Med Errors- would you report one?

[country mom]

How comfortable do you feel reporting a medication error? How about a "close-call"? If you do not feel safe in reporting an error, or a near-miss/good catch/close call, why not? What if someone else made an error and you discovered it, would you report it?

[lisamc1RN, LPN]

There was a time in my facility when it would make my stomach sick if I even thought that I had made a med error and I was definitely hesitant to report a co-worker. The reason is that we were automatically written up and even treated like we were idiots for making such an error. Near misses caught by me were simply fixed, and I moved on. Now, we have an awesome DON, who I truly believe cares about the staff as well as the residents. I have not hesitated since getting to know and trust her to report med errors and even near misses. She isn't interested in punishing us but working with us to make things better.

[blondy2061h, MSN, RN]

By the way, have you ever made a med error (that you know of)?

Probably not, as she's a CNA.

[WalkieTalkie, RN]

Yes I have reported both myself and mistakes found from previous shifts. It's the right thing to do, and it can potentially prevent harm in the future. Also, our reporting system is set up to not be "damning" to the person who either made the mistake or caught it. It's simply there to help figure out why things go wrong and what we can do to prevent errors in the future. There have been times when certain nurses making a lot of mistakes have been counseled, but I am not aware of anyone actually being reprimanded (at least in my unit). The idea is that the incident reporting system is there to help everyone...

[maxthecat]

I'm pleased to see that most of your facilities use a non-punitive approach to med errors, use reports to track trends and investigate systems. In the past I have worked for those kinds of facilities, too. And in the past I had no qualms about reporting errors or near-misses. Unfortunately, I currently work at a facility that uses error reports against individual nurses. When I started here I was warned by long term employees to be very careful what I reported. I thought they were being paranoid, but then I watched what happened to employees who made errors. Error reports showed up on annual evaluations, and affected how much of a raise was given or if a raise was given at all. Two errors in a year resulted in being put on probation. So...in my current environment I would report errors sparingly if at all. I think it's sad.

[maxthecat]

I should have added to my previous post that although my fellow nurses and I don't officially report, we talk to each other privately, so individuals are aware of errors and near misses, and of course we notify physicians. We just try to fly under adminstration's radar.

[Katie82, RN]

Everyone seems to have forgotten the real "victim" of medication errors - the patient..... Not reporting a medication error could eventually cause harm to a patient. When you accept a license as a professional nurse, you are obligated to put the patient first. What may seem like a small medication error may actually be a pattern. I agree with other posters who have stated that most of the time, management is looking to track trends. I think in the case of a "near miss" where the patient was not harmed, I would speak with the person making the mistake. Sometimes that's all it takes...

[GilaRRT]

Reported myself about a year and a half ago. Reported a LPN a few years ago. This is a serious concept that should be addressed. Anybody who has been in nursing more than a few years who has not committed an error is either lying or unwittingly committed an error.

Agree that many errors involve a multitude of concepts to include systems failure, high stress and workload, and miscommunication. A good root cause analysis of an error should identify the multiple components that led to the error. Typically, a cascade of events occurs.

[Virgo_RN, BSN, RN]

Yes, I have and will report medication errors.

[country mom]

I sure feel for the people who work in an environment that uses error reporting in a punitive manner. I've been in that kind of place myself, and it's very stressful. You can't change anything because you cannot bring the problem to light. In the end, it's the patient who suffers. It needs to change. No way should med error reports be included in a performance review!

[kanzi monkey]

I have reported myself 5 or 6 times--2 med errors where luckily no harm was done, patient falls, the beginning of a stage II on a patient that came from a SNF where unfortunately the skin hadn't been well examined on admission, etc.

I believe that in each of these cases I was part of a mechanism that has some faulty wiring. I accept as much responsibility as is appropriate, and in my incident reports I include extraneous factors that prevented me from providing acceptable care. For those factors I am only responsible in as much as I am an employee of the hospital.

As for reporting other people--that depends on what the outcome was (ie, was the patient harmed?), and what factors may have led to the error. I always talk about it with my coworker--if it's something that happened that clearly would benefit the system to report, I tell them that. They can report themselves. Someone told me to report myself once. I have a very good relationship with this nurse, and her pointing out my error was helpful and I had no problem filing the report.

We're nurses. We have to be accountable for our actions, like any other professional. The way I see it is, non-punitive reporting gives us the opportunity to speak out for ourselves and show the powers that be some of the obstacles we face day to day.

[nina4nursing]

Probably not, as she's a CNA.

Yes, I am a CNA but as my first post stated I work in a MR/DD group home. I pass meds via a Medication Administration Record and have to sign off on it just as nurses do. Threre are also Certified Medication Aides that are CNA's but also trained to dispense meds to a certain degree.

Nina

[nina4nursing]

I think you're missing the reason for reporting errors - its to identify patterns of errors and to improve systems to reduce them. You aren't "turning in" an error or a person. And everyone at some point in time is going to make an error. What is dangerous is when people are afraid to talk about them or to acknowledge them. Then nobody gets the chance to learn from them or to improve systems or working conditions to reduce them. I am comfortable reporting errors, including ones that I make, but I don't act like I am turning anyone in.

By the way, have you ever made a med error (that you know of)?

Yes I have and have been written up once out of two years of employment. The statement you made above,

"What is dangerous is when people are afraid to talk about them or to acknowledge them" is what is going on where I work. I have even tried to avoid turning med errors in however when you come in and the pill is punched but the med book not signed, or the med book is signed but the pill is not punched, or the pill is not passed nor is the med book or the punch card signed as is often the case where I work and you try to bring it up you get the

"Just go ahead and turn me in then" response. A certain individual I work with had two valid med errors in less than three days. And at this point have not even asked her to retake med training. Also a lot of her other work is reflecting this same attitude. As my boss told me not to long ago, I am kinda square and by the book.

Nina