Fentanyl Patch med error

Nurses Medications

Published

Specializes in INTERNAL MEDICINE, PSYCH.

I am a LTC nurse. To make the back story short, pt has Fentanyl Patch to be changed Q3days, only applied to upper back out of reach, old patch must be discarded(wasted into sharps container) by two nurses & signed in narc book by both nurses. One day, I went to change patch as ordered, the previous patch was not on patient but was signed out in narc book (next to signature reads "old patch wasted" but no co-sign from second nurse). I then found an even older patch. Did full body audit with second nurse, could not locate patch that was supposed to be on pt.. Filled out appropriate med error paperwork, left with supervisory staff.

Next day...I am called to director of nursing office. She says "It seems like you only find med errors when per diem nurses work, call me crazy..." I am pretty upset/offended. I am full time on my unit, and yes mistakes happen BUT this mistake is a narcotic error! The nurse who placed the older patch on the pt was a PRN nurse yes, and likely just discarded the new patch innocently. However, that is not my job to figure out. There have been two other occasions where per diem nurses have incorrectly placed the Fentanyl patch on this particular patient IMHO, why is my director coming down on me? I feel the concern should be with the per diem staff members who are not educated on proper placement of the patch!

Just wanted some input - would you be offended if your director said this to you? How would you respond? I was dumbstruck, so I just nodded my head at the time.

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Me: Right?! I'm hoping you will get to the bottom of this soon because it's very concerning and way past coincidental..

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Specializes in Neuro, Telemetry.

I would be a little perturbed that you are somehow being blamed or made to feel bad about finding the error. The other nurse either didn't place the patch and said she did, or diverted it. I'm either case, it is not your fault. I actually would be upset that the patient went some time without their pain relief.

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I would have asked her how she preferred I handle similar situations in the future, let her back-peddle for a few minutes, then gotten on with my day.

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Specializes in Adult Internal Medicine.

You found a serious error. It is not your job to judge if it was an innocent error or not! I would have serious concerns about a manager that wasn't very interested in the error you brought forward. A narcotic is missing, a highly abuse narcotic, and a patient was without pain medication for 3 days.

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Specializes in INTERNAL MEDICINE, PSYCH.
You found a serious error. It is not your job to judge if it was an innocent error or not! I would have serious concerns about a manager that wasn't very interested in the error you brought forward. A narcotic is missing, a highly abuse narcotic, and a patient was without pain medication for 3 days.

Thank you ALL for your comments & reassurance. I am honestly concerned about the lack of concern, although my director did state she will be speaking with that nurse. I don't know...I don't report little nit-picky errors like a dressing not being changed or something...but a narcotic error must be reported....it's my license on the line too for false documentation! I did speak to my director more, she said "as a more senior nurse you should be leading by example". I suppose this is just not going to go my way & I will never understand. Thanks for letting me vent!

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Specializes in Adult Internal Medicine.
I did speak to my director more, she said "as a more senior nurse you should be leading by example".

I would honestly report this up the chain.

In my opinion you are leading by example.

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No RN or LPN discards a patch innocently...that is more then likely an excuse. It's also possible that it fell off. I have told this story once on here. I was changing a patch on a patient, same patch, same dosage. Another nurse I was training was with me. We took off the old patch but couldn't find the new patch. We searched everywhere and finally I ended up going and getting another patch. The next morning I was putting on my work shoes and low and behold the patch was firmly stuck to the bottom of my shoe!

Don't let this eat you up. Just go on and pick your battles wisely. It sounds like your boss is set with what's been done. Did they do any drug tests? Go on and learn from it. They always have to have someone to blame. Sorry you work in one of those kinds of facilities.

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Specializes in PICU, Pediatrics, Trauma.
I would be a little perturbed that you are somehow being blamed or made to feel bad about finding the error. The other nurse either didn't place the patch and said she did, or diverted it. I'm either case, it is not your fault. I actually would be upset that the patient went some time without their pain relief.

This too! Is it possible.that it was rubbed.off and lost in the sheets?

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Specializes in PICU, Pediatrics, Trauma.
Thank you ALL for your comments & reassurance. I am honestly concerned about the lack of concern, although my director did state she will be speaking with that nurse. I don't know...I don't report little nit-picky errors like a dressing not being changed or something...but a narcotic error must be reported....it's my license on the line too for false documentation! I did speak to my director more, she said "as a more senior nurse you should be leading by example". I suppose this is just not going to go my way & I will never understand. Thanks for letting me vent!

I am still dumbfounded by why the manager is implying that you did something wrong. I don't get it.

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Specializes in Hospital medicine; NP precepting; staff education.

What I see is a process failure. If regular employees are doing this correctly, what is the breakdown for the others?

What's the common denominator?

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Specializes in Adult Internal Medicine.
What I see is a process failure. If regular employees are doing this correctly, what is the breakdown for the others?

What's the common denominator?

How is a brand new missing fentanyl patch a process error? It was signed out of the emr and never placed while the old one was left on for 6 days?

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