still infusing? What was the rate on the IV pump? the bolus rate or the maintainence rate?

psu_213, BSN, RN · Apr 21, 2011

It has been a lonnng time since I have worked acute care, so, how long would that mag bolus take to infuse? Since it was hung at 1042 and your floor didn't get the patient till ~1500, was the mag finished by then? Or would it have been still infusing? What was the rate on the IV pump? the bolus rate or the maintainence rate?

Mag (in a non-code situation) is usually 1, sometimes 2, gram(s) per hour. One place I worked, the Mag would have been written for by the MD at 1042 and still wouldn't be up on the floor by 1500 (a pharm. issue). I don't think its possible to prove who did or did not infuse the mag.

Either way, an incident report is a must. An incident report is meant to report on an incedent (and hopefully a solution is found to prevent it from happeneing again...getting rid of the silly handwritten report thing would be a start). The report is not to "tattle" on a staff member. Shame that your coworkers do not realize that.

LouisVRN, RN · Apr 21, 2011

WOW! Incident reports where I work generally are just written to show that orders/policy wasn't followed. There isn't any blame. It just is a way of documenting what areas could benefit from improvement.

SilentfadesRPA · Apr 21, 2011

i listed what i thought was critical points of your post in bold and black and responded with my response in bold and blue :

looking for valued input - here is what i have to offer -

receive the handwritten report left by the evening nurse - ?

the evening shift leaves right at midnight

we receive their handwritten reports

not much in the way of overlap.

report looks brief and basic

horrible that you received no verbal report no walking rounds and i assume no phone numbers to contact off going staff

initial rounds - new pt. his iv pump is "beeping"

retrospect....beeping in the background when i arrived on the floor before shift change.

i noticed a primary of ns and an ivpb of mag sulfate - the bag was full.

mag sulfate? i didn't get in report that the pt had a mag sulfate bolus

found that the medication had been administered at 1042...14 hours after administration time

1500, the pt was transferred to my floor.

i call the physician he questioned why the delay. i had no answer -

a.)the med was never administered, or b.) there might have been backflow ... either way i do not know

i didn't get any information about the mag bolus in report.

i do assume that the medication didn't infuse properly

good initial assessment on your part with noted documentation of when a critical incident began and correct intervention

it appears...given the information....this is a medication error

i decide - to call the house supervisor ....would be documenting on it.

suggested that i file an incident report

thinking about quality assurance stuff ...take it down so there is no confusion

incident report was conveyed to the oncoming charge nurse

all complete and totally appropriate /reasonable actions on your part

started yelling about the incident report being filed

she said it wasn't worthy of an incident report and that it was a communication issue.

unacceptable response from day charge who rendered an opinion but not a corrective plan of action to error to correct a potential sentinel event

room is full of all the evening shift nurses- it is strangely quiet / not making eye contact

nearly all of the nurses....making comments to the nurse that had admitted the pt

comments like, "yeah, i know what you mean, that shouldn't happen to you" or "yeah, some people..."

with one other nurse present she confronts me, demanding to know why i wrote an incident report

i tried to explain to her - and when i indicated it wasn't in her report, she exclaimed, "i just forgot!"

clear example lateral violence and unacceptable leadership of charge nurse

but - if i'd had that piece of information, i might have handled things differently.

she stormed out and left she was acting as charge nurse.

she left no safety huddle sheet, other paperwork not filled out

she should not have left the floor when she did. we are required to have two rns on the floor at all times - last night when she left - it was just me and an lpn on the floor at shift change.

behavior that defines professional abandonment and gross dereliction of duty

she says i probably shouldn't have filed an incident report

because it was either saline solution or the mag sulfate in the bag.

she said i could have just infused the mag.

she also encouraged me to try to see this from the other nurse's point of view

that i should talk to her when this blows over (which i will).

all are entitled to opinions however what did supervisor direct you to do and what is policy of which it appears you followed

i've been cautioned about making enemies where i work.

rumors about others' cars getting keyed and vandalized

i'm concerned

i'm also concerned about retaliation

rumor has it that nurses on this floor will look for things

pick other nurses apart - especially when one feels threatened or attacked.

now we are talking about another situation that is a critical incident and entirely that requires action on your part for your safety

i'm a little afraid to even go to work.

i'm not sure what i will face, what kinds of attitudes and treatment.

i don't exactly feel supported my manager, either.

but, the best i can do is press on and hope for the best.

any thoughts-

this place does not deserve you and the patients deserve better

you did nothing wrong -nothing at all friend

consider your protection - regarding your safety personally and professionally -
this hospital is the definition of a hostile work place -
no professional should ever go through what you have gone through.
never mind scratches on your car but do seriously be concerned about and worried aboutabout being brought up on false charges as retaliation.

after much thought i suggest the following -

document everything you stated regarding what actions have occurred.

immediately - with no hesitation -give a written resignation but no work notice

send a copy of your detailed resignation to the don and hospital administration

file for unemployment citing hostile work enviroment

file a complaint and ask for an investigation with the bonregarding the nurse who abandoned patients without adequate / and left the floor against policy staffing ratios.

notify the state doh and jacho about the policy and method of reporting on patients at shift change

consider obtaining legal counsel for direction and advisement

conclusion and reasons for my rationale -

one may think this is over the top or dramatic however not when one considers the following both separate and in total :

serious and potentially lethal error of an iv medication

patient safety compromised by lack of adequate off going report

the very idea that a nurse has fear of retaliation due to historical rumors

the lack of support by a so called manager who clearly does not professionally

nurse manager is inept demonstrated by refusing to intervene with offending staff and more so refuses to insist on safe patient care and a safe working unit

duality of direction by manager/charge nurse and shift supervisor

willingness of nurses not to follow procedure /policy in reporting med error

willingness of nursing staff not to follow standards of care by the nursing profession

lateral violence by being yelled in front of others and tolerated by n manager

lateral violence by entire shift of nurses encouraged by a charge nurse

patient abandonment and serious violation of staffing policy

lack of report as a retaliatory action following incident

considering all the suggestions are not dramatic but ethical appropriate and sincerely suggested for survival.

when nurses do no longer tolerate abuse and show that there is accountability for such actions directed toward us and our patients that such abuse will stop. when put in such situations of dangerous compromise it is appropriate to have consequence and actions that proportionate to such risk.

negotiation and denial of the veracity of such situations not only tolerates but promotes that which is clearly never acceptable as a person or as a professional.

i sincerely wish you well and safety on every level - i hate that you have gone through this.

marc

fierceangel · Apr 21, 2011

You were completely in the right. We have these issues on our unit as well, and I've made it clear that I'm not there to make friends, but to ensure safe patient care and med administration. I'm a newer nurse (just about 2 years) and even newer to the charge position (4 months) and I constantly butt heads with the day charge (who has been there 35 years) when filing incident reports for things that were done incorrectly in the previous 12 hours.... but it is what it is.

Not to mention, you said that it was suggested that you complete an incident report - so why isn't everyone on the same page? Because they don't want a blemish on their record? I see incident reports as a tool for improvement, not ratting out. I wish others would get over their pride (because we've all made mistakes!) and work harder on improving their observations/skills/care for the patient.

Thanks for posting this - and letting me say my piece!