Should I self report?

[Sunnywd]

I work on a very busy heart/ stroke floor. I got a write up but not terminated for pulling too many Lopressor 25mg on a patient one day! We scan our meds so it shows the pt only received the correct dose! I honestly do not remember if I pulled a partial sheet in a hurry and forgot to return the rest and left them in my cart or if I didn't log out correctly and someone else went in but why would someone take Lopressor and not narcotics if that was the case??? I am just lost here! My question is should I self report this to the board? Any help is appreciated!

Sunny

[ladedah1, BSN, RN]

NurseKatie08: "How do they know you/the patient didn't drop the med and you had to get another?"

My thoughts exactly!!! How many do they think were pulled unnecessarily? I wouldn't be able to tell you for the life of me how many times I dropped a pill, a patient dropped a pill, or I crushed up a whole bunch of meds and someone decided they didn't like the substance they were placed in and spit them all over the place! Stuff happens... and no one has ever come to me and asked me why I pulled any replacement meds. Same goes for IV meds that get diluted... sometimes you draw them up, dilute them, and then someone's situation changes and you end up wasting it. Stuff happens. Fingers fumble. People (and some situations) are unpredictable. I guess I just always thought that this type of thing, while it shouldn't happen on a regular basis, does in fact happen... and that any med tracking might take this into account.

That being said, I'm still interested in just how much medication was thought to be missing... it would have to be something significantly peculiar... otherwise, I don't think that anyone would be making this big of a deal out of it.

[Ruby Vee, BSN]

Wile E Coyote said:

Definitely do not self-report. Some things that you didn't share here, but perhaps they covered when they contacted you was if a prior user had miscounted, meds found in another bin and this didn't get accounted for, etc. They need to display they did their due-diligence before following through with this corrective action.

Self reporting is good if you're alerting your manager to an easily discoverable mistake. "I see the system recorded me as removing far more Lopressor than I did . . . I'm not sure how that happened, but I'll get in touch with pharmacy and see if we can figure it out together." But getting the BON involved would be a huge mistake!

[Kooky Korky, BSN, RN]

It is incredible to think that being short of a med is being blamed on you without any apparent proof.

It is more incredible that the BON would become involved. I guess if your employer thinks you stole it,

they might tell the BON. Otherwise, I don't see BON being involved.

Good luck.

[brillohead, ADN, RN]

I wonder if someone forgot to refill their own scrip for Lopressor, and they're just taking one from the Pyxis every day instead? Or if they took a whole handful to take some home to get them through the week?

Regardless, I still say the whole thing is bogus. On an uncounted (non-controlled) med, ANYONE who has been in that drawer (or that particular cubie, if it's even a covered one).

[CapeCodMermaid, RN]

The BOARD has more important things to do than check on an error like this. Was there patient harm? We all need to cut ourselves a break for being human

[applesxoranges, BSN, RN]

How do they even track who took a whole bunch of lopressors unless they count each time which would make pulling meds a pain in the butt. With narcotics you can kind of tell because you can narrow it down to two people, either the person pulling or the person who pulled before. I have never had to count how many lopressors are in the drawer.

[foggnm]

That's not really a nursing board issue since it doesn't involve narcotics or patient harm. Don't beat yourself up over it, just be careful when you pull meds in the future.

[FutureSTLNurse]

If you happen to overdose someone or give them the wrong medicine the doctor will tell you to monitor them 9/10 times. Take vitals q 30 mins. If they are ok then dont stress yourself out. A wise women once told me what happens is between you amd Jesus. The fact that you are asking the question shows you have a good heart just be careful going forward