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Med errors

Posted

Specializes in psych,maternity, ltc, clinic. Has 15 years experience.

I was taught to not chart med errors in patient record. Of course, we fill out an incident report saying what was done, any adverse reaction, how to keep this from happening etc, but that those are to be kept internally. Of course if we are surveyed we must turn this over, but these are not to go into a client record.

has this changed and what are people learning now, doing now. ?

unicoRNurse

Has 3 years experience.

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.

Edited by unicoRNurse
Clarification

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

You can document that med X was given...MD notified. patient monitored. See orders......If there were any. DO NOT mention incident report written.

KelRN215, BSN, RN

Specializes in Pedi. Has 14 years experience.

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.

KRVRN, BSN, RN

Specializes in NICU.

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.