Medication Error

[suturethis]

Hello,

At my current place of employment we use Point Click Care. If a medication error is made then an incident report is made, and you have to sign it. The incident report can be seen by everyone who uses point click care. I feel this is violating my privacy. I understand if I make an error, that is my own wrong doing, but I don't feel comfortable with the fact that anyone can view this. I was wondering what other facilities do for this. This is a newer process for med errors that started a few months back. 

[amoLucia]

It's usually an incident report at most, if not all, places today. Since you would have to notify the PMP, you might be able to get a 'covering order'. I've done so a few times. Fortunately, there was no harm to the pt, and I would have explained out the whole situation. Seems this worked out for you. But there still remains a reason why the situation occurred and how it could be prevented for the future.

If your EHR has already identified a 'med error', you will need to do any other documentation as req. But you're right, the situation does seem like an invasion of your privacy.

I'm confused re your current screen name and that of the OP. PLEASE consider using an anonymous name! TOO MANY folk can read about this here.

[purple unicirn, BSN]

I did write a note in the chart regarding my conversation with the doctor

How do I change my screen name

[amoLucia]

Ask the mods. They can help.

[purple unicirn, BSN]

OK told my manager the situation and she was OK except I didn’t have an actual order

[WendyTu]

I'm shocked that this isn't on paper.  These don't get reported to the State unless a certain class of injury was sustained by the patient.  Why would your facility include it in the computer records where the state surveyors will definitely see it, if other users on Point Click, can see it.  That's a bad policy all around.  The narrative notes will describe the phone calls to MD and family, then the follow up observations by succeeding staff on the next 24 hours or so.  The incident report SHOULD NOT BE ONLINE! IF the State selects THAT chart to review, they will ask to see the incident report.

[TriciaJ, RN]

On 6/17/2021 at 7:00 PM, purple unicirn said:

Is it a medication error if the doctor was fine giving a extra dose

Yes, because it wasn't what the doctor originally ordered so an error did occur and needs to be learned from.

It's a nice courtesy if the doctor is able and willing to amend the order after the fact.

Try not to think of an incident report as "telling on" yourself or someone else.  The professional approach is to recognize that all errors have causes which need to be identified.