Is this really a med error?

[gemini14]

Hi!

I work at at Methadone Center. Mon 6AM the 2 RNs (myself included) attempted multiple times to open our safe and retrieve the necessary medication to begin our daily doing of outpatient clients (they call them clients rather than patients here). After multiple attempts by both nurses, we were unable to unlock safe. We contacted our supervisor at home via cell and were given instructions to contact a locksmith and have them come ASAP to open the safe. The locksmith arrived at approx 06:40, by 0930 they had opened the safe and we began our routine of daily doing. Clients that had arrived while safe was NOT open were informed of situation, given the clinics number, instructed to call back to see when/if safe was open and they could return to dose later in the day. At the end of our work day, 2 clients had called to let us know that they would not be able to make it back to clinic- two never informed us of their decision to not return that day. This information was communicated to DON by our supervisor. She (the DON) then insisted that we were to fill out medication error forms for these clients. We told our supervisor that we would be very glad to fill out whatever Occurrence/Incident form they desired to document what had happened that day, but would not fill out med errors as we did not believe there was a med error! Our supervisor informed me that the DON had told him it would be insubordination if we do not fill out a med error for each client that did not dose on Moneday., and I quote, "Any beginning nurse know that this is a med error"- I have been a nurse for >29yrs, my co-worker have been a RN for approx the same # of years. I guess my question is....IS THIS A MED ERROR? WOULD YOU SIGN ONE? WHAT SHOULD WE DO? She expects this from us on Moneday. Help!!!

[gemini14]

Thanks everyone. Came down to signing the Med Report or looking for new job....so we signed....(wimps). Was very illuminating how the DON's attitude was regarding at fault...then threatened to report each of us to the Ky Board of Nursing...as since they were not received in 24hrs, we have made an illegal act according to the "Nursing Process". Love my job....LOL!

[Jaade]

The original purpose and what I was taught is that the error reporting isn't meant to assign blame even if you interpreted the error as being caused by the nurse forgetting as opposed to an unavailable med due to something outside of the nurse's control. The reports are supposed to be used to analyze data and identify system failures. It wasn't supposed to be punitive, because that would discourage people from making reports and providing the input needed to reduce error rates.

It seems that more and more they are seen as a punitive action, even managers use them in that way, unfortunately. Anyway, that wasn't my opinion, but that of a few references I found that came from credible sources.

This.

Also, I was once told by a dr/former medical director that JC looks hard at facilities that report very few med errors because they know mistakes are being made and assume they aren't being caught or reported when there are too few.

The hospitals I work at seem to take this as intended and I only know of one nurse being called to the carpet for her errors (which were numerous).