Med or documentation error?

[Ms Mischief]

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?

[luvmy3babies]

Hi,

This could be considered both in some places. Just learn from your mistakes and NEVER sign the Mar ahead of time that is a big Stateboard and Joint Commission no-no. Sounds like this nurse was on a witch hunt and she found something and ran with it. Give her no ammunition next time. Why can't we help a fellow sister or brother when they are down? Besides we are in the best profession around.

[azhiker96, BSN, RN]

Hopefully nothing will come from this and you also gained some valuable information about your coworker. I learned a similar lesson a while ago. I was doing lunch breaks. In my PACU, a nurse will take report and watch another nurse's patients so she can have lunch. I had admitted a pt from surgery and completed the initial assessment along with telling the hus to order a bed. The nurse came back from lunch, I gave her report and headed to my next lunch relief. 45 minutes later the hus yelled out my name and came to where I was relieving another nurse for lunch. She asked why I'd cancelled the bed for that first patient. I said I hadn't cancelled any bed. She said bedboard had called asking why the bed order had just been cancelled by me. We went back to where the first nurse was charting on the patient and asked if she'd cancelled the order. She said she hadn't cancelled anything. Then I pointed out my name at the top of the computer screen, I'd forgotten to log off when I left. I took the mouse, closed the chart and asked the hus to reorder the bed. I also made a mental note to always close my chart when giving report to the next nurse.