RN medicated my patient without documenting!

[poppy07]

I need some help regarding a situation in which another RN medicated my patient without documenting. This patient was seeking medication when I came to see them, and it had been well enough time before they were allowed medication (according to the computer documentation), so I administered the med. The other RN came by later on to inform me that they were going to chart on this medication that they gave earlier and noticed that I gave the med just a little while ago (and had never told me they gave it.) Now, this makes it seem as if I gave the medication too early after the other RN had done so because this person is able to adjust the time in the computer when they document. Best advice?

[leslie :-D]

tell cn or nm, followed by incident report.

how/why did this happen?

leslie

[poppy07]

I'm in orientation and the preceptor medicated the patient without telling me. It is policy to document before admin. med. It was probably an hour later that this RN informed me that they were going to chart and noticed that I gave the med. To add to this, this person then said that it's a good idea to always check to see when was the last time the medication was pulled from the stock machine (an inaccurate presumption anyway since half of the med could be saved in the pt's room for later use and be taken out much much earlier.) I don't want to create problems in my work environment, but this could become a liability.

[ukstudent]

Communication, or lack thereof is the problem here. It was not YOUR pt, rather it was your preceptors and your pt. Communication goes both ways. Your preceptor should have kept you informed about the pt and any prn meds given as you should have to them. If she/he had informed you about the med you wouldn't have given it again. And if you had said, prior to giving it that you were about to, then she/he could have then stopped you. Learn from this and keep the communication lines open.

As to the charting, they can tell at what time meds are charted compared to the time documented given if any problems arise from this.

[ebear, BSN, RN]

??????????????? :nono::nono:

ebear

[poppy07]

"my pt or our pt"...regardless, it was understood that I was doing everything for this pt that day, and the other RN was "around" (not necessarily nearby) for reference. I'm not sure if it shows when documenting, when the documenting was actually done compared to the time entered in the documentation (as you can change the time) to show when a med was administered.

[ukstudent]

If the timing is a problem they should b able to go back into the computer and see that the other med was charted after you charted your med regardless of the time documented as given.

Sorry about the "my/our pt" bit, but in the first post it sounded like some random nurse had just given some meds to your pt. In the second you say your on orientation but not that you have control of that particular pt.

I will say again that it all comes down to communication. Communication between you and your preceptor and communication here on this board. With adequate communication from your preceptor to you then even without the documentation you would not have re-medicated the pt.

[poppy07]

Communication is key for sure! I was irritated that this person failed to accept any responsibility for not charting and not communicating. I mentioned filling out an incident report, and they said "well it's up to you...you can if you want"

[RainDreamer, BSN, RN]

I agree that communication is key here.

If you're at a stage in your orientation in which you're doing everything for the patient, then that nurse shouldn't have given any kind of med without informing you.

And yes, with any kind of computer system, you should be able to tell what the actual entry time was. If you dig a bit, it should show when the valued entry time was (meaning the time she actually gave the med) and the actual entry time (the exact time she charted it into the computer).

[TazziRN, RN]

Does not much matter whose pt it was, bottom line is that a med was given and not charted, so the OP had no reason to suspect that the pt had been medicated. When medicating a pt I have NEVER checked to see when a med was last pulled, rather I have looked at the chart to see when the last dose was charted.

[woody62, RN]

I was taught and I did this, when administering a narcotic to a patient, you sign it off in the MAR. No problems with a patient getting a medication before or too long after, it is due. If another nurse gives my patient a narcotic without notifying me and without signing off in the MAR immediately after giving it, it is her problem. Not mine. She is the one who failed to follow protocol.

Woody:balloons:

[poppy07]

should I complete an incident report, say something to NM, etc? I don't want to stir trouble early on.