My fault????

morte, LPN, LVN · Sep 7, 2008

what was the volume of the bag/bottle that you threw away? it wouldnt surprise me if the 500 ml DOSE, was made up of TWO 250 ml bottles.....but that should have been reflected on the MAR....as in two places to sign off....looks like one of those "system errors".....

debnky · Sep 7, 2008

I must agree. It was not your fault. Don't beat yourself up over it.

Debbie

imanedrn · Sep 8, 2008

Last night during shift report I noticed a pt had orders to recieve 500cc bolus of albumin with start time of 1530. The orders were signed on the chart and marked off on the mar. The nurse giving me report at 1930 stated that, yes it was almost done infusing and when done to just throw away tubing and all. So that is what I did. Well this morning after I had given report to a different day nurse she went to do her assessment and found a bottle of albumin tucked in the corner next to the sink in pts room. I never noticed it there and frankly did not look as I was told it was done and the pt did not get anymore. The day nurse was more than a little perturbed at me. I explained to her that the orders were signed off on the chart and on the mar so that means it was done (?). She said I was wrong and stormed off. I am a new nurse (6 months+) and I have tried hard to be a good nurse and I get so mad at myself when I miss something !!! What do you all think?

You're there to assess (and care for) the patient, not the room! Yes, you will find things in the room occasionally, but (last time I checked, anyway) my job is not to assess the room!

In any case... the bottle that was "tucked in the corner," was it still full? (I'm assuming so, otherwise, the other nurse wouldn't have been "perturbed.") If so, then the nurse who was supposed to have administered it may have actually not done so and out-right lied OR it could have been a simple mistake. In either case, YOU should not be held accountable for this, and YOU did not miss anything!

And, yes, if a med is signed off, then LITERALLY it should be done. If it is not, then the nurse who signed for the med should be held accountable for the error -- not the reporting nurse (you, in this case). That's the whole reason we sign off on charting assessments, meds, shift reports, and chart checks. And that's also why we're licensed by a state entity! WE are held accountable for OUR OWN tasks -- done or not!

iluvivt, BSN, RN · Sep 9, 2008

I agree not your fault. The medication was signed off as given and you were also given a verbal report stating that as well. You would have no reason to suspect the other nurse only gave 1/2 of the prescribed dose unless you found the other 250 ml......and even then you would still have to cal that nurse and have to verify what was really given. You take responsibility for your actions or inactions only...not any one elses....that the way the law will see it as well. I would have told that nurse in no uncertain terms that you do not and will not take responsibility for another nurses practice and she is out of line. Even to correct the problem at that juncture do you assume it was not given or do you have to call and check. You have to call and check.

Laughs-a-lot, RN · Sep 9, 2008

Definately not your fault. The second bottle should have either been hung on the iv pole next to the first one or left at the med cart, or whatever system you use. Agreeable also that the MAR should have had another time maybe 30 min later to sign off for the second bottle. Not to mention it should have been clarified in report. That day shift nurse should be more concerned about contacting the physician to see if they want it given, etc, than placing blame. Luckily the day shift on my unit are mostly experienced nurses, and I could see it now. Somebody would probably have the dr paged and explain situation and get orders before I'm even finished with report.

**NickiLaughs, ADN, BSN, RN** · Sep 25, 2008

I thought all nurses were psychic?

Wasn't that a requirement of nursing school entrance?

Kidding.

I know that I would have missed it also, as would the majority of us.

It is NOT your fault. If it was signed, in essence: it should have been done.

barefootlady, ADN, RN · Sep 28, 2008

Not your fault, but you should learn from this mistake. The nurse who gave report should have told you which bottle of albumin the patient was on. It should have been reflected on the MAR. I would have thrown away a used set but never an unused one. I probably would have called this nurse at home and asked her about the extra bottle in the room. Chalk this up to a learning experience.