I've worked in a facility where they encouraged us to fill out incident forms for misses or near misses so that they could be tracked, and if a pattern emerged, a solution could be worked on.
My current hospital does have a reporting system but it's not *really* anonymous since we have to enter the date and the pt's MRN which would pretty much peg the caregivers. I really want to report a medication error I nearly made because I feel it's one where a system gap partially contributed to the problem. I can imagine many other nurses making the same mistake and this mistake would be one that could result in serious patient harm.
This lack of anonymity is preventing me from filing a report and I think it's a shame. I've heard of other RNs self-reporting but I'm not crazy... when do you guys report?
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.
if you are not the only one who knows about the situation, including patients or families, report it. If you are the only one, think twice. My opinion, of course.
Specializes in Critical Care, Administration, Education.
If you feel that it is a system failure that is setting up the situation to fail (creating a med error) then you need to call "Risk Management" ASAP. A root cause analysis will be done to find out where and how a mistake can be made and how it can be averted before injury or loss of life is caused. Remember this injury is not only to the patient but to the nurse that may not catch the error in time as you did.
near miss...as in the 10 mile wide asteroid was a near miss to planet earth. it missed, we are here, nothing happened. but if its something that can be improved you should send an anonymous letter because if you dont then management will make sure you are not a near miss to be fired.
do what you think is right and necessary. pt gets 2 multivitamin-not a problem, patient gets 100units of regular insulin instead of 10-well somewhere along the the day like very soon, this patient is going to be foaming at the mouth and seizing, patient gets med that theyre allergic to-well they may or may not have reaction, i could go on and on. these patients trust you. their lives are in your hands, remember that. if you gave wrong med 1st time, i would talk to you maybe, maybe, even the 2nd time but after that you are a problem and we need to understand why. if it continues you will destroy yourself.learn from your mistakes. this is something i was taught, "bad habits become routine" dont get into bad habits.
Watch out:there are nurses that will hang you for the most trivial thing.
When reporting things there IS a difference between reporting it and going out of your way to tell on someone else.
here is my story- a nurse one time left me a patients crushed meds to give. it had a narcotic in it.(the nurse had a personal emergency) when i went to give it there was NO narcotic in the med crushed or otherwise. i've seen and given tons of crushed meds, it aint in there. so the next time i saw her again(next day) i told her never to lie to me, she knew what she did and did not lie. i am not going to have my co-worker lose their career or life even BUT i am not going to lose mine.some nurses would say i should have reported her and destroyed her life. if she had lied to me i would have made it known.it is hard... i certainly dont advocate stealing but i dont advocate destroying others lives.and believe me the patients are very important to me but so are my co-workers.
another story-i had 6of 14 patients all getting blood sometime within my shift and the next shift.variuos levels of consents and labs were done. 4 all had same blood type and 2 were getting blood on my shift in the same room. i went and got blood and checked it with a nurse but not at bedside.i walked to patient(the wrong one) and gave blood.management asked who i checked blood with. i would not give the name because it was my fault.i knew the policy and i hung the blood. we all knew the policy.it was busy, we each had 14 patients on night shift.that will never ever happen again. but one can never say never. did i learn from that? oh yeah very much!just do the best you can and never hesitate to ask for help! God bless!
FYI: go to any and all state board disciplinary actions and see what nurses get disciplined for, from the mundane to serious. it is the mundane that disturbs me.
KelRN215, BSN, RN
1 Article; 7,349 Posts
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.