Med error documentation

[Ruger2014]

I forget. Why do we not put "no adverse effect" in follow up monitoring for a med error? I mean obviously you would want to put actual assessment info in the NN besides just that statement but why else?

[mrsboots87]

I've never even heard of notating a med error in the nurses note. Where I've worked and had clinical, there just a medication event form that is filled out and filed with whoever is in charge of them. The facility then usually buries it tonorotect them self in the even if an adverse reaction.

For charting, we never mention the med error. We purely chart an assessment like any other. If something is abnormal, we simply chart the abnormal finding and or intervention after contacting the physician. No mention of med error or implying we are monitoring for reactions due to an error.

[quiltynurse56, LPN, LVN]

Where I work, once we realize there was a med error, we assess the patient and take their vitals. We then fill out a medication error form and include our assessment on it. We also state what happened and why we think it happened. We notify the physician and the patient. We have our manager look at it, add any remediations to be done and fax a copy to the physician.

[wannabeny]

I forget. Why do we not put "no adverse effect" in follow up monitoring for a med error? I mean obviously you would want to put actual assessment info in the NN besides just that statement but why else?

It could be for legal reasons, couldn't it?