Reporting Errors

If you had a near-miss, I would definitely report it. Think about all of the other nurses that could make that same mistake, especially if it is one where harm could reach the patient.

We recently got a medical event reporting system. It is statewide and all info goes into a database somewhere.

I've reported a couple of things - silly stuff, in retrospect. IV tubing not labeled, an IV med not labeled and apparently not given, etc. However, we are encouraged to report misses, near-misses, or events, like falls or a patient improperly identified. Some of the things I've heard reported are physician taking too long to call back despite multiple pages as pt deteriorated, pt was double-dosed or extra-dosed with something accidentally, lab draws not being put in at the correct time or not at all, missed consults, patient falls, critical values not reported in a timely manner, and so on.

I'm not concerned with the anonymity part. When they rolled out the new system, they told us that incident report does not equal being written up. It's not stigmatized in our hospital. The worst part, honestly, is that our manager reads all of the reports to us at the monthly meeting. It's not meant to be punitive, more like, "we are noticing that people are reporting issues with bed alarms not being on at night. What should we do to improve this?"

I have no guarantee of non-punativeness....you've seen how some RNs have unwittingly found themselves in the snares of management with one wrong move.

Vespertinas speaks truely (truly?). I believe there's no such thing as anonymity, and things can be tracked back. It's called an internal investigation! It's a shame that such a program can't be fully utilized as intended for good purposes, but personally I would be suspicious. Just my humble opinon!

We have a similar system in the hospital that I work at. I got reported in a round-a-bout way. There was a charting error that began on day shift and was something that I didn't catch -- which was reported. I received an email from my nurse manager with the bare details of the report, along with a general "can you explain the situation surrounding what happened here." No pressure, wasn't called into the nm's office or anything drastic.

However, I am under no illusions that this system can and does get used to track what in the past would have been a write up. I would be wary of the casual-ness in which these reports can happen and how they are addressed because, yeah, they do ultimately fall back on you and you could lose your job.

(I also feel like this system could be used in a positive manner -- but I see it misused quite often. On my unit, it tends to highlight animosity between certain individuals. Or between day shift and night shift. Also, as a new hospital nurse who has been off orientation for about seven weeks now, I feel like this particular system gets used by other nurses who don't either want to confront me or simply tell me that I did something wrong.)

Imagine this, if you nearly made a mistake, others may have nearly made this mistake too. And then one day this mistake will be made. Report it now before it is actually a med error. This is honest, aboveboard, and culture of safety.

This is how changes occur that make your facility safer for everyone.

:)

Those of us who work in facilities where reporting of near-misses is considered normal and a 'good' thing to do and have never suffered any repercussions from reporting close calls probably find it hard to understand that it isn't always like that.

I wouldn't hesitate to report a near-miss but after reading these boards for a while, I can understand why many would think twice or not do it at all. It's quite shocking to me that there are workplaces where reporting a potential problem or an issue that is likely to cause a problem can result in disciplinary action or worse. It's crazy!!

We actually have regular 'hazard hunts' where everyone has to find and report one or two hazards or potential hazards and these reports go to the safety committee for consideration and are addressed according to priority. The sort of things that get reported aren't anything to do with medication errors, just saying that in the same way as we are expected to report a trip hazard, we're also expected to report near-misses and we know the issue will be addressed wherever that is possible.

It's the same with actual errors - if similar actual errors are being made, the process will be looked at just as closely as the person or persons making the error.

Fortunately, I have never made a med error in years of nursing, but teaching is the way to improve this system, not self-reporting. I do not want to sound harsh, but never report something that did not happen. You can explain to a Nurse Educator or a Clinical Nurse Specialist about the potential situation, but do not blame yourself. The Nurse Educator or CNS should utilize your "concern" over the system and potential for errors as a teaching tool, but never blame yourself. If you do, you are opening a large can of worms and you must be fairly new to nursing because nurses predominantly do not support other nurses. If you are ever reported to the State Board--they are like wolves waiting to devour you, according to an attorney friend of mine. Take the issue to an educator who can hold a class on preventing errors and be the "good" nurse who is concerned about potential mistakes and saw the need for a teaching opportunity. Your manager will praise you instead of blame you for something that did not happen. I have been an RN/APN for 30 years and cringe at the number of good nurses that I have seen get disciplined or it show up on an evaluation negatively for reporting near-misses. I have seen hundreds of nurses drug tested or even accused of mental issues for self-reporting. I have seen the results of horrific errors over time from physicians to nurses to anyone in patient care and drawing attention to yourself is not the way. Prevention through education, initiating a committee to improve the system, etc., is the way. The person who talks about the culture of safety has never experienced the wolves. Explain to a preceptor, CNS, nurse educator etc., and let this person do the appropriate teaching to prevent potential med errors. Do not blame yourself for a system that does not work. I am not saying do nothing, but just saying advise an educator of the potential problem and explain that you want to help others to not make an error. If the system does not change and you feel it is unsafe, then anonymously notify Joint Commission. I have reported hundreds of errors in my day, but anonymously as nobody will stand with you if you point out a poor system and it could be punitive against you........ridiculous, but true. Hold your head high and be thankful that no error occurred, but you will find yourself very unpopular if you begin complaining about "how things are done", especially to a manager who is wanting his/her unit to reflect their good name. It's a joke and a game. I have turned in so many unsafe people, including physicians, but they never knew who did it. Systems, policies, and protocols get changed, but I just laugh on my way home knowing I did cause change for the better and for the safety of human lives, but not at my expense. Protect your patients and yourself. Find yourself an experienced mentor that you admire and trust and talk things over with this person often. Your manager is usually not your friend, nor mentor. Good luck and may God bless you for watching out for the safety of patients. BUT YOU CAN STILL WATCH OUT FOR THE PATIENT anonymously. You would be shocked at how many things I have had changed from the lack of a view for critical care patients to the quality of the air in the facility (OSHA helped out on the air quality and we all stopped getting upper respiratory infections also). No-one knew who reported these things. Now, I just sit back and giggle under my breath as hospitals spend their money caring for the patients instead of planting flowers around the doctor's parking lot. I have nothing against physicians/married a good one. Take care.

If this incident was a "near miss" then that means that an error was not actually made, so the patient was not harmed. You caught the error, and recognized a problem in the system. I'm not sure why you would think you would be punished for catching an error and reporting it in order to help improve the system.

But if you're that concerned, don't write an incident report. Instead, write a letter that details the error that was almost made and the system breakdown that contributed to it. Submit it anonymously to your risk management office and your manager. Or fill out the incident report but leave out the specifics such as the date and the patient.

Then what happens if I DID make a med error? Everyone talks about fixing the system but while I'd think that the reasons to raise an alarm are even greater so are the stakes.

When I worked at the hospital, the system was not anonymous by any means. It was an online reporting system and you had to include all the patient's demographics. Your name was automatically attached to it and it was sent to the Risk Management department (or whatever the hospital called it) as well as to your manager and the patient's Attending physician/the designated "Risk Management" doctor for that service.

There were times where I felt I had to write incident reports but I knew that it would lead to a colleague getting spoken to. For example, a patient on chemotherapy admitted from the oncology clinic for G-tube cellulitis/fever and neutropenia started on double antibiotics (Vanco and Zosyn). Neutropenic patients can go septic at the drop of a hat so early IV antibiotic treatment is crucial. In this kid's case, he was admitted in the afternoon and had received a dose of Vanco in the clinic. When it was ordered, something like this happened: It was ordered q 8hr and the system defaulted the start time to 4pm. He had received a dose in clinic, so the day nurse charted it "not done" and went to reschedule the next dose for 11pm (based on what time the first dose had finished, which had been delayed d/t the development of red man's syndrome). However, because the 4pm dose had disappeared and it was scheduled q 8hr, the next dose was already scheduled for midnight and the date was the next day. What it appeared to me was that she must have forgotten to flip the date back to that day's date because when I picked up the kid the next morning, he had an order for Vancomycin q 8 hr with no doses scheduled for my time and one dose scheduled for 11pm. The night nurse (who was new) hadn't noticed that she hadn't given any Vanco in her 12 hr shift despite it being ordered for q 8hr when I asked her about it. So, essentially, the child had missed 1 full dose of Vanco and the 2nd one ended up being given quite late. It didn't end up affecting him at all and I believe it ended up being stopped the next day, but it was a potentially serious oversight in a patient at high risk for sepsis. It was partly a system error because the system allowed a dose of a q 8hr medication to be rescheduled over 24 hrs from the current time. Seems like the system should be able to fix this and filing an incident report was one way to call attention to it. I felt bad for my colleague because she was new and I knew she would get spoken to about it (I did warn her that I had to write the incident report and that our manager would likely speak to her) but the patient was the priority and it was something that needed to be reported.

I think it definitely does hinder people from writing reports when they think that there will be consequences which is unfortunate... the purpose is to learn from mistakes and fix the system so they don't happen again.