Med Error Report

ktwlpn, LPN · Dec 9, 2008

Hi I am updating our report of med errors- I want to include points for each error- for example if the medication is Tylenol it gets one point, if its antibiotic it gets 3 points etc.
Do any of you have a point system in use that I can look at?
I tried to Google and couldn't find ...
any help would be greatly appreciated!

Why would you want to do that? I would think that other factors related to the error are more important because then you can indentify a pattern. Severity is judged by the amount of harm to the resident,correct? A mistake is a mistake where I work-our policy is progressive discipline. First time is counseling by the supervisor-we review the incident report.2nd error within a certain time frame sends you to staff developement for training.Another one sends you to employee health -by then the stress of so many errors has driven you crazy if you weren't crazy to start with...Can you explain the pros of a points system? I'm not getting it...But I'm drinking egg nog...

CapeCodMermaid, RN · Dec 10, 2008

I agree. The point system seems to make no sense. It's more important to find WHY the med error was made and fix that.

achot chavi · Dec 10, 2008

Why would you want to do that? I would think that other factors related to the error are more important because then you can indentify a pattern. Severity is judged by the amount of harm to the resident,correct? A mistake is a mistake where I work-our policy is progressive discipline. First time is counseling by the supervisor-we review the incident report.2nd error within a certain time frame sends you to staff developement for training.Another one sends you to employee health -by then the stress of so many errors has driven you crazy if you weren't crazy to start with...Can you explain the pros of a points system? I'm not getting it...But I'm drinking egg nog...

I make mistakes everyday- not all of them in the area of medicine administration of course ( I don't pass the meds every shift) and I don't believe in stressing my nurses out just because they make an honest human mistake. Not all mistakes are serious- giving insulin to the wrong person is serious, giving antibiotics to a person with an allergy to it is also. Most of the form that I built deals with an explanation of how the error occurred and a care plan to reduce the chance of it reoccurring. We are usually very creative about the care plans and it helps.

But I don't want the nurse to feel demoralized because of it- most mistakes are not serious and therefor don't get reported - why report it when you will only get in trouble and the patient wasn't really hurt....

In fact a hospital near me put hidden tiny cameras in the nurses room and the med cart to catch unreported errors and there were plenty of them. If the points of the error is low then no disciplinary action is taken- but our Risk management folder is updated and corrections can be made to prevent worse mistakes. If the points are higher, we just do another in service for the nurses.

NO ONE gets "counseled" or scolded or punished. I don't believe in it.

I have sent nurses on a 3 day vacation when I see too many mistakes.... :coollook:

To me it is a red flag- my nurses dont feel like they have to hide mistakes or feel ashamed.

Noone has ever gotten stressed because we scolded them on a mistake.

Perhaps you're right and the point system is unnecessary- I will try it and tell you.

Enjoy the EggNog!!

ktwlpn, LPN · Dec 10, 2008

I make mistakes everyday- not all of them in the area of medicine administration of course ( I don't pass the meds every shift) and I don't believe in stressing my nurses out just because they make an honest human mistake. Not all mistakes are serious- giving insulin to the wrong person is serious, giving antibiotics to a person with an allergy to it is also. Most of the form that I built deals with an explanation of how the error occurred and a care plan to reduce the chance of it reoccurring. We are usually very creative about the care plans and it helps.
But I don't want the nurse to feel demoralized because of it- most mistakes are not serious and therefor don't get reported - why report it when you will only get in trouble and the patient wasn't really hurt....
In fact a hospital near me put hidden tiny cameras in the nurses room and the med cart to catch unreported errors and there were plenty of them. If the points of the error is low then no disciplinary action is taken- but our Risk management folder is updated and corrections can be made to prevent worse mistakes. If the points are higher, we just do another in service for the nurses.
NO ONE gets "counseled" or scolded or punished. I don't believe in it.
I have sent nurses on a 3 day vacation when I see too many mistakes....
To me it is a red flag- my nurses dont feel like they have to hide mistakes or feel ashamed.
Noone has ever gotten stressed because we scolded them on a mistake.
Perhaps you're right and the point system is unnecessary- I will try it and tell you.
Enjoy the EggNog!!

That egg nog was too strong for me-I went to bed early.True-not all mistakes are serious but in our facility the state dept. of health wants to see what we are doing to address each and every one-be it an aspirin,missed antibiotic or wrong dose of an antihypertensive med.They don't care.And once a med error report is generated it has to be followed up.Even if it's a multi vit we have to notify the doc,the family etc.. In years past often mistakes were covered up depending upon who was involved (more on that later) We don't do that any longer-we have to complete the documentation.I don't mean to imply that our powers that be stress us out-actually it is a very supportive and learning environment-not punitive.Counseling and staff developement have actually un-covered a few problems in the system.BUT-a good and caring nurse will stress herself out over a mistake-we tend to beat ourselves up. And it can be very upsetting. IN 20 yrs I have seen a few whoppers covered up-staff involved went on to seriously harm patients. In the past few years I have seen 2 nurses let go and a few brand new nurses not make it out of orientation.That's the way it should be-for the protection of our residents. Sheesh-if I get dementia my employers will catch it first-I hope..The way the economy is going it's likely that may happen. I won't be retiring as planned..I can see it now-I'll forget where I have left the med cart. Anyway- I would like to see an example of your care plan.man-it's hard to type with a kitten on your boobs

achot chavi · Dec 11, 2008

that egg nog was too strong for me-man-it's hard to type with a kitten on your boobs...
[color="red"]well if you're gonna have strong eggnog-expect company!!.
true-not all mistakes are serious but in our facility the state dept. of health wants to see what we are doing to address each and every one-be it an aspirin,missed antibiotic or wrong dose of an antihypertensive med.
absolutely- its the same everywhere- our russian docs and nurses claim that in russia- one mistake=being fired immediately!! reporting, following up on the patients status- including vitals, ekg, sugar levels etc. serious errors mean reporting to the sw and family- and perhaps doh. creating a careplan to reduce the chance of recurrance is to satisfy our risk management and ceo.
they don't care.and once a med error report is generated it has to be followed up.even if it's a multi vit we have to notify the doc,the family etc..
its up to our don if we involve the family- i think its ridiculous to bother them if its a multivit and a rare occurance. i guess it depends on the family- some want to know of every zit and cough and others don't
in years past often mistakes were covered up depending upon who was involved (more on that later) we don't do that any longer-we have to complete the documentation.i don't mean to imply that our powers that be stress us out-actually it is a very supportive and learning environment-not punitive.counseling and staff developement have actually un-covered a few problems in the system
.but-a good and caring nurse will stress herself out over a mistake-we tend to beat ourselves up.
too true, i wish our elected officials, ceo's, head of home security, etc. had consciouses like ours!!!
and it can be very upsetting. in 20 yrs i have seen a few whoppers covered up-staff involved went on to seriously harm patients.
its very rare- i could only report one that went covered up - a night nurse gave an unruly copd 98 yo woman an extra valium without an order and we found the pt dead in the morn, probably would have died anyway- the don decided not to report it, the fact that the nurse was a relative of hers i'm sure had nothing to do with the decision!
in the past few years i have seen 2 nurses let go and a few brand new nurses not make it out of orientation.that's the way it should be-for the protection of our residents.
usually if they are let go then the med errors are only part of the problem, the nurses that are let go exhibit other aspect of sloppy, uncaring behavior and are usually just accidents waiting to happen. when we have to let a nurse go we usually advise her to try a different branch of nursing, or update her education and skills.
sheesh-if i get dementia my employers will catch it first-i hope..the way the economy is going it's likely that may happen. i won't be retiring as planned..i can see it now-i'll forget where i have left the med cart.
thats nothing today i was searching for my keys that i found clutched in my left hand!!!
anyway- i would like to see an example of your care plan.

careplans depend on the problem. you have to do an assessment of the mistake. for example (true examples)

assessment: med given pg intended for one patient were mistakenly given to another. patients beds are nest to each other. names begin with "b"

goal: proper adm of meds

intervention: move beds to opposite side of room, not next to each other, consider moving one patient to another room, instruct nurse to avoid multitasking at the time of med adm. (no answering phones, no talking to others, etc.)

label cup with meds with patients full name- first and given

follow up in a month

another example:

assessment : pt given antibiotic according to doctors orders . patient with a known history of allergy to this antibiotic. patient immediately developed rash and hives to both arms and stomach. dr's order was written at 12:05 when the nurse was giving meds and monitoring lunch activity. dr asked that the antibiotic be started stat . pt was given med from another pts drawer in order to accommodate drs order. pts chart was appropriately labeled with allergy warnings in 5 different places

intervention: new policy- new doctors orders can not be picked up during mealtimes. in the event of an emergency, a second nurse who is not passing meds and monitoring the meal, should be brought to unit to help. under no circumstance should meds be taken from one patient to another except under the approval of the don or shift supervisor. patient given antihistamine and cream to rash as per dr. order, pts vitals to be monitored until stable for 3 days. no med can be given till it is properly signed for an transfered to the mar (which incidentally also lists allergies on top in red)

daily monitoring till stable. follow up in one month. inservice planned for this tuesday to discuss the error.

hope this helps.

CapeCodMermaid, RN · Dec 12, 2008

We only care plan RESIDENT issues. A nurse's mistake wouldn't be care planned.

PsychNurseWannaBe, BSN, RN · Dec 12, 2008

If you care plan an incident... doesn't that become a part of the patient's record... no longer making it an "in house" event that is to be investigated. Basically what I am trying to say is we never chart that we filled out an incident report... So doesn't creating a care plan for it defeat the purpose?

PsychNurseWannaBe, BSN, RN · Dec 12, 2008

Careplans depend on the problem. You have to do an assessment of the mistake. For example (true examples)
Assessment: Med given PG intended for one patient were mistakenly given to another. Patients beds are nest to each other. Names begin with "B"
Goal: Proper adm of meds
Intervention: Move beds to opposite side of room, not next to each other, consider moving one patient to another room, Instruct nurse to avoid multitasking at the time of med adm. (no answering phones, no talking to others, etc.)
label cup with meds with patients full name- first and given
Follow up in a month

Where I work the above written would be written on the incident report. If I were to make a mistake, I have to state what I did. Then in a spot on the report it asks us, what are some things that might have contributed to the event. (That would be you "assessment" data).

On our report there is a spot that asks us, what can you do or what are you suggestions so that this mistake doesn't happen again? ("intervention" area above)

I would like to say the this part, "Instruct nurse to avoid multitasking at the time of med adm. (no answering phones, no talking to others, etc.)" Would be next to impossible to do in our facility. Doctors call...family call...resident's are sent to MD appts...SW might need to talk with you about something. The med pass should not be interrupted if possible, but as many of us know... that doesn't happen, even though we would love to be left alone during the med pass. When you have 25 residents, you are constantly shuffling around.

achot chavi · Dec 12, 2008

We only care plan RESIDENT issues. A nurse's mistake wouldn't be care planned.

Not a part of the patients record, silly!, but a part of the med error report. The way I figure it- it clearly analyzed the mistake, and plans how to prevent them.

I could care plan anything in my life. When my teenage son has a problem, I teach him to think of it in 4 step- assess the problem, decide on a realistic goal, come up with a plan of action,( obviously carry it out) then evaluate the effectiveness of your plan to meet your goal. Sometimes when its written it keeps you on track. but it doesn't have to be written.

I never considered a care plan to be limited to residents issues.

achot chavi · Dec 12, 2008

I would like to say the this part, "Instruct nurse to avoid multitasking at the time of med adm. (no answering phones, no talking to others, etc.)" Would be next to impossible to do in our facility. Doctors call...family call...resident's are sent to MD appts...SW might need to talk with you about something. The med pass should not be interrupted if possible, but as many of us know... that doesn't happen, even though we would love to be left alone during the med pass. When you have 25 residents, you are constantly shuffling around.

That's the way things were done when I first came to the facility I work at, I have taught the SW's to tell the families that other than real emergencies, the nurses cant be interrupted during med pass. 95% of them understood and agreed with the rationale- after all they don't want a nurse making a mistake on their family member, the other 5 % I deal with- if I'm passing through the unit and a call comes in- I ask the family to call back in an hour. Sometimes the question is so stupid- "I just wanted to know which nurse is working today and who will be on this evening..."(yes I know that some families prefer some nurses over others etc- but to interrupt med pass over this is ridiculous). Anyone who calls is told to call back in an hour. Even in the hospital there are hours that Dr's and nurses cant be interrupted. Why not med pass?

The Doctors have been informed of the same, and agree with it, any traffic of residents to and from appointments are done before or after med pass, The CNA's know that other than an emergency- not to interrupt the nurse during med pass etc. My only exception is my DON who still has no compunction to interrupt it for any old reason- but she thinks she understands bedside nursing and hasn't a clue.

BTW-Our units have from 25 to 45 patients,

Try the above- I bet your nurses will applaud you!!!

BTW- by care planning the error report instead of just answering questions, I elevate the system of care planning and add a professionalism to the error report. I know its just doing the same thing as you are currently doing, but it sounds better and the Risk Management lawyers liked it.

achot chavi · Dec 12, 2008

If you care plan an incident... doesn't that become a part of the patient's record... no longer making it an "in house" event that is to be investigated. Basically what I am trying to say is we never chart that we filled out an incident report... So doesn't creating a care plan for it defeat the purpose?

I hear what your saying- as I explained - this care plan is for the incident report- not the patient chart, it gets signed by the involving parties themselves. It is an internal document. It attempts to solve an internally made error.

BTW _ discovered through this that a head nurse was making the night nurse prepare for her her meds!!! Couldn't get over it, I was so mad.

What happened is that the evening nurse discovered the pts morning pills in a cup in the patients pocket- a med error report was written, the pills came to me, I discovered 2 of the same pill in it and asked the day nurse who then admitted that the night nurse had helped her prepare them. She promised it would never happen again. The Dr. tells me that when I went on a 2 week vacation, it resumed. I'm thinking of rotating my nurses. What do you think?