Med or documentation error?

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Last week, I was working with a nurse I had never worked with before. 8 hours into my shift (2pm)I get a call that my son fell off his skateboard, so of course I wanted to come home asap. Now, I have never once in the 2 years I have worked at my hospital had an emergency that resulted in me going home early. This is not a regular occurrence.

Now, where I messed up is here. I like to initial my mars early, so I don't forget to later. If it happens I did not give a med or whatever, I circle it and write in why on the back. I will only do this to patients I know won't be discharged and are stable.

When I left the other RN's divided my patients. I'd had a discharge, so only had 4 pts. Of those only 1 patient that needed a peg tube flush at 5pm. All my meds had been given, this was the only thing left on my mar unfinished, yet initialed by me. The RN I didn't know well was assigned this pt. I gave her report and told her this was all that was left for to do. However, in my worry about my son and hurry to finish my charting, I forgot to cross out my initials on that one last peg tube flush. The other RN's were understanding, we work together and make a great team. It was just this 1 RN I didn't know who was very bitter about me leaving, kept mumbling about being stuck with this pt.

I had been gone for about 1 1/2hrs. when my supervisor calls telling me that I had initialed the peg tube flush as if I had completed it, that this other RN had come to her unaware if it had been done or not. I told my supervisor I hadn't given the 5pm peg tube flush (it's 3:30 when she called) and I was certain I had given this info in report. I apologized and told her it wouldn't happen again. She didn't sound upset and told me she'd let the other nurse know that it hadn't been done yet.

I know I'm not innocent here, but I am really annoyed. She did get this info in report and still lied about it, jumped chain of command and went straight to our supervisor, instead off the charge nurse. I haven't been back to work yet, I go tomorrow. I was wondering if this is considered a med error or a documentation error?

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Specializes in neuro, critical care, open heart..

I may be way off base here, but I think it could technically be considered falsifying documentation. You documented something that did not occur. Once again, may be way off base, but just a thought.:twocents:

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Specializes in ob/gyn med /surg.
I may be way off base here, but I think it could technically be considered falsifying documentation. You documented something that did not occur. Once again, may be way off base, but just a thought.:twocents:

yes falsifying documentation and you could be turned into the board for that.. never sign a mar ahead of time...

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Specializes in Acute Care.
yes falsifying documentation and you could be turned into the board for that.. never sign a mar ahead of time...

Ditto.

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Specializes in Peds Critical Care, Dialysis, General.

Unfortunately, I must agree wholeheartedly with the above posters.

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Specializes in LTC, MDS, Education.

Sounds like that "bitter" nurse is making a mountain out of a molehill. Watch her like a hawk. BUT.... you have learned a lesson here. Never chart anything in advance! Call me superstitious but you are asking for trouble. Patient may expire or be transferred . If you are written up, don't make a big deal out of it. Suck it up and agree not to do it again. Now relax*wine

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I agree with what everyone said. We don't use handwritten MAR's but aren't they suppose to be with you while you are administering the medication. It doesn't seem like it would take that long to initial them when you are giving them. We use computer charting and must have a computer at the bedside to check the patient wristband for name and medical record number against the info on the MAR on the computer, we give the med, then chart it in one swoop.

On the other hand was it just a normal saline PEG flush like 20-40cc? If so would it have been that big a deal to flush it twice?? Not sure of the pt situation.

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Specializes in ICU/CCU.

On my unit, whether or not the flush was done would have been secondary to the fact that you *charted* something as done when, in fact, you hadn't done it. It's considered falsifying documentation, and nurses have been suspended for doing it at my hospital. I would rather forget to chart a med than to get busted for false documentation.

I don't think that what happened with your patient is all that big a deal--I mean it was just a flush. But someone (like that other nurse) could make a lot of trouble for you over it if they wanted to. Whatever small amount of time you save by charting in advance is not worth the risks you are taking with that practice. I hope everything works out for you.

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Thanks for your replies. I know what I did was wrong and won't make the mistake of doing it again. I hope I'll get off lucky, because my supervisor knows me and didn't sound too concerned. We're told technically we can't pre-chart, but if it doesn't get done, we get little yellow sticky love notes from our auditor, so the don't make a big deal about it. Especially since we do paper chart and change of shift begins at 5:45pm, so it has happened to a few of us, that our mars are pulled to be readied for the next shift, before we've had a chance to sign them. No more of that though, I've learned my lesson.

I'm just upset that this person was such a witch and ready to make a huge deal of it. I guess I should have known better, I was told she worked for a registry through another place and applied at this place, but they didn't want to hire her, because she had a rep for causing drama. I try to make my own judgements, so didn't pay too much attention. Another mistake of mine. :(

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I was on the receiving end recently of a similar situation. I came on and the nurse told me she had not done a tx. I greed to do it, no problem. I really believe we are all to work together. I went to chart it and found it have been charted as if given hours before. I was able to adjust the time of the next tx. so the patient got what he was supposed to, and I charted my tx. It did not rock his world or mine but...

It does make me slightly concerned when following this nurse. Are things done or did she get busy and not do them, just charted she did? Please don't chart until something is done. The next person might be more nasty than I was. The nurse and I are friendly and it saddens me that I have lost some confidence in her.:sniff:

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Hi, nIn understand your position but i also undestand the other nurse's point of view. she is new to your environment, she too has a license to be concerned with, her ethics may differ from yours and you admit the two of you did not have a relationship. There was not trust established so why would she cover for you or assume that your process worked within the unit community? I would have felt a little "out there" Maybe even paranoid about being set up. The bottom line is you were in error and you got caught, "man up" thank the nurse that something really bad didn't happen. nanacarol

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Specializes in Oncology.

I never sign out anything before I do it. What if the patient dies or something completely random like that and you have meds circled that aren't due for 4 more hours?

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