Nurse went "ballistic" over her medication error.......

prmenrs, RN · Dec 23, 2001

Where I work, anything that is seen as a deviation from the stated mission and goals of the institution warrants a "Quality Variance Report".

That might mean going to the ER w/asthma 2ndary to pneumonia, and having to wait 2 hours for Resp Therapy to show up and give the pt. a treatment. It might mean having a planned discharge that has to wait 2-3hours for their scripts to be filled. Med errors, falls, an IV infiltration, an adverse drug reaction (which gets an ADO form from pharmacy as well). Having a piece of equipment fail or not being able to get equipment you need, having the lab take 2 hours to report a stat value. Not being able to get adequate staffing, a delay in surgery that is detrimental to pt. care--these are all examples of deviations from quality care.

When people perceive reports of this nature as punitive, they avoid filling them out. That can, in some instances, leave the institution's [and the nurse's] proverbial a** hanging in the breeze. We got some people over this by saying it was a method of warning the liability/risk management folks of a potential/actual problem, and giving everybody a bit of warning. That way steps can be taken to deal w/the peoblem instead of being surprised when the lawyers come around.

There a whole lot of research and literature regarding thinking of med errors as system errors, not people errors. Was the nurse too rushed to calculate properly, did the pharmacist not understand how the MD wanted the med given, was the docs handwriting too difficult to read, was the plan of care not communicated, etc.

The last thing I want to mention is that for some cultures, any error is seen as a loss of personal esteem. We're all human, we all make mistakes, what can we do to prevent it in the future. The report should NEVER wind up in someones personnel folder!!!

Management needs to be proactive in changing how staff view these things so that the focus is always on ways to "engineer prevention" of problems. On other words, take the personality out of the situation.

The nurse you're describing may have some ego issues, but she also may know how she missed the med, and how to rectify the situation. Management should help her solve the problem of the med error, not try to do a personality makeover!!!

Good Luck!

thisnurse · Dec 23, 2001

write,

you say:

"Occurrence forms do serve specific purposes."

In fact what you should say is:

"Occurrence forms ARE SUPPOSED TO serve specific purposes."

they are MEANT to find, correct and keep track of things like errors.

let me tell you what they are used for where I work...

Nurse Suzy, Nurse Jo, Nurse Donna, and Nurse Judy are all friends. They don't like Nurse Nancy. When they follow Nurse Nancy they write up an occurance report for anything she might do or not have done.

Say for example one of Nurse Nancy's patients has 200 litres of NSS left in his bag. She tells Nurse Suzy the bag is nearly empty. By the time report is finished and Nurse Suzy who is following her comes in the patients room, the bag is empty and the pump is beeping. Nurse Suzy fills out an occurance report.

The next day Nurse Donna is following Nurse Nancy and she finds that Nurse Nancy's former patient has no water in her pitcher. The patient states that she hasnt had water all day.(the pt is a walkie talkie and it is obvious that she is exaggerating)Nurse Judy fills out an occurance report.

Meanwhile Nurse Jo accidently gives Nurse Donna's patient 10 units of regular insulin.(She is not diabetic and she is not conscious) She tells her friend what she has done. Nurse Donna says, we will just keep an eye on her and if she has any problems we will call the doc. No occurance report is written and it is kept just between the two of them.

After a few weeks of this, Nurse Nancy...who IS a good nurse but who for one reason or another has fallen out of grace with the clique, piles up quite an amount of occurance reports regarding her care. She is called into the managers office in front of her peers. Of course they ALL know why she is being called in and the tongues start wagging.

Nurse Nancy arrives to find the manager and the coordinator both waiting for her. Quite intimidating. The manager proceeds to tell her "what the other nurses are saying" about her.

She tries to explain what is going on but she comes off looking paranoid and childish. "They just dont like me"

40% of Nurse Nancy's evaluation is based on "customer service" including how good of a "team player" she is.

During evaluation her manager pulls out her file and guess whats in there? Ah yes, all of the occurance reports filled out by the clique. Guess who doesnt get as much of a raise.

Now you have told us what occurance reports are SUPPOSED to do. I am telling you what occurance reports DO in our hospital.

The managers not only condone this behavior, THEY ENCOURAGE IT.

The only way I can ever see myself filling one out on another nurse is if that nurse is repeating the same behavior and there could be grave consequences to the patients.

I am not above making a mistake. I have reported my own errors when I thought they could have a negative impact on my patient. I also express how I will correct whatever lead to the mistake to begin with and how to avoid repeating it.

If the occurance reports were actually used the way they are supposed to be used I might think differently about it.

nurs4kids · Dec 23, 2001

This,

I agree completely. On my unit, we just rarely do them, but I've seen what you're talking about too many times.

I'm not above making a mistake, nor do I have a problem reporting/being reported, but I still think management has the wool pulled over some eyes

My question is this: IF the report is for QA, and NOT to punish, then why is the nurse and/or patient's name required on the report????

galenight, BSN, RN · Dec 23, 2001

Ok.. I have to admit.. I'm one to go ballistic...... but not because I'm written up, but because I made the error in the first place. I drive myself crazy feeling badly about it. I get so ticked off at myself... but then I get over it.

I have filed occurance report many times. I tend to do it more when there was actual or potential harm.... and especially if said nurse has a history of errors. I don't think it's fair to the patients to let a person like that continue to practice... unfortunately one specific person who is extremely dangerous seems to have some special form of favoritism with the DON. I personally think it is because he is the only male nurse in the hospital and I think he threatens them with a sexual harrassment or discrimination lawsuit.. But anyway.. i digress.

We had an inservice in which the pharmasict said that some governing body (JACHO, some pharmacy group???) said that our error rate was too low... and that no body was that good. They were right... c'mon.. the average error rate is something like 6-8% ( I forget that actual number) and we were something like 2-3%. And I have to admit, that I have even learned from not only my own mistakes, but those of my coworkers as well.. It really does need to be a learning tool...Problem is... it's rarely used that way.

Oh well.. here's to happy med passing...lol

workinurse@aol. · Dec 23, 2001

Originally posted by WriteStuff
Hi all,

Just want to talk about why it is some Nurses (not all for sure), go absolutely "ballistic" when another Nurse has to make out a medication error report when an error is found.

Last weekend I found an error in a pre-op med that was to be given four times a day, for two days, prior to this resident's surgery on Monday morning. (The day shift Nurse did not give the med on her shift, for two days.)

I contacted the Doctor, who stated, "not a big deal, just get two doses in before the resident leaves for the hospital on Monday morning. We did.

But, I realized that this was an error that needed to be documented according to policy and procedure, so followed through on the right thing to do.

When the Nurse involved saw the report she went absolutely ballistic!! Started making all kinds of claims, accusations, and went into a tangled scenario as to why "this just cannot be so."

She's one of these Nurses and persons who can "do no wrong" and has been at the facility for 100 years now.

But I have seen this same "reaction" by other Nurses during my lengthy tenure in this profession. What is that all about anyway???

Any of you experience the same with your peers?

Wondering, in Minnesota.

Negative occurence report is the word. We answer to these.

Positive occurence reports, where are they, do we get called to answer these?? We peck each other to death.

Ballistic, a sign of Traumatic Stress Syndrome. The prolonged elevated Glucocorticoid levels from the prolonged stress of hospital nursing causes physical changes in the brain, and the punitive nature of hospital nursing causes psychological hypervigilance/guilt/defensiveness.

Positive occurences, good performance and behavior are little celebrated and, due to the hectic pace, the unavoidable errors are magnified and highly celebrated.

The expected end to a bedside hospital nursing career is "down in flames" not happy farewell at age 65, 60 or 55 with reasonable health.

By only commiting to paper those negative occurences we leave a paper trail on each other that is a lie, truth told selectively that would lead the reader of our files to wrong conclusions about our performance.

Oh, the time it would take (that we don't have?) to write each other up for the positive occurences makes me wonder where we find the time (that we do have?) to write those negative occurence reports that in reality ARE used as punitive tools.

Do we also ignore our kids when they are good and spotlight their mistakes??

It's basic.

Mijourney · Dec 23, 2001

Hi. I agree with previous posters. Incident reports conjures up thoughts of punishment, incompetence, and possible legal ramifications. Historically, incident reports have been the domain of risk management which is not incorporated under the umbrella of quality management.

IMO, what's important is that the quality management, quality control, or risk management staff educate those who manage clinical staff as well as the staff. The objectives of an incident report need to be clearly written and followed so that staff are not intimidated by these reports and know when and how to properly write them. They also need to know the process the information goes through and possible consequences.

fiestynurse · Dec 23, 2001

Mijourney-incident reports are incorporated under the umbrella of quality management and are protected by QA and peer review laws. (lawyers for the other side, generally can't get ahold of these reports) It's difficult to separate risk and quality assurance because they are so closely related. Incident reports should be filled out on all med errors or deviations from the standard of care. The risk and quality management departments not only use this information to track and improve systems, but it gives them a heads-up on potential problems or law suits. There is much that can be done immediately after an error occurs, to protect the hospital and everyone involved.

On that note, incident reports should not be seen as punitive or as "writing someone up." However, in many institutions this is the case. I have seen nurses disciplined harshly for med errors. I would much rather see errors as a potential for learning and improving the systems that we work under. Doctors use a peer review model to deal with errors. I recently came across an oath that new doctors take at a nearby medical school and it reads like this: "I will recognise the limits of my knowledge and seek to maintain and increase my understanding and skills throughout my professional life. I will acknowledge and try to remedy my own mistakes and honestly assess and respond to those of others."

I wish nurses could develop the same type of attitude toward errors. I know that JCAHO encourages hospitals not to use a punitive approach to errors and looks down on this.

VickyRN, MSN, DNP, RN · Dec 23, 2001

Hello, we are talking about the REAL WORLD of bedside nursing, not some ivory-tower concept (however noble, however good) of "what should be." In the unfortunate REAL WORLD of bedside nursing, "occurrence" forms are used to punish, not rehabilitate. I do not trust management in my facility. I refuse to play these management games of "telling on one another." In the REAL WORLD, incident reports are just another tool used by managment to intimidate, to keep nurses under their thumb. This is why I do not fill out "occurrence" forms unless the medication error is very grave, with the potential for causing harm or actual harm occurring. I do communicate to the nurse about the error, and I also let the doctor know (what does he/she want done to remedy the error--often they just let it pass).

grouchy · Dec 24, 2001

I think the informal system it seems many of us use, of talking to the nurse who made the error, and maybe the doctor, accomplishes most of the goals the formal incident report is supposed to accomplish. In my experience, the nurse who finds out she made an error this way always seems to take it seriously and reflect on how she can prevent a similar mistake in the future. Of course, it doesn't allow for systemic causes of errors, such as understaffing, or dumping 6 admissions on a unit in 2 hours, to be addressed and changed. But, then again, have you ever seen incident reports accomplish this either? Have you ever seen anything change these problems? So really, the only thing the informal route doesn't accomplish is giving risk management a heads up. We ARE reporting incidents, we are reporting them using an informal system of peer review, in the spirit of that doctor's oath that someone referred to in a previous post.

WriteStuff · Dec 24, 2001

But healingtouch, what is your critieria for determining if the error was "very grave", as opposed to "grave", or "could be grave" over time, etc.?

And if you "always" talk with the Nurse involved, and call the Doctor, wouldn't you want something in the way of documentation that you did just that?

I would want a written record of all of the actions I took where a med error is uncovered, regardless of how "minor" it may appear on the surface, and I do that on the Physician's Order sheet in the resident's chart (facility policy and procedure where I work).........but I do NOT mention any names of Staff involved on the order sheet. I also write the exact words of the Physician's response when I call.......on the order sheet.

If push comes to shove, there isn't a hospital or LTC facility around that is going to side with the Nurse in a Court of Law. They always want a "handy" scapegoat to keep their side of the street clean.

Bonnie

mcl4 · Dec 24, 2001

Originally posted by canoehead
We use incident reports to track problems and to hlp us find ways of reducing errors. Recently we adjusted staffing on 3p-7p because of increased errors during that time.

We also deduct a percentage of the annual merit increase if someone has a pattern of errors- this is after counselling and reeducation have not worked.

Do you think nurses stop reporting error incidents knowing it influences their merit pay. What is an unacceptable level of med errors that require more education?

mcl4 · Dec 24, 2001

Originally posted by WriteStuff
Hi all,

Just want to talk about why it is some Nurses (not all for sure), go absolutely "ballistic" when another Nurse has to make out a medication error report when an error is found.

Last weekend I found an error in a pre-op med that was to be given four times a day, for two days, prior to this resident's surgery on Monday morning. (The day shift Nurse did not give the med on her shift, for two days.)

My question is with the line of communication. Since it appears the next shift gave the medication and they should have noted on the MAR it wasn't given on the day shift, why didn't they report the day shift error to prevent it from happening the next days?