reporting a med error

Sun0408, ASN, RN · Nov 12, 2012

I have written myself up for med errors.. I am honest and didn't want it to be found later. Did I get in trouble no, because our med error reports are to improve the process not to blame.. Is this how your reports are viewed? If I had made one and not aware; I would want to know. Of course they are upsetting. If you talked to her as in just FYI and not how dare you, I don't think you over reacted. But, I was not there for the conversation and "tone" can play a big part in how someone takes something.

Bec7074 · Nov 12, 2012

Obviously you feel bad about the situation since she was upset. However, you really did the right thing. Medical error reporting is for "process improvement." It's done so organizations can study behavior and factors contributing to errors so they can be improved in the future. Did you explain that to her and that it wasn't done to get her in trouble?

Just curious, what exactly was the med error? I once knew a nurse who wrote up an orientee for almost giving a few extra mL's of a stool softener because she mis-measured. She was the orientee's preceptor and actually stood there and watched while the orientee measured and wanted to see if she caught herself. She filled out an incident report for almost giving too much docusate. While I understand incident reports and process improvement, I felt that this situation did more harm than good. She was a brand new nurse and it really shook her up and made her question herself all time.

dudette10, MSN, RN · Nov 29, 2012

You did the right thing. I also believe your characterization of how you spoke to the nurse who made the med error.

Although this doesn't change my opinion, I have to ask why the other charges thought you shouldn't fill out an incident report. Are the reports used punitively at your facility? If so, maybe this would be a good opportunity for you and the other charge nurses to get involved with a culture change on incident reporting.

KelRN215, BSN, RN · Dec 2, 2012

If I was ever questioning if an incident report needed to be filed, I wrote one. If my manager felt it didn't need to get reported, she could get rid of it. As Sun said, these are not meant to be punitive and I hated the attitude that somone filed an incident report ON someone else. The incident report was on the situation not on the person. I have written incident reports on mistakes I made as well as on mistakes that I have caught. All these incidents needed to be reported and I don't think anyone got "in trouble" after them... they were, as they should have been, used to improve things so these errors don't happen in the future.

One that comes to mind. I worked inpatient neurology/neurosurgery until earlier this year. We had patients with invasive epilepsy monitoring who had surgical grids implanted on their brain to track their seizures. All of these patients had subdural drains in place. They were all on prophylactic antibiotics because of the hardware in their heads. Well, one time, a patient's drain was pulled and the antibiotics were dc'd because they were ordered "while drain in place." As soon as I came on, I noted the error and questioned why the antibiotics were discontinued. Both the resident and the nurse said "because the drain was pulled." As soon as I pointed out that the patient still had grids in his head and that that was the true reason for the antibiotics, they were resumed. The patient only missed one dose of antibiotics and no harm was done (I believe they even started him on a larger dose when they restarted) but there was a huge potential for harm, so an incident report was filed. It wasn't filed *on* anyone in particular but on the situation. My manager actually followed up with me about this and- the last I knew- the surgical team and the pharmacy were working on a template (our orders were all computerized) so that this would be less likely to happen in the future.

T-Bird78 · Dec 3, 2012

You did the right thing. A med error occurred, you documented it and brought it to the attention of the nurse. She might not have realized the error or that it even happened and now will be more vigilant. I've made dosing errors with allergy shots and had the appropriate documentation for that and the subsequent systemic reaction. I felt horribly that I did something so stupid but it made me more aware. I was very shaken up at the time and kept apologizing to my manager and was better the next day. You did fine and the nurse will be fine.

psu_213, BSN, RN · Dec 3, 2012

Was the nurse devastated by how you delivered the message or by the fact they she made a med error and she is just mad at herself for making the error? If it is the latter, it is not on you at all. Besides for incorrectly measuring a stool softener (and other minuscule errors), med errors need to be reported. Even if this particular error did not result in patient harm, it could be a part of a trend that eventually could result in harm to a patient. Part of your responsibility is report the error in an objective manner. Why is it the other charge nurse think you should ignore it? Just saying "there is no patient harm" is not a reason to totally ignore a med error.

katherine100, LPN · Dec 17, 2012

Did I just read that correctly. Fellow charge nurses said you should have let it go? WOW. Now I see why nurisng is in such bad shape. No one cares.

I recently found a med error and followed through with a med error report ( I am the charge nurse for that shift). There was no harm done but the potential was there. The nurse who made the error was devastated even though I spoke to her about it in a non threatening way and told her about errors I had made in the past. I felt so bad after, seeing how hard she was taking it. Fellow charge nurses have since made it known that I "over reacted" and felt I should have just let it go seeing there was no harm done.
Did I over react?? I don't care to have my license suspended for non-compliance.

Anne36, LPN · Jan 15, 2013

I have seen med-errors handled in a few different ways. Either an incident report, calling the Doctor to get approval for a one time order to "correct" the med error, Nurses circleing doses as not given with an incorrect order, or not doing anything depending on the situation. I have filled out an incident report on myself for changing a fentanyl patch a day too early, even though the client wears them continuously and no harm was done.