Med error...what to do?

[kh2013]

Okay. I made a med error on Friday...and I don't think I was instructed to document it properly.

I am a new grad with a preceptor. Long story short, patient was in pain and absolutely hysterical, thrashing around in her bed, begging and screaming for me to do something. Her MAR with PRN pain medication was a mile long. The patient, while hysterical, kept changing her mind about what meds she wanted and when. Once she made a decision, I, while flustered, prepared the medications in the unit's Medication Room and from there went into my patient's room and scanned my medications...but did not realize the computer system did not properly scan all of the meds before I administered them. I gave the correct pain medication dose ...but I incidentally gave double the Benadryl IV dose for itching (the one medication that did not scan properly). I tried to scan the med and document the amount I actually gave and not the ordered dose. The computer wouldn't let me and I told my preceptor. We called information systems to ask how to document it, they said just report it to MD and see if I can get an order for one time dosing. I called the MD. MD wasn't worried, came to floor 10-15 mins later for roundings, assessed the patient and cleaned up PRN pain med list and gave me a one time order for Benadryl IV dose I actually administered.

My preceptor told me there was nothing more that needed to be done (I asked about filing an incident report...and the response was along the lines of that the MD provided an order, so it is fine to do without).

I go back to work tomorrow morning. This incident has been eating at me this whole weekend. I will file an incident report tomorrow.

Should I add an addendum to the patient's chart stating, "At 0900 50 mg IV Benadryl given. Discussed with MD."? Or what? Does the one time order after the fact cover me?

I know the timing of this documentation is not ideal, but better late than never, right?

Luckily, the patient had no adverse effects. I am so upset that this occurred, especially during training. And now, with more time to think about it, I hate the fact that it looks like I tried to cover it up. However, I honestly did not mean to come across this way. I told my preceptor and manager what happened as soon as I realized it. I feel awful, and I don't want to cover it up. I will definitely be more careful in the future.

If you have any advice, please share.

Thanks,

One devastated new grad.

[Been there,done that, ASN, RN]

You are focusing on the wrong issue."The patient, while hysterical, kept changing her mind about what meds she wanted and when. "

When a patient complains of pain, the NURSE assesses the cause of the pain, and what medication is required... NOT the patient.

The patient is a LOONG time drug user, doctor knows this, you should too. Your preceptor failed YOU and the patient.

By the way, in THIS case the Benadryl was a potentiate, ( patient knows this) it was not being administered for possible "itching".

Yes, be more careful in the future when a patient tries to (haha) call the shots. Do NOT shoot yourself in the foot and write yourself up.

[gemmi999]

One thing I've learned over the past year as a new grad is

1) assess the pt. and determine level of pain;

2) look at MAR or doc to see what is available at the time for that level of pain

3) Tell the pt. without allowing them time to try to manipulate you (and drug seeker's will). "Right now you are experiencing severe pain; the MD has cleared me to give you X and Y. Do you want this at this time?" If pt. requests something else, clarify again "This is what I'm able to give you. Do you want it?" and if they say no or try to negotiate, chart what was offered, why, your pain assessment, and that you will follow up with the pt. in x amount of time.

If you don't think the pain medication is enough given the pt.'s symptoms, or if you aren't sure if pain is the problem, look at other PRNs. Benadryl can help with itching, etc, but it also helps make pain medication "stronger", for lack of a better word; is the pt. anxious?

I had a pt. the other day say they were in 7/10 head pain. I got an order for Norco and went to the pt with it; pt. said no because when she said pain she really dizzy/lightheaded; her bp and vitals were stable/WNL. Got the order for antivert instead and that helped.

Long story short--1) don't do the incident report if you got the order; 2) sometimes you have to treat patient's like 2 year olds, give them a simple choice--"This is the medication, yes or no?". 3) Your assessment is what is key, not necessarily what the patient is saying. That isn't to say don't listen to the patient, but your assessment goes beyond what the patient says. Would you give IV morphine if the pt's BP was low? Resp. low? Would you give 2mg of Ativan if ordered IVP if the pt has never had it? You're the nurse, you make the assessment.

[cjcsoon2bnp, MSN, RN, NP]

So here is my opinion on this, in the ideal world you would write up an incident report detailing the situation because (a) you did in fact make a medication error and (b) the computer system (EMAR) didn't allow you to document the dose that you actually administered (only what you should have administered). With that being said, I think that many people would advise you not to write an incident report because you got an order from a physician for the dose that you gave and there are times that incident reports have been used as a disciplinary tool against nurses instead of a tool for reporting safety issues and addressing them at the appropriate level. The problem with not reporting it is that hypothetically speaking if an adverse outcome happened as a result of the medication error the odds are that the physician will report that they only gave you the order after you made the administration error.

I'm not passing judgment or attempting to chastise because I have made medication errors in the past and been in a similar situation as the OP. Thankfully, when this occurred I worked at an organization that typically did not use incident reports as punishment and so I felt free to report the error, review the situation with my manager, and use the experience to help me grow as a nurse. This situation requires careful assessment of the error that occurred, the likely outcome of reporting versus not reporting the incident, and what learning has taken place to prevent a similar mistake from occurring again.

On a side note, from a documentation and technology standpoint I'm not sure what system you are using but likely you would have to scan the medication and make an addendum to the administration itself, which I would write as "Administered 50 MG Benadryl, IV at 0900, MD notified and RN will continue to monitor." Your documentation should never make any sort of reference to an incident report or risk management and should avoid including words like "error" or "mistake". Your documentation should just state the facts of what occurred, period.

Best of luck OP!

!Chris

[nutella, MSN, RN]

It sounds that you and your preceptor did all the necessary steps. The MD came to assess the patient.

Here comes the real life advice:

We all make mistakes, especially when new. You gave a double dose of benadryl, which did not result in any injury. The MD backed you up by writing a one time order. Please let it go. You can discuss with your preceptor if an incident report needs to be written - perhaps your preceptor did it already or/ and discuss it with your manager. But do not make too much wave about it.

[amaryllis135]

The doctor's order saves you on this. I agree with your preceptor...now that you have the order for the medication nothing else needs charted. There is no "error" at this point. I would definitely let this die and learn what you can from it.

[heron, ASN, RN]

The RiskManager would like to see an incident report on this, since his interest is piqued by the computer refusing to allow you to enter the administered amount. RiskManager would send the incident report to IT and ask them what gives on this situation. In terms of an addendum to the chart, if the med administration is adequately documented in the chart via the order and the medication administration record, I am not overly concerned over writing an addendum. If it is not documented in the medication administration record due to the computer issues, I would make an addendum documenting that the med was given. Be sure to note this as an addendum made after the fact, however your electronic healthcare record system allows for this.

Did anyone read this post? The OP wants to do the right thing - report the incident for follow up - for the wrong reason - fear of the appearance of a cover-up.

There is no cover-up, OP, not even the appearance of one. You notified your supervisors and their response shows no trace of a punitive agenda. Your preceptor witnessed the incident and was not anxious to hang you, either. The actual med error was handled and documented appropriately. Why undercut a process that's working the way it's supposed to, allowing a possible tech malfunction to go unaddressed. Is there another way to make sure IT checks it out?