Med errors

I haven't taken NCLEX yet, but what we were taught in school, and what the practice NCLEX questions I have been doing also teach, is that you document in the chart what was actually administered. There is also an incident report, but the fact that it even exists is NOT charted. If a nurse were to write, "blah blah blah, incident report generated," in the pt record, that incident report becomes discoverable by opposing counsel should the matter ever end up in court.

How do you not document that a med error happened? You can't document that you administered everything correctly when you didn't. What you DON'T document is that an incident report was written.

I document errors but I see that some nurses at my work don't. I'm not sure why they don't - to me it needs to be mentioned! But never mention the incident report.

Before our computerized order entry, we had a doctor that, if an error was made would handwrite an order like "Xmg of ABC drug to be given correctly, as previously ordered. Write incident report." He was repeatedly told that was inappropriate. We had varying reactions to that sort of order. Yes, I'll give the med correctly, but no, I'm too busy to write an incident report about something I have no knowledge of.